Diabetes Management

Patient Selection and Administration Timing

Morning administration of diabetes medication may be appropriate for patients experiencing nocturnal hypoglycemia, and can provide better daytime coverage for some patients, according to the American Family Physician 1
The American Diabetes Association suggests that bedtime administration may be preferable for most patients, particularly those experiencing morning hyperglycemia 2, 3
Most type 1 diabetes patients on basal-bolus regimens may benefit from morning administration considerations 3
Patients with dawn phenomenon (early morning hyperglycemia) may require alternative administration timing 3
Patients with steroid-induced hyperglycemia may need morning administration adjustments 3

Adding a DPP-4 inhibitor, such as sitagliptin, to the regimen can help with fasting hyperglycemia without increasing hypoglycemia risk, as recommended by the American Association of Clinical Endocrinologists 4
Insulin glargine is a long-acting basal insulin that provides relatively constant insulin levels over 24 hours, but its effectiveness may wane before 24 hours in some patients, as recommended by the American Diabetes Association and the American College of Clinical Endocrinologists 3, 2
Switching to bedtime administration of insulin glargine may provide better coverage during early morning hours, as recommended by the American Academy of Family Physicians and the American Diabetes Association 3, 2, 1
Consider adding a GLP-1 receptor agonist to reduce insulin requirements, as recommended by the American Diabetes Association 3

The American Diabetes Association recommends reducing insulin dose by 10-20% and determining the underlying cause if hypoglycemia occurs, and treating hypoglycemia with 15-20g of glucose and rechecking blood glucose after 15 minutes, repeating treatment if necessary 5, 3, 6
Providing a meal or snack once blood glucose is trending up can help prevent recurrence of hypoglycemia, as suggested by the American Diabetes Association 5, 6
Ensuring glucagon is available for severe hypoglycemia episodes is crucial, as recommended by the American Diabetes Association 5, 6
Evaluate for overbasalization signals, including high basal dose, high bedtime-morning glucose differential, frequent hypoglycemia, and high glucose variability, as indicated by the American Diabetes Association 2
Implement a 2-3 week period of strict hypoglycemia avoidance and consider raising glycemic targets temporarily to reverse hypoglycemia unawareness, as recommended by the American Diabetes Association 6

Regular exercise and consistent carbohydrate intake help improve insulin sensitivity and maintain stable blood glucose, as recommended by the American College of Sports Medicine 7
Avoid overreliance on sliding scale insulin and abrupt large dose changes, which can lead to glucose fluctuations, as strongly discouraged by the American Diabetes Association 8, 3
Consider interrupting prolonged sitting every 30 minutes to help maintain stable blood glucose levels, as recommended by the American College of Sports Medicine 7
Avoid evening alcohol consumption to help improve insulin sensitivity and maintain stable blood glucose levels, as suggested by various health organizations

Basal insulin should be adjusted based on overnight or fasting glucose patterns, as suggested by the American Diabetes Association 2
Monitor overnight patterns by checking blood glucose at bedtime, 3 AM, and upon waking for several nights to establish a pattern, as recommended by the American Association of Clinical Endocrinologists and the American Diabetes Association 2
Consider continuous glucose monitoring (CGM) to help identify overnight patterns, as suggested by the Endocrine Society and the American Diabetes Association 2
Increase frequency of blood glucose monitoring, especially before driving or operating machinery, according to the American Diabetes Association 9