Table 2.

Suggested Changes in Insulin Therapy Based on Current A1C and Current Insulin Regimen at the Time of GLP-1 Receptor Agonist Initiation

Insulin Regimen	A1C <8.0%	A1C ≥8.0%
Basal insulin only	Reduce basal insulin by 20%. Consider further reduction of basal insulin (e.g., 50%) with escalating doses of GLP-1 receptor agonist depending on glucose profile. Consider reducing or holding basal insulin before initiating the maximum dose of GLP-1 receptor agonist based on current fasting blood glucose levels.	No change in insulin therapy unless there is concern about barriers to taking insulin or the patient is on a >0.5 unit/kg insulin dose, in which case consider a 20% reduction in basal insulin. Consider reducing basal insulin by ≥20% with escalating doses of GLP-1 receptor agonist depending on glucose profile.
Intensive insulin therapy (e.g., multiple daily injections or pump therapy)	Reduce all insulin therapy by 20% initially. Consider holding prandial insulin and further reducing basal insulin with escalating doses of GLP-1 receptor agonist. Prandial insulin may be added back, if indicated, once the maximum dose of GLP-1 receptor agonist is reached.	No change in insulin therapy unless there is concern about barriers to taking insulin or the patient is on a >0.5 unit/kg dose of basal insulin, in which case consider a 20% reduction. Consider reducing insulin by ≥20% with escalating doses of GLP-1 receptor agonist with an attempt to reduce or minimize prandial insulin first.

Insulin titration is based on patients’ total daily dose of insulin, but care must be taken to frankly discuss the daily dose of insulin patients are actually taking versus the dose prescribed.