ADA Standards of Care 2024
1. Many adults with type 2 diabetes eventually require and benefit from insulin therapy. The progressive nature of type 2 diabetes should be regularly and objectively explained to individuals with diabetes, and clinicians should avoid using insulin as a threat or describing it as a sign of personal failure or punishment.
2. The utility and importance of insulin to maintain glycemic control once progression of the disease overcomes the effect of other agents should be emphasized.
3. Educating and involving people with diabetes in insulin management is beneficial. For example, instruction of individuals with type 2 diabetes initiating insulin in self-titration of insulin doses based on glucose monitoring improves glycemic management.
4. Comprehensive education regarding blood glucose monitoring, nutrition, and the avoidance and appropriate treatment of hypoglycemia are critically important in any individual using insulin.
5. Basal insulin alone is the most convenient initial insulin treatment and can be added to metformin and other noninsulin injectables for individuals with type 2 diabetes.
6. The principal action of basal insulin is to restrain hepatic glucose production and limit hyperglycemia overnight and between meals.
7. Starting doses can be estimated based on body weight (0.1–0.2 units/kg/day) and the degree of hyperglycemia, with individualized titration over days to weeks as needed.
8. In adults with type 2 diabetes, initiation of insulin should be considered regardless of background glucose-lowering therapy or disease stage if there is evidence of ongoing catabolism (e.g., unexpected weight loss), if symptoms of hyperglycemia are present, or when HbA1C or blood glucose levels are very high (HbA1C >10% or blood glucose ≥300 mg/dL).
9. In adults with DM 2, a GLP-1 RA, including a dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 RA, is preferred to insulin.
10. If insulin is used, combination therapy with a GLP-1 RA, including a dual GIP and GLP-1 RA, is recommended for greater glycemic effectiveness as well as beneficial effects on weight and hypoglycemia risk for adults with type 2 diabetes. Insulin dosing should be reassessed upon addition or dose escalation of a GLP-1 RA or dual GIP and GLP-1 RA.
11. In adults with DM 2, glucose-lowering agents may be continued upon initiation of insulin therapy (unless contraindicated or not tolerated) for ongoing glycemic and metabolic benefits (i.e., weight, cardiometabolic, or kidney benefits).
12. To minimize the risk of hypoglycemia and treatment burden when starting insulin therapy in adults with type 2 diabetes, reassess the need for and/or dose of glucose-lowering agents with higher hypoglycemia risk (i.e., sulfonylureas and meglitinides).
13. Clinicians should be aware of the potential for overbasalization with insulin therapy.
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