Insulin Therapy for Children with Type 2 Diabetes

Indications for Insulin Therapy

The American Diabetes Association recommends starting insulin therapy immediately in children with type 2 diabetes who have diabetic ketoacidosis or ketonuria, a random blood glucose level ≥250 mg/dL, or an HbA1c level ≥8.5% 1, 2, 3
Insulin therapy is required for children with diabetic ketoacidosis (DKA) to correct hyperglycemia and metabolic disturbances 1, 3, 4
Children with ketonuria or diabetic ketoacidosis require immediate insulin replacement therapy 3, 4, 5
The American Diabetes Association recommends insulin therapy for children with a random blood glucose level ≥250 mg/dL or an HbA1c level ≥8.5% 1, 3, 4
Children with an HbA1c level >9% may benefit from initial insulin therapy even in the absence of ketonuria 3, 4

Children with poor glucose control but without ketonuria (blood glucose 200-249 mg/dL or HbA1c 8.5-9%) may benefit from initial insulin therapy 4, 6
Early initiation of insulin therapy may improve long-term adherence and allow for beta-cell rest and recovery 2, 3, 4

Metformin should be added after resolution of ketoacidosis, while continuing subcutaneous insulin therapy 1, 3
The initial insulin dose should be 0.5 units/kg/day, with adjustments every 2-3 days based on blood glucose monitoring 1
Many patients can be weaned off insulin and managed with metformin and lifestyle changes 2, 3, 4

HbA1c should be checked every 3 months until targets are achieved 1, 3
Blood glucose monitoring with fingerstick tests is recommended for patients on insulin or medications with a risk of hypoglycemia 1, 3
Intensification of therapy is recommended if targets are not met 3
Consider adding a GLP-1 receptor agonist approved for children ≥10 years if glycemic targets are not met with metformin (with or without long-acting insulin) 1, 3
Empagliflozin (SGLT-2 inhibitor) is now approved for type 2 diabetes in children 3