Treatment Intensification for Uncontrolled Type 2 Diabetes

Rationale for Insulin Initiation

• When A1C ≥10% or blood glucose ≥300 mg/dL, insulin therapy should be initiated immediately, particularly when catabolic features may be present 1
• The American Diabetes Association recommends initiating insulin therapy immediately for patients with severe hyperglycemia, as glucose toxicity is likely impairing both insulin secretion and insulin sensitivity, and insulin is the most effective agent to rapidly reverse this 1

Specific Treatment Algorithm

• The American Diabetes Association recommends starting basal insulin (glargine or detemir) with an initial dose of 10 units at bedtime or 0.1-0.2 units/kg/day, and continuing metformin at the current dose 1
• Increase basal insulin by 2-4 units every 3 days until fasting glucose reaches 100-130 mg/dL, as recommended by the American Diabetes Association 1

Monitoring Plan

• Check fasting blood glucose daily during insulin titration, as recommended by the American Diabetes Association 1
• Recheck A1C in 3 months, according to the American Diabetes Association guidelines 2
• Target A1C <7% for patients without significant comorbidities, as recommended by the American Diabetes Association 1