PERSONALIZED INSULIN STRATEGIES: A CLINICAL FRAMEWORK FOR TRANSITIONING FROM PREMIXED INSULIN TO GLARGINE IN RESISTANT TYPE 2 DIABETES
DOI:
https://doi.org/10.22159/ijpps.2026v18i6.58450Keywords:
Basal insulin, Glycemic control, Insulin glargine, Insulin resistance, Personalized therapy, Premixed insulin, Type 2 diabetes mellitusAbstract
Premixed insulin regimens, though convenient, often fall short in managing glycemic variability, hypoglycemia, and dosing rigidity in patients with insulin-resistant type 2 Diabetes Mellitus (T2DM). Insulin glargine, a long-acting basal insulin analog, offers a more stable pharmacokinetic profile, reduced hypoglycemia risk, and flexibility suited to patient lifestyles. This narrative review provides a clinical framework for switching from premixed insulin to insulin glargine in resistant cases.
Methods include selection and extraction of data from relevant studies to develop an evidence-based clinical framework for switching from premixed insulin to glargine in insulin resistant diabetes.
This review outlines the underlying pathophysiology of insulin resistance, key treatment challenges, and practical steps including patient selection, dose conversion, titration, addition of prandial insulin or oral agents and Special situation. This review aims to equip clinicians with practical, evidence-based guidance to navigate insulin transition in challenging T2DM populations. A structured, stepwise flowchart is provided to assist clinicians in implementing this transition safely and effectively in real-world settings.
Downloads
References
1. Antar SA, Ashour NA, Sharaky M, Khattab M, Ashour NA, Zaid RT, et al. Diabetes mellitus: Classification, mediators, and complications; a gate to identify potential targets for the development of new effective treatments. Biomed Pharmacother. 2023;168:115734. doi: 10.1016/j.biopha.2023.115734.
2. Wu T, Betty B, Downie M, Khanolkar M, Kilov G, Orr-Walker B, et al. Practical guidance on the use of premix insulin analogs in initiating, intensifying, or switching insulin regimens in type 2 diabetes. Diabetes Ther. 2015;6(3):273–287. doi: 10.1007/s13300-015-0116-0.
3. Tambascia MA, Nery M, Gross JL, Ermetice MN, de Oliveira CP. Evidence-based clinical use of insulin premixtures. Diabetol Metab Syndr. 2013;5(1):50. doi: 10.1186/1758-5996-5-50.
4. Cunningham AM, Freeman AM. Glargine insulin. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2025.
5. Silver B, Ramaiya K, Andrew SB, Fredrick O, Bajaj S, Kalra S, et al. EADSG guidelines: Insulin therapy in diabetes. Diabetes Ther. 2018;9(2):449–492. doi: 10.1007/s13300-018-0384-6.
6. Yang W, Du J, Zhang M, Hou J, Zhang X, Cui N. Predictors of HbA1c reduction and hypoglycemia in type 2 diabetes mellitus individuals switching from premixed to basal insulin: An exploratory analysis of optimization study. Curr Med Res Opin. 2022;38(11):1807–1814. doi: 10.1080/03007995.2022.2105538.
7. Clissold R, Clissold S. Insulin glargine in the management of diabetes mellitus: An evidence-based assessment of its clinical efficacy and economic value. Core Evid. 2007;2(2):89–110. PMID: 21221178; PMCID: PMC3012430.
8. Petrovski G, Gjergji D, Grbic A, Vukovic B, Krajnc M, Grulovic N. Switching from pre-mixed insulin to regimens with insulin glargine in type 2 diabetes: A prospective, observational study of data from Adriatic countries. Diabetes Ther. 2018;9(4):1657–1668. doi: 10.1007/s13300-018-0467-4.
9. DeFronzo RA. Banting Lecture. From the triumvirate to the ominous octet: A new paradigm for the treatment of type 2 diabetes mellitus. Diabetes. 2009;58(4):773–795. doi: 10.2337/db09-9028.
10. Belay KE, Ayalew BL, Meherete Etana A, Ashrafi Mahabadi M. Extremely high-dose insulin requirement in a diabetic patient with psychiatric illness: A case report. SAGE Open Med Case Rep. 2023;11:2050313X231220834. doi: 10.1177/2050313X231220834.
11. Church TJ, Haines ST. Treatment approach to patients with severe insulin resistance. Clin Diabetes. 2016;34(3):97–104. doi: 10.2337/diaclin.34.3.168.
12. Apostolopoulou M, Lambadiari V, Roden M, Dimitriadis GD. Insulin resistance in type 1 diabetes: Pathophysiological, clinical, and therapeutic relevance. Endocr Rev. 2025;46(3):317–348. doi: 10.1210/endrev/bnae032.
13. Belay KE, Ayalew BL, Etana AM, Mahabadi MA. Extremely high-dose insulin requirement in a diabetic patient with psychiatric illness: A case report. SAGE Open Med Case Rep. 2023;11:2050313X231220834. doi: 10.1177/2050313X231220834.
14. Walter SR, Popp RA. Factors Associated With Improved A1C Values Among People With Uncontrolled Type 2 Diabetes. Clin Diabetes. 2022 Fall;40(4):458-466. doi: 10.2337/cd21-0120.
15. Owens DR, Bolli GB. Beyond the era of NPH insulin—long-acting insulin analogs: Chemistry, comparative pharmacology, and clinical application. Diabetes Technol Ther. 2008;10(5):333–349. doi: 10.1089/dia.2008.0023.
16. M A, K K. Pharmacoeconomic evaluation of antidiabetic therapy at a tertiary health care institution. AJPCR. 2021; 14(6):115-20. doi:10.22159/ajpcr.2021.v14i6.41653.
17. Mehta R, Goldenberg R, Katselnik D, Kuritzky L. Practical guidance on the initiation, titration, and switching of basal insulins: a narrative review for primary care. Ann Med. 2021 Dec;53(1):998-1009. doi: 10.1080/07853890.2021.
18. Type 2 diabetes in adults: management. London: National Institute for Health and Care Excellence (NICE); 2022 Jun 29. (NICE Guideline, No. 28.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK553486/
19. American Diabetes Association Professional Practice Committee. 9. Pharmacologic approaches to glycemic treatment: Standards of care in diabetes—2024. Diabetes Care. 2024;47(Suppl 1):S158–S178. doi: 10.2337/dc24-er07a.
20. Howard-Thompson A, Khan M, Jones M, George CM. Type 2 diabetes mellitus: Outpatient insulin management. Am Fam Physician. 2018;97(1):29–37. PMID: 29365240.
21. Owens DR. Stepwise intensification of insulin therapy in type 2 diabetes management—exploring the concept of the basal-plus approach in clinical practice. Diabet Med. 2013;30(3):276–288. doi: 10.1111/dme.12019.
22. Anderson S L, Trujillo J M, Anderson J E, Tanenberg R J. Switching basal insulins in type 2 diabetes: practical recommendations for health care providers. Postgraduate Medicine. 2018; 130(2): 229–238. https://doi.org/10.1080/00325481.2018.1419048
23. Chun J, Strong J, Urquhart S. Insulin Initiation and Titration in Patients With Type 2 Diabetes. Diabetes Spectr. 2019 May;32(2):104-111. doi: 10.2337/ds18-0005. PMID: 31168280; PMCID: PMC6528396.
24. Raskin P, Allen E, Hollander P, Lewin A, Gabbay RA, Hu P, et al. Initiating insulin therapy in type 2 diabetes. Diabetes Care. 2005;28(2):260–265. doi: 10.2337/diacare.28.2.260.
25. Home PD, Fritsche A, Schinzel S, Massi-Benedetti M. Meta-analysis of individual patient data to assess the risk of hypoglycaemia in people with type 2 diabetes using NPH insulin or insulin glargine. Diabetes Obes Metab. 2010;12(9):772–779. doi: 10.1111/j.1463-1326.2010.01232.x.
26. Chen HS, Wu TE, Jap TS, Lin SH, Hsiao LC, Lin HD. Improvement of glycaemia control in subjects with type 2 diabetes by self-monitoring of blood glucose: comparison of two management programs adjusting bedtime insulin dosage. Diabetes Obes Metab. 2008 Jan;10(1):34-40. doi: 10.1111/j.1463-1326.2006.00676.x.
27. Yadav NK, Mazumder R, Rani A, Kumar A. Current perspectives on using nanoparticles for diabetes management. Int j app pharm. 2024;6(5):38-45. doi: /10.22159/ijap.2024v16i5.51084.
28. Monami M, Marchionni N, Mannucci E. Long-acting insulin analogues versus NPH human insulin in type 2 diabetes. Diabetes Res Clin Pract. 2008;81(2):184–189. doi: 10.1016/j.diabres.2008.04.007.
29. Ivers NM, Jiang M, Alloo J, Singer A, Ngui D, Casey CG, et al. Diabetes Canada 2018 clinical practice guidelines: Key messages for family physicians caring for patients living with type 2 diabetes. Can Fam Physician. 2019 Jan;65(1):14-24. PMID: 30674509; PMCID: PMC6347316.
30. Rees C. Recommendations for Insulin Dose Calculator Risk Management. J Diabetes Sci Technol. 2014 Jan;8(1):142-149. doi: 10.1177/1932296813511725.
31. Eledrisi M, Suleiman NN, Salameh O, Hamad MK, Rabadi O, Mohamed A, et al. Twice-daily insulin glargine for patients with uncontrolled type 2 diabetes mellitus. J Clin Transl Endocrinol. 2019;15:35–36. doi: 10.1016/j.jcte.2018.12.002.
32. Pearson SM, Trujillo JM. Conversion from insulin glargine U-100 to insulin glargine U-300 or insulin degludec and the impact on dosage requirements. Ther Adv Endocrinol Metab. 2018;9(4):113–121. doi: 10.1177/2042018818760962.
33. Noschese M, Donihi AC, Koerbel G, Karslioglu E, Dinardo M, Curll M, et al. Effect of a diabetes order set on glycaemic management and control in the hospital. Qual Saf Health Care. 2008;17(6):464-8. doi: 10.1136/qshc.2006.021790. PMID: 19064664.
34. American Diabetes Association Professional Practice Committee. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022 Jan 1;45(Suppl 1):S125-S143. doi: 10.2337/dc22-S009.
35. Lechleitner M, Roden M, Haehling E, Mueller M. Insulin glargine in combination with oral antidiabetic drugs as a cost-equivalent alternative to conventional insulin therapy in type 2 diabetes mellitus. Wien Klin Wochenschr. 2005;117(17):593–598. doi: 10.1007/s00508-005-0429-5.
36. Raghavan A, Nanditha A, Satheesh K, Susairaj P, Vinitha R, Nair DR, et al. A prospective, multicentre, randomized, open-label comparison of a long-acting basal insulin analog glargine plus glulisine with premixed insulin in insulin naïve patients with Type 2 diabetes - A study from India. Prim Care Diabetes. 2024 Apr;18(2):210-217. doi: 10.1016/j.pcd.2024.01.006.
37. Bin Rakhis SA Sr, AlDuwayhis NM, Aleid N, AlBarrak AN, Aloraini AA. Glycemic Control for Type 2 Diabetes Mellitus Patients: A Systematic Review. Cureus. 2022 Jun 21;14(6):e26180. doi: 10.7759/cureus.26180.
38. Tian T, Aaron RE, Huang J, Yeung AM, Svensson J, Gentile S, et al. Lipohypertrophy and insulin: An update from the Diabetes Technology Society. J Diabetes Sci Technol. 2023;17(6):1711–1721. doi: 10.1177/19322968231187661.
39. Fiallo-Scharer R, Horner B, McFann K, Walravens P, Chase HP. Mixing rapid-acting insulin analogues with insulin glargine in children with type 1 diabetes mellitus. J Pediatr. 2006 Apr;148(4):481-4. doi: 10.1016/j.jpeds.2005.11.036. PMID: 16647408.
Published
How to Cite
Issue
Section
Copyright (c) 2026 B DHARANI, SUBA.A
This work is licensed under a Creative Commons Attribution 4.0 International License.