Type 2 Diabetes: Next-Line Treatment When Basal Insulin Has Not Achieved Its Target
This protocol applies to patients with type 2 diabetes who have been receiving basal insulin therapy but have not achieved the target of fasting plasma glucose at goal without hypoglycemia. When that target remains unmet, a more intensive injectable regimen becomes the next step.
Previous Treatment & Why It Was Not Sufficient
The prior line added basal insulin — either human NPH or a long-acting insulin analog — with the specific goal of reaching fasting plasma glucose target without causing hypoglycemia. When that goal is not achieved, escalation to this next-line protocol is indicated.
Next-Line Approach (Partial Overview)
This protocol advances to a combination injectable regimen, building on the existing basal insulin by introducing a prandial component timed to meals with the greatest postprandial excursion. The complete titration sequence and escalation criteria are available in the full protocol.
Clinical Goal
Achievement and maintenance of the individualised glycaemic goal: A1C below 7%.
References
DOI: 10.2337/dc26-S009
- Further intensification of insulin therapy entails adding doses of prandial insulin to basal insulin.
- We suggest starting with a prandial insulin dose of 4 units or 10% of the amount of basal insulin at the largest meal or the meal with the greatest postprandial excursion.
- Increase dose by 1–2 units insulin dose or 10–15% twice weekly.
- Many individuals will require dual-combination therapy or a more potent glucose-lowering agent to achieve and maintain their goal A1C level.