Insulin Regimen for Type 2 Diabetes Management

Initial Insulin Regimen

The American Diabetes Association recommends starting insulin immediately when A1C ≥10-12%, especially if symptomatic with polyuria, polydipsia, or weight loss, with an initial basal insulin dose of 10 units or 0.1-0.2 units/kg daily, typically administered at bedtime, combined with metformin 1
Initiate basal insulin at 10 units or 0.1-0.2 units/kg daily, typically administered at bedtime, combined with metformin, for a type 2 diabetic patient with an A1C of 12% and sedentary lifestyle 1, 2

For pre-meal blood glucose readings using regular insulin, the American Diabetes Association guidelines suggest the following correction doses: <150 mg/dL: No correction dose, 150-250 mg/dL: 0-2 units, 251-350 mg/dL: 2-4 units, >350 mg/dL: 4 units, administered 30 minutes before meals 3
The American Diabetes Association explicitly states to stop sliding scale when not needed daily—this approach should only be temporary while establishing proper basal insulin dosing 2, 3

Check fasting blood glucose daily during titration, and increase basal insulin by 2 units every 3 days until fasting glucose reaches 80-130 mg/dL, with a target fasting plasma glucose of 80-130 mg/dL 2
If hypoglycemia occurs (glucose <70 mg/dL), reduce dose by 10-20% 2

If after optimizing basal insulin the A1C remains above target, add mealtime rapid-acting insulin analog starting with 4 units before the largest meal or 10% of basal insulin dose, or consider adding a GLP-1 receptor agonist instead of mealtime insulin for additional glucose lowering with weight loss benefit 1, 2
Increase mealtime insulin by 1-2 units every 3-7 days based on 2-hour postprandial glucose readings (target <180 mg/dL) 2

Calculate total daily insulin dose, then divide as 50% basal and 50% prandial, and split prandial insulin evenly between three meals 1, 2
This represents a more intensive regimen typically needed when simpler approaches fail 1

Check fasting glucose daily during titration, pre-meal glucose before each meal when on mealtime insulin, and 2-hour postprandial glucose after the largest meal to guide prandial insulin adjustments 2
Measure A1C every 3 months until target achieved, with a target A1C <7% for most patients, though <7.5% may be appropriate if hypoglycemia risk is high 4, 5

Carry 15-20 grams of fast-acting carbohydrate at all times, monitor for hypoglycemia 2-4 hours post-injection when regular insulin action peaks, and avoid regular insulin at bedtime due to nocturnal hypoglycemia risk 2, 3
If severe hypoglycemia occurs, reduce insulin dose by 10-20%, and prescribe glucagon for emergency use and educate family members 2

Encourage at least 60 minutes of moderate to vigorous physical activity daily, include muscle and bone strength training at least 3 days per week, and decrease sedentary behavior as this directly impacts insulin sensitivity 4, 5
Regular physical activity improves insulin sensitivity and may require dose adjustments to prevent hypoglycemia 2

Expect A1C reduction of 2.5-3.5% with proper basal insulin titration and metformin, and target A1C <7% for most patients, though <7.5% may be appropriate if hypoglycemia risk is high 2, 4, 5