Initiating insulin therapy

Are you nervous to start insulin for your patients? I know I was at first. Here is a quick rundown of how I design an insulin regimen for patients. Insulin therapy is highly individualized but this will give you a basic plan as you get started to feel more comfortable with initiating insulin. 

I typically consider insulin for someone when you first diagnose diabetes if their A1c is 10 or higher. I also consider initially if they have severe hyperglycemia (fasting glucose >250 or random glucose >300), A1c >9 with ketonuria, or weight loss. You will likely need to approach the insulin conversation with a patient that is a known diabetic and you are not having success with managing glucose after trying oral agents and/or GLP-1 medications. 

For most patients, start with a basal insulin. It will improve nocturnal and fasting glucose levels. It is also easier for the patient to use and understand as an introduction to insulin. The initial choice of basal insulin will likely depend on their insurance coverage so pick one and change accordingly. 

Basal insulin choices: 

Insulin glargine brand names: Basaglar KwikPen, Basaglar Tempo Pen, Lantus, Rezvoglar KwikPen, Semglee, Toujeo 

Insulin NPH brand names (available OTC): Humulin N, Novolin N 

*Glargine and NPH are very similar. Choice typically based on insurance coverage as stated above. Insulin Glargine may have less risk of nocturnal hypoglycemia compared to NPH but usually cost more. 

_{Initial Dosing: same if you are adding on to existing diabetic medications or initial therapy. You can do it by weight (0.2 units per kg daily and do 10-20u based on calculations). I almost always just start everyone at 10 units nightly. It is a safe starting point and easy for you and the patient.} 

Titrating: I use the rule of 3 and 3’s. The goal is to have the morning fasting sugar <150. So tell the patient to start with 10u every night. Check a morning fasting glucose every morning. You will increase by 3 units every 3 days until you are at that goal (fasting sugar 150). 

Example:
Monday- morning glucose 200, starts insulin with 10u Monday night

Tuesday- morning glucose 190, takes 10u Tuesday night 

Wednesday- morning glucose 170, takes 10 Wednesday night 

Thursday- morning glucose 180, increases to 13u Thursday night (adding 3 units every 3 days until morning fasting sugars are below goal of 150)

Follow up with them in 2-4 weeks. Every patient is different but I will consider changing to twice daily dosing (morning and night) when I get to a nightly dose of >50-60 units. For example, if your patient is up to 60u nightly, you can adjust to 30u in morning and 30u at night to prevent hypoglycemic events and get better 24 hour coverage of glucose levels. 

Come back next week to go over adding in mealtime insulin. 

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Allison Sowders, CNP