Insulin Therapy in Type 2 Diabetes Mellitus

Introduction to Insulin Therapy

The American Diabetes Association recommends GLP-1 receptor agonists, including dual GIP/GLP-1 receptor agonists, over insulin for glycemic management in adults with type 2 diabetes 1, 2

Insulin should be started immediately in patients with evidence of ongoing catabolism, symptoms of hyperglycemia, A1C >10%, or blood glucose ≥300 mg/dL 1, 2, 3

For patients with heart failure, the American College of Cardiology recommends SGLT2 inhibitors for glycemic management and prevention of HF hospitalizations 1, 2
For patients with chronic kidney disease (CKD) and eGFR 20-60 mL/min/1.73 m², the National Kidney Foundation recommends SGLT2 inhibitors to minimize CKD progression and reduce cardiovascular events 1, 2
For patients with advanced CKD (eGFR <30 mL/min/1.73 m²), the American Diabetes Association recommends GLP-1 receptor agonists due to lower hypoglycemia risk and cardiovascular event reduction 1, 2

For insulin-naive patients, start with 10 units once daily or 0.1-0.2 units/kg/day of basal insulin, and administer at the same time each day 1, 2, 3

The American Diabetes Association recommends combination therapy with a GLP-1 receptor agonist for greater glycemic effectiveness, beneficial effects on weight, and reduced hypoglycemia risk 1, 2, 3
Continue metformin when initiating or intensifying insulin therapy unless contraindicated or not tolerated 1, 2, 3

Monitor for signs of overbasalization, including basal dose exceeding 0.5 units/kg/day, significant bedtime-to-morning glucose differential, postprandial-to-preprandial glucose differential, occurrences of hypoglycemia, and high glycemic variability 1, 2, 3

When basal insulin exceeds 0.5 units/kg/day, add prandial insulin rather than continuing to escalate basal insulin alone 1, 2, 3

The American College of Physicians recommends human insulin for managing blood glucose in adults with type 2 diabetes for whom insulin is indicated 5
Long-acting insulin analogues may be considered for patients who have frequent severe hypoglycemia with human insulin 5

Routinely assess patients for financial obstacles that could impede diabetes management, and consider lower-cost medications within the context of their risks and benefits 1, 2, 3