Table 3.

Strategies for initiating and titrating insulin for treatment-naïve patients with T2DM

Suggest that insulin will help patients achieve glycemic targets and minimize the risk of long-term complications Allow patients to actively participate in their insulin dose titration Always praise patients on insulin at their visits for their efforts at achieving their glycemic targets ○ Remember, patients who are using insulin do not have normally functioning pancreases ○ They are performing their own insulin dose calculations, perhaps multiple times each day ○ Insulin prescribers should do everything possible to help patients become successful users of insulin Individualize therapy to meet the needs of each patient ○ Determine which treatment algorithm might work best for every patient Emphasize the importance of lifestyle intervention ○ This should minimize weight gain and reduce PPG excursions Consider group office visits to have patients meet with a certified diabetes educator diabetes educator ○ Often, 8–20 patients can be seen at group visits; they are time-efficient and reimbursable by third-party payers Provide each patient with an individualized, written insulin protocol to which they can refer Prescribe insulin pen devices whenever possible ○ Dose titration of insulin is much more accurate with pens than with vials and syringes Teach patients how to identify and appropriately manage hypoglycemic events When initiating basal insulin, use 0.4 U/kg/day as the starting dose ○ Continue metformin if possible If patient requires > 60 U of basal insulin per day, and his or her A1C level is >7%, add a rapid-acting insulin analog at the largest meal of the day ○ The dose for rapid-acting insulin is 0.1 U/kg/meal If A1C level is not reduced to target after 3 months of basal plus bolus insulin, add a second injection at the next largest meal of the day ○ Repeat the A1C test at 3 months and if still above target, add a third mealtime injection Patients on basal-bolus insulin therapy should consider modified paired glucose testing in order to fine-tune their treatment regimens

Abbreviations: A1C, glycosylated hemoglobin; PPG, postprandial glucose; T2DM, type 2 diabetes mellitus.