Continuing Oral Hypoglycemic Agents When Starting Insulin Therapy

Evidence-Based Approach to OHAs When Starting Insulin

The American Diabetes Association recommends continuing metformin and other beneficial oral hypoglycemic agents when starting insulin therapy, while reassessing the need for sulfonylureas and meglitinides due to hypoglycemia risk 1, 2
Metformin should be maintained when initiating insulin therapy due to its complementary mechanism of action and beneficial effects on glycemic control and cardiovascular outcomes 1, 2
The combination of insulin plus metformin is particularly effective for lowering glycemia while limiting weight gain 3

When starting insulin, reassess the need for and/or dose of glucose-lowering agents with higher hypoglycemia risk, such as sulfonylureas and meglitinides, and consider reducing or discontinuing them to minimize hypoglycemia risk 1, 2
SGLT2 inhibitors may be continued for their cardiorenal benefits even when starting insulin, especially in patients with heart failure or chronic kidney disease 1, 2
The initial insulin regimen should start with basal insulin, with a typical starting dose of 10 units per day or 0.1-0.2 units/kg/day, depending on the degree of hyperglycemia, while continuing metformin and reassessing other oral hypoglycemic agents 1, 5
When using GLP-1 receptor agonists with insulin, insulin dosing should be reassessed upon addition or dose escalation of the GLP-1 receptor agonist 1, 2
In severely uncontrolled diabetes, insulin therapy with lifestyle intervention is the treatment of choice, and after symptoms are relieved and glucose levels decreased, oral agents can often be added and it may be possible to withdraw insulin if preferred 3