Answer FAQs About Insulin for Type 2 Diabetes

Insulin is in the spotlight...and you can help answer questions.

Medicare Part D now caps insulin co-pays at $35/month. And manufacturers are rolling out their own co-pay caps...and lower prices.

Plus Rezvoglar (insulin glargine-aglr) will soon join Semglee as a lower-cost interchangeable biosimilar for Lantus.

Expect all of these changes to lead to more questions about how to use insulin for patients with type 2 diabetes.

When should insulin be started?  Continue to use basal insulin first-line in some cases...such as if A1c is over 10% or in patients with symptomatic hyperglycemia (polyuria, polydipsia, etc).

Or consider adding insulin if other med combos aren’t enough.

Start with 10 units or 0.1 to 0.2 units/kg once daily of a long-acting analog (glargine, etc) or NPH in most patients.

Generally titrate by 1 to 2 units or 5% to 10% once or twice meet fasting glucose goals.

How should other diabetes meds be adjusted when insulin is added?  Consider continuing GLP-1 agonists (Ozempic, etc), metformin, and SGLT2 inhibitors (Jardiance, etc).

Continuing these meds may help limit weight gain...and allow patients to use lower insulin doses.

And GLP-1 agonists or SGLT2 inhibitors may be used for their CV or kidney benefits in some patients.

It’s also okay to continue gliptins (Januvia, etc).

But be cautious about using insulin with pioglitazone...due to possible weight gain, edema, and heart failure.

Stop sulfonylureas once mealtime insulin is added...there’s little added benefit and possibly more hypoglycemia.

When should mealtime insulin be added?  Consider bolus insulin if patients have good fasting glucose but can’t reach their A1c goal...or are using over 0.5 units/kg/day of basal insulin.

Add rapid-acting (lispro, etc) or regular insulin before the largest meal...then add a dose before other meals if needed.

Think of premixed insulin (70/30, etc) for patients who need a simpler approach...but keep in mind that doses are harder to adjust.

See our resource, Tips to Improve Insulin Safety. And access our Diabetes Resource Hub for help with switching, monitoring, and more.

Key References

  • Diabetes Care. 2023 Jan 1;46(Suppl 1):S140-S157
  • Diabetes Care. 2022 Nov 1;45(11):2753-2786

Prescriber's Letter. April 2023, No. 390415

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