Initiating Basal Insulin Therapy in Type 2 Diabetes

Introduction to Basal Insulin Initiation

The American Diabetes Association recommends starting basal insulin at 10 units once daily or 0.1-0.2 units/kg body weight for insulin-naive patients with type 2 diabetes 1.
Starting at 20 units significantly exceeds guideline-recommended initial dosing and increases hypoglycemia risk without evidence of superior efficacy 1.

The American Diabetes Association recommends increasing metformin to at least 1000 mg twice daily (2000 mg total), with a maximum effective dose of up to 2500 mg/day 1.
Metformin should be continued and optimized when adding or intensifying insulin therapy, as it reduces total insulin requirements and provides complementary glucose-lowering effects 1.
The patient's Jardiance dose can be increased to 25 mg daily for additional glucose-lowering effect if tolerated, as SGLT2 inhibitors like Jardiance provide cardiovascular and kidney disease risk reduction benefits that should be maximized before advancing to insulin 2.

Increase metformin to 1000 mg twice daily (2000 mg total daily dose) unless contraindicated by renal function or gastrointestinal intolerance 1.
Consider increasing Jardiance from 10 mg to 25 mg daily if the patient tolerates the current dose without adverse effects 2.
Reassess A1C in 3 months after these medication adjustments 2.
Initiate Lantus at 10 units once daily (not 20 units), administered at the same time each day, if A1C remains above goal after optimizing oral agents 1.

Increase Lantus by 2 units every 3 days if fasting glucose is 140-179 mg/dL 1.
Increase Lantus by 4 units every 3 days if fasting glucose is ≥180 mg/dL 1.
Target fasting plasma glucose of 80-130 mg/dL 1.
If hypoglycemia occurs without clear cause, reduce the dose by 10-20% immediately 1.

An A1C of 6.9 with blood sugars consistently in the 200s suggests significant postprandial hyperglycemia with relatively controlled fasting glucose, indicating the need to address meal-related glucose excursions, not just add basal insulin 2.
The patient may benefit from adding a GLP-1 receptor agonist to address postprandial hyperglycemia while minimizing weight gain and hypoglycemia risk 2, 1.

Proper insulin injection technique and site rotation to prevent lipodystrophy 1.
Recognition and treatment of hypoglycemia with 15 grams of fast-acting carbohydrate 1.
Self-monitoring of blood glucose, particularly fasting glucose during titration 1.
"Sick day" management rules and when to contact healthcare provider 1.
Insulin storage and handling to maintain potency 1.