Insulin Therapy Management

Basal Insulin Regimen

• For patients on premixed insulin, the American Diabetes Association recommends transitioning to a simplified regimen with 70% of the total daily dose as basal insulin administered in the morning, while discontinuing prandial insulin and adding appropriate non-insulin agents 1, 2
• The optimal basal insulin choices include glargine U-100/U-300, detemir, degludec, or NPH, and should be administered in the morning 1, 2
• Insulin glargine is a long-acting basal insulin analog with an onset of 1-2 hours, a relatively peakless action profile, and a duration of 24+ hours, designed for basal insulin needs, according to the American Diabetes Association 3

Dose Adjustment and Monitoring

• The target fasting glucose level is 90-150 mg/dL, and the dose should be adjusted accordingly, with an increase of 2 units if 50% of fasting fingerstick values are above target, and a decrease of 2 units if more than 2 fasting fingerstick values per week are below 80 mg/dL 2, 4
• Regular monitoring of blood glucose is crucial, especially when initiating therapy or changing doses, to minimize the risk of hypoglycemia 4
• The American Diabetes Association recommends adjusting goals based on overall health and care objectives, and considering patient comorbidities such as chronic kidney disease, atherosclerotic cardiovascular disease, and weight concerns when selecting additional agents 1, 2

Premixed Insulin Regimens

• Premixed insulin regimens, such as Humulin 70/30, should be administered 30-60 minutes before meals due to their slower onset and longer duration compared to analog premixes, as recommended by the American Diabetes Association 5
• These regimens may be suitable for older adults with consistent meal patterns, simplifying insulin regimens in elderly patients to reduce hypoglycemia risk, as suggested by the American Geriatrics Society 6
• The administration timing for premixed insulin is as follows:

• Premixed insulin doses should be adjusted based on pre-meal and bedtime glucose patterns, with thrice-daily premixed insulin analogs considered if twice-daily dosing fails to achieve glycemic targets, as recommended by the American Association of Clinical Endocrinologists 8, 9

Additional Agents and Considerations

• For patients with an estimated glomerular filtration rate (eGFR) of 45 mL/min or higher, metformin 500 mg daily is recommended, with dose increases every 2 weeks as tolerated, while for those with an eGFR below 45 mL/min or who cannot tolerate metformin, second-line agents should be considered 2
• The American Diabetes Association suggests targeting a premeal glucose level of 90-150 mg/dL, and adjusting the dose or adding another agent if 50% of premeal values over 2 weeks exceed target 2
• Consider patient's meal timing consistency before switching to premixed insulin, as those with highly variable meal schedules may not be ideal candidates, and consider alternative regimens such as basal insulin plus rapid-acting insulin or a combination of basal insulin with a GLP-1 receptor agonist, as recommended by the American Association of Clinical Endocrinologists and the American Diabetes Association 8, 10, 7
• Continue metformin and consider discontinuing sulfonylureas, DPP-4 inhibitors, and GLP-1 receptor agonists when switching to premixed insulin, as recommended by the American College of Physicians with moderate strength of evidence 11, 8

Glycemic Targets and Deintensification

• The American Diabetes Association recommends targeting an A1C level of less than 8.0% for patients with complex or intermediate health status, and less than 8.5% for those with very complex or poor health status 2
• Deintensification should be considered if severe or recurrent hypoglycemia occurs, and rapid-acting insulin at bedtime should be avoided 1, 12
• Premixed insulin therapy is not recommended for inpatient use due to high rates of iatrogenic hypoglycemia, according to the American Diabetes Association and other guidelines 13