Insulin therapy is an essential tool in managing type 2 diabetes, but it can feel overwhelming due to the complexity of options, dosing, and delivery methods. In this guide, we’ll break down key aspects of insulin use to help patients and providers understand when and how to use it effectively, minimize complications, and improve outcomes.

When to Start Insulin Therapy

Insulin isn’t always the first option for managing type 2 diabetes, but it’s necessary for some patients—particularly those in the pancreatic insufficiency phase of the disease, where the body can no longer produce enough insulin on its own.

However, insulin therapy can be challenging for patients due to:

• Frequent blood sugar checks (up to four times a day).

• Increased risk of hypoglycemia, leading to fear and overeating.

• Potential weight gain associated with insulin use.

While insulin is necessary for some, every effort should be made to improve insulin sensitivity and explore non-insulin agents first, especially in earlier stages of type 2 diabetes.

How to Dose Insulin Properly

Insulin dosing should reflect the body’s natural physiology, which involves two types of insulin:

1. Basal Insulin: Long-acting insulin that manages blood sugar between meals and overnight.

2. Bolus Insulin: Short-acting insulin that manages blood sugar spikes during meals.

To calculate the total daily dose of insulin:

• Divide the patient’s weight in kilograms by 2.

• Split this total evenly between basal and bolus insulin.
  For example, a 60 kg patient would need 30 units of insulin daily—15 units of basal and 15 units of bolus, divided across three meals (5 units per meal).

Common Pitfall: Many patients are over-basalized, meaning they take too much basal insulin and no bolus. This leads to poor blood sugar control with highs during the day or lows overnight. Properly balancing both types of insulin is critical for achieving steady blood sugar levels.

Using the Insulin Sliding Scale

The sliding scale helps manage high blood sugar levels in addition to meal-time insulin.

How it works: Patients check their blood sugar before meals and take extra insulin (on top of their bolus dose) to bring their levels down to a target range, typically 150 mg/dL or less.

Tailoring the scale:

• Low dose for patients using <40 units/day.

• Moderate dose for 40-100 units/day.

• High dose for >100 units/day.
  Adjust the starting point for insulin-sensitive or high-risk patients, such as the elderly, to avoid hypoglycemia.

Choosing the Right Insulin

Not all insulin types are created equal. Here are the best options for most patients:

• Basal Insulin: Glargine and Degludec offer long-lasting, steady effects without significant peaks.

• Bolus Insulin: Aspart and Lispro (including ultra-rapid versions) act quickly to control post-meal spikes.

Older insulins, like NPH or regular insulin, are more prone to causing hypoglycemia and require careful timing, making them less ideal unless cost is a major concern.

Exploring Non-Injection Insulin Delivery Options

For patients who find injections burdensome, several alternative delivery methods are available:

• Insulin Pumps: Provide continuous insulin delivery, reducing the need for multiple daily injections.

• Wearable Insulin Patches: Discreet and easy to use, they improve adherence for some patients.

• Inhaled Insulin: Rapid-acting insulin delivered via inhalation for eligible patients.

These options can improve compliance and make insulin therapy less daunting for patients.

Takeaways for Effective Insulin Management

1. Start insulin therapy only when necessary, focusing on improving insulin sensitivity first.

2. Use a balanced approach with basal and bolus insulin for better control.

3. Leverage sliding scales to address hyperglycemia without over-reliance on basal insulin.

4. Opt for newer, more stable insulin types whenever possible.

5. Explore non-injection delivery options to improve patient comfort and adherence.

With the right strategies, insulin therapy can be a powerful tool for managing type 2 diabetes, improving both blood sugar control and quality of life for patients.

Stay Updated

Subscribe to our newsletter in the footer below to get updates as we release more videos in the Diabetes Essentials series.

Watch all of the published course modules in order here.