Diabetes Treatment Steps

Diabetes treatment

• The steps below outline my approach to treating type 2 diabetes. Detailed information on obtaining medications at reduced or no cost is provided, along with resources that provide specific recommendations on insulin dosing.
• Pricing for diabetes-related labs like a hemoglobin A1C, CMP, cholesterol, and urine protein are available here - lab pricing
• If you have any questions about your diabetes treatment, please feel free to email me

• Initial therapy choice (insulin vs stepped approach)
• Stepped approach (starting with noninsulin therapy)
• Insulin therapy
• Insulin cost (details on insulin costs and savings opportunities)
• Insulin dosing
• SGLT2 inhibitor patient assistance program information
• GLP-1 analog patient assistance program information
• DPP-4 inhibitor patient assistance program information

Initial therapy choice (insulin vs stepped approach)

• Treatment-naïve diabetics
• A1C > 10%
• Insulin should be considered as an initial therapy in new diabetics with an A1C > 10% and in those who are experiencing significant symptoms (e.g. weight loss and dehydration). Insulin should only be considered in patients who can administer it properly and are willing to perform frequent blood sugar monitoring. Some patients are apprehensive about injecting themselves with insulin and prefer to start with other therapies. Starting with other therapies is fine, but the patient should be aware that it will take longer to get their blood sugars under control.
• See insulin therapy and stepped approach (starting with non-insulin therapies) below
• A1C < 10%
• Most new diabetics with an A1C < 10% will be able to get their blood sugars under control with a stepped approach (starting with non-insulin therapies)
• See stepped approach below


• Diabetics currently receiving therapy
• For diabetics who are already being treated, the approach to therapy will depend on their current medications, current control, and satisfaction with current therapy. Noninsulin therapies may be appropriate in some patients while insulin can be added to any treatment regimen and is the only therapy that does not have a maximal effect.
• See insulin therapy and stepped approach below

Stepped approach

• The table below lists the medications available to treat type 2 diabetes along with factors to consider when choosing therapy. The ADA recommends metformin as first-line therapy in all diabetics who do not have a contraindication. After metformin, any other medication is considered suitable, although SGLT2 inhibitors are now preferred in patients with heart failure or kidney disease, and SGLT2 inhibitors and GLP-1 analogs are preferred in patients with CVD (or high risk for CVD). See ADA type 2 diabetes treatment recommendations for a complete review.
• SGLT2 inhibitors and GLP-1 analogs do not have generics, and they are expensive. Other classes of diabetes drugs have been around for much longer and are generally very affordable. Some patients may qualify to get SGLT2 inhibitors and GLP-1 analogs for free (see SGLT2 inhibitor PAP and GLP-1 analog PAP below).

Insulin therapy

• It goes without saying that insulin is an important part of treating diabetes. Unlike other treatments that have a maximal effect, insulin can be increased until blood sugars are controlled. Most insulins are expensive, but there are some cheaper options available now, and patients without insurance who meet certain criteria can get certain insulins for free.
• NPH or a long-acting insulin (see insulin chart) should be the initial insulin used in most patients with type 2 diabetes. Lantus, Semglee, Basaglar, and Tresiba are preferred. Toujeo is not as potent as these 3 and typically requires doses that are 27% higher to achieve the same effect. Levemir has a shorter duration of action (< 20 hours) at lower doses (< 0.4 units/kg) and may require twice daily dosing. NPH has to be dosed twice daily in most cases, and unlike the long-acting insulins, it has a peak effect which can increase the risk of hypoglycemia. Despite this, NPH is still one of the cheapest insulins available ($25/vial at Walmart) so it may be preferred in some patients.
• Options for obtaining insulin at reduced or no cost are outlined in the table below. The free insulin programs from Lilly, Sanofi, and Novo Nordisk use 400% of the federal poverty level as a financial cutoff for eligibility (see federal poverty levels).
• Dosing recommendations for insulin are detailed here - insulin dosing

Insulin dosing

• When initiating and titrating insulin, the greatest concern in most patients is the occurrence of hypoglycemia. Any patient on insulin therapy should be counseled on the symptoms and treatment of hypoglycemia (see hypoglycemia information for more)
• Approaches to insulin therapy in different patient types are given below

• New diabetic (see therapy approach)
• Long-acting insulins
• Starting dose: 10 units/day or 0.1 - 0.2 units/kg/day
• Dose titration: see three-day method for adjusting basal insulin
• NPH
• See twice-daily NPH dosing


• Treated diabetic (adding insulin)
• Long-acting insulins
  • Starting dose: 10 units/day or 0.1 - 0.2 units/kg/day
  • Dose titration: see three-day method for adjusting basal insulin
• NPH
• A1C > 9%: see twice-daily NPH dosing
• A1C < 9%: Patients with A1C < 9% may respond to once-daily NPH. I start with 6 - 10 units. If the patient has normal fasting AM blood sugars, the NPH should be given in the morning, otherwise, it can be given at bedtime. Titration can then follow the three-day method.


• Diabetics who would like to change their insulin
• See recommendations for converting between insulin brands and types