Starting Insulin in Type 2 Diabetes: A Practical Guide for Nurse Practitioners
Starting insulin in type 2 diabetes can feel intimidating—especially when you’re a new NP looking at an A1C of 12%, 13%, or 14% and wondering: Does this patient need insulin? Can I safely manage this outpatient? And if I start insulin, how much do I actually prescribe?
In this updated episode, I walk through a practical approach to starting basal insulin in adults with type 2 diabetes, based on current ADA and AACE guidance. We’ll cover when to consider insulin, when severe hyperglycemia may need a higher level of care, how to calculate a starting basal insulin dose, how to titrate using fasting blood glucose, and how to support patients as they learn a completely new skill.
We’ll also talk about CGM and glucose monitoring, preventing hypoglycemia, and patient education so patients can safely and realistically manage their diabetes at home.
Want a quick desk reference for this topic? The Starting Insulin in Type 2 Diabetes Cheat Sheet is fully updated to include 2026 guidelines and is included in the Digital NP Binder. For more comprehensive support with managing type 2 diabetes in primary care, including choosing and adjusting medications and insulin therapy, see the Diabetes Management in Primary Care course, updated in 2026.
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What I Covered in This Episode:
When insulin may need to be considered in a patient with type 2 diabetes
How to start basal insulin, including fixed-dose and weight-based approaches
Using fasting blood glucose to guide basal insulin titration
How often insulin doses may need to be adjusted
What to do when a patient develops hypoglycemia
Why insulin initiation often requires close follow-up and patient education
How to use shared decision-making without overwhelming patients with everything at once
Key Takeaways
Basal insulin is usually the simplest place to start when insulin is being initiated in type 2 diabetes.
Starting insulin is only part of the job. Patients also need to know how to use it, how to monitor glucose, and what hypoglycemia looks like.
Fasting glucose helps guide basal insulin titration, but treatment goals should be individualized rather than using the same target for every patient.
Insulin initiation can be overwhelming. Breaking education and treatment changes into manageable steps can make it much easier for patients to follow through.
Close follow-up matters, particularly while the patient is learning insulin administration and the dose is being adjusted.
Shared decision-making is especially important in diabetes care because patients are the ones managing this condition every day.
Resources mentioned in this episode:
If you liked this post, also check out:
Want More Support Managing Type 2 Diabetes?
The Diabetes Management in Primary Care course walks you through how to manage type 2 diabetes in real-world primary care—including choosing medications, adjusting treatment when patients aren’t at goal, initiating and titrating insulin, monitoring treatment, and knowing what to do next.
Original Episode: Starting Insulin in Type 2 Diabetes
In this original episode, I walk through the practical side of starting basal insulin with a patient for the first time—from calculating a starting dose and using fasting blood sugars to guide titration to monitoring for hypoglycemia and providing close follow-up.
A big focus of this episode is also how to make insulin initiation manageable for patients: breaking down a lot of new information into smaller steps, adjusting the plan to the patient's health literacy and comfort level, and using shared decision-making rather than trying to accomplish everything in one visit.
2026 note: This episode was recorded in 2020, and the type 2 diabetes treatment algorithm discussed at the beginning is outdated. In particular, don't use this episode to guide which medications should be used before insulin or when insulin should be initiated. For current recommendations on when to consider insulin and how it fits into type 2 diabetes treatment, start with the updated episode above.
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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confident, capable, and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff, you're in
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the right place.
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Make sure you subscribe and leave a review so you won't miss an episode.
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Plus, you'll find links to all the episodes with extra goodies over at realworldnp.com
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slash podcast.
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Well, hey there, it's Liz Rohr from Real World NP and you're watching NP Practice
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weekly videos to help save you time, frustration, and help you learn faster so you can take
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the best care of your patients.
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So today I'm talking about a super highly requested topic, which is insulin initiation
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in type 2 diabetes.
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And I have a couple of notes before I jump in.
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So number one, I have a cheat sheet down below this video.
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I would love to be able to share my screen and make a beautiful presentation like
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I usually do, but quarantine life is a little different right now and limited time
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to make these with my daughter at home.
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The second note is that the lab interpretation crash course for new nurse practitioners
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opens this Friday, which I'm so excited.
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I would love to have you if you're struggling with labs, you're a new grad in primary
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care or an experienced grad and you still don't like labs.
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It's CBCs, CMPs, TSH, lipids, and all the main endocrine labs that I see in
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primary care as well as your analysis.
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And then my third note is that Kim Ellis, I want to give a shout out to her, is
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practitioner on YouTube as well and makes YouTube videos specifically about
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diabetes management.
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So definitely go check out her stuff if you haven't already and you have more
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diabetes related questions and then definitely let me know if you have other
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questions and things you want me to talk about when it comes to diabetes.
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So jumping right in though, number one, who needs insulin in diabetes and
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type 2 diabetes?
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So kind of three main scenarios.
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One is that somebody comes in with severe hyperglycemia that is symptomatic.
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So they have things like weight loss, ketonuria, malaise, things like that.
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And their A1C is greater than 9% or their blood sugars are greater than 300 or
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so persistently.
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And a quick note is that I have a video, a case study about hyperglycemia
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where I talk a little bit more about the symptoms of hyperglycemia and
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differentiating between type 1 and type 2.
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So I'll link down below this video to that if you want to check that
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out if you haven't seen that one already.
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Another scenario is that somebody has a persistent severe hyperglycemia,
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meaning their blood sugars on average are typically greater than 300 and
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their A1C is greater than 9%.
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And they may or may not have symptoms.
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They may not have the weight loss or ketonuria and they might feel fine.
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Those patients you can consider insulin therapy for them as well.
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And then the other situation is if they are in either of those
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categories and you're not quite sure if they have type 1 or type 2
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diabetes, those patients should be on insulin as well.
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And again, I talk about that a little bit more in that video.
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So I should back up and say that all of this is based on the AACE
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guidelines and I don't have rights to share their stuff.
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And so on my presentation itself, I am not able to reproduce it.
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So without permission, so I have it linked down below this video.
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I definitely encourage you to review that PowerPoint presentation that they
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have on their website and print out the slides that I'm going to be
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referencing to keep it at your desk to kind of make things a little bit
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easier. And I keep looking down because I have my notes and I want to
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make sure I don't forget anything.
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So kind of just to back up a little bit when it comes to the AACE
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guidelines, typically going from initial management all the way up to
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somebody is diagnosed with diabetes when their A1C is 6.5 and above.
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And so from there, patients are typically started first line on
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metformin if they don't have contraindications.
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And I'm not really going to get into all the nitty gritty here.
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I'm doing really high level overview because I could talk for hours
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and this is really just to kind of like the quick and dirty of it.
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So making sure that they don't have contraindications to metformin.
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And then the next steps from there, depending on their A1C level is
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if they want to do oral agents versus insulin.
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So do they do a second agent, a third agent.
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And once they get to three, then they have to progress to insulin if
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their A1C is still uncontrolled.
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However, you can always jump over that oral medication, the dual and
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triple therapy to go right to insulin if the patient prefers.
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So before I go any further into the nitty gritty of it all, I want to
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make a really important point here is that the most important thing is
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that you understand this well enough to explain it plainly to your
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patients, because it might feel as a brand new grad, I remember
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feeling totally like stressed out that someone's A1C was 13% and I needed
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to do all of the things for them right now.
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They didn't have their monofilament checked.
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They didn't have their microalbumin checked.
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They didn't have any education about the risks and benefits and
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side effects and all that stuff.
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And, and they needed all these medications.
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We had to get it down.
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They had to check their blood sugars.
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Like it was a lot of information.
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And can you imagine how overwhelming that is for a patient?
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Maybe it doesn't mean that much to you as somebody in healthcare,
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but the, my main takeaway, if you can, from this video is to
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include your patients and it's okay to break it into smaller chunks
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because this is, this is, you don't have to fix them right now.
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This is a lifelong diagnosis and a lifelong challenge that they
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need to manage themselves.
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And the more you can explain and get buy-in from patients to
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manage their own care, the more successful they're going to be.
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And then you are going to be in helping them to achieve
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the goals that they want.
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So when I, another thing to say about the management of, of type
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two diabetes, according to the ACE guidelines, is that a diet
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and my lifestyle always come first, which you know, but I
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have to say that each of the medications only lower A1C by
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about 1.5% maximum.
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So if you have one medication that lowers the A1C by 1.5%
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and their A1C is nine, it's not going to meet goal.
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And so knowing that, and some of the medications are only
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0.5%, right?
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So knowing that even if you max out a triple oral therapy, you
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may need to add insulin and dietary modification alone can
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drop somebody's A1C from 13 to six, like that.
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Like it's, it's not a hundred percent of the time.
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It's not a magic fix, but patients who are really
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motivated and able to consistently maintain those
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modifications, that is way more impactful than any
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medication you can give somebody.
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So really, again, having those conversations and
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explaining that to patients of like, listen, you have control
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over this, you can, you can do this and I can help you.
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And here are the ways that we can help you is very
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impactful versus, Hey, your A1C is 13%.
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Here's my checklist of all the things I need to do for
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you.
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And here's this medication and we need to tight
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treat it this way.
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So with that all said, I just want to jump into the
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actual nuts and bolts of probably why you're watching
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today.
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So when it comes to initiating insulin, you need to
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make that decision, share decision making with your
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patient.
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It's a pretty simple algorithm.
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So what you start with is basal insulin, meaning it's
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just that the longer acting insulin once or twice per
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day, depending on the, on the specific type that
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you're choosing.
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And then it's a weight based dosing on average.
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It depends on the resource that you're looking at,
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but to keep it really simple, it's typically
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0.1 to 0.2 units per kilogram per day is the
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total amount of their daily basal insulin.
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So those are things like insulin, Glargine, or
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there's a couple of other ones.
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And really the choice there depends on the
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insurance in my experience.
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The efficacies, I don't see a lot of differences
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between them.
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The most important thing is that they actually take
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them.
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So some of them are 12 hours and some of them
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are cue 20, every 24 hour dosing.
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And so you just have to look at the
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particular medication that is covered for your
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patient and what they're willing to do.
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So that's the total amount.
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The next step is that the patient needs to check
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their fasting blood sugar in the morning, every
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single morning, write them down.
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And then you titrate that dose of the total
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basal daily insulin dose based on that.
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And so if their blood sugar is greater than
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180, it depends.
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So the goal, it depends on the age of the
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patient, what their goal is.
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But typically I tend to go on the higher
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side for my older patients.
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So greater than 180 ish.
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But the true like normal fasting is like
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less than 130 or less than 110, depending
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on how strict you're being.
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I typically go to 130 just because I tend to
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be a little bit cautious, but that's your
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goal of your fasting blood sugars in the
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morning.
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And so every, every three days, the
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recommendations are to titrate up on the
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basal insulin.
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And so, for example, if somebody's basal
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insulin comes out to be 10 units, you can
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either do weight-based dosing or you can
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start with just 10 units.
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So starting with 10 units, you can do
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checking their fasting sugar.
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It's still not at goal.
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You increase it by two to four units,
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depending on how much higher it is.
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So if you're feeling a little overwhelmed,
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can you imagine how your patients feel?
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So the, the way, again, print out the
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cheat sheet down below this video if you
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haven't already.
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But the main thing here is that it is
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complicated and depending on the patient's
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health literacy, they might need a little
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bit more hand-holding.
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If someone has super high health
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literacy, they're very savvy with
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health-related things, they can do that.
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They can follow the directions, write
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it all down, go up and up and up
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and all that stuff.
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Then that's perfect.
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And once they get to the goal fasting
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blood sugar of less than 130 and they
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don't have hypoglycemia, they can
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chill at that dose.
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However, what typically happens is that
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this is confusing for nurse practitioners
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and people who are not nurse practitioners.
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So what I do for patients is I talk
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about, talk about it with them, right?
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It would be great to get it down
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immediately, but again, this is the
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rest of their life.
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So they need to make that decision.
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And so there's a couple of options.
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So I can either, as long as they feel
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comfortable checking their blood
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sugars and they have that skill down,
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they can go home and they can check
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it. They can come back in a week
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with me, two weeks, a month.
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They can come back with the nurse in
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a week or two weeks or a month.
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They can come in with the diabetes
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educator if you have that luxury.
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And then you can kind of just take
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it slow and go from there.
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I mean, most of the time when I'm
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titrating up on insulin for
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patients in this manner, they need
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some hand holding.
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So it's usually done in person
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and typically not even over the
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phone because it's just such a
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new skill. It's so overwhelming.
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Like there's, there's a lot to
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think about.
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So a note about hypoglycemia.
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If patients have any hypoglycemic
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episodes, less than 70 is typically
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the cutoff for the, for the blood
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sugar level.
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You can either decrease the daily
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basal dose by 10% or four units,
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whichever is greater, I believe.
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And it's again, in those ACE
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guidelines.
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But typically I'm, I'm scaling
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back by about four units at a
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time when patients are having
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those hypoglycemic episodes.
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And even if their fasting
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levels are high, I'd rather
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them not have hypoglycemia.
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There are further steps to
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take. You can add prandial
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insulin, meaning meal time
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shorter acting insulin.
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You can add on more oral agents.
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It's getting a little bit
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outside of the scope of this
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video for today, but I'm
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happy to talk about that more.
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If that's something that you're
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interested in.
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But yeah, the moral of the story
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is print out the cheat sheet,
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walk your patients through it
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really slowly and easily for
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them very clearly and definitely
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getting their buy-in, watching
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out for hypoglycemia, making
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sure that they understand what
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signs of hypoglycemia are,
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checking their blood sugars,
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how to use it, and just like
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giving them as much support as
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you can, because especially if
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this is a brand new diagnosis,
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that is incredibly overwhelming
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to them.
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So I hope you like this video.
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Definitely let me know if you
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have any questions or further
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topic requests when it comes to
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diabetes or otherwise.
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And definitely join us for the
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00:11:27.950 --> 00:11:29.030
Lab Interpretation Crash Course
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for new nurse practitioners on
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Friday.
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If you feel so called, I'm super
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00:11:32.730 --> 00:11:33.110
excited.
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It's at realworldnp.com slash
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00:11:34.770 --> 00:11:35.230
labs.
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Thank you so much for watching.
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Hang in there and I'll see you
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soon.
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That's our episode for today.
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Thank you so much for
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00:11:45.660 --> 00:11:46.100
listening.
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00:11:46.340 --> 00:11:48.340
Make sure you subscribe, leave
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00:11:48.340 --> 00:11:49.940
a review, and tell all your
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00:11:49.940 --> 00:11:51.940
NP friends so together we can
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help as many nurse practitioners
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as possible give the best care
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to their patients.
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If you haven't gotten your
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00:11:58.000 --> 00:11:59.520
copy of the Ultimate Resource
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00:11:59.520 --> 00:12:01.740
Guide for the new NP, head over
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00:12:01.740 --> 00:12:04.440
to realworldnp.com slash guide.
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00:12:04.860 --> 00:12:06.440
You'll get these episodes sent
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straight to your inbox every
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00:12:07.760 --> 00:12:09.460
week with notes from me,
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00:12:09.860 --> 00:12:11.100
patient stories, and extra
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bonuses I really just don't
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share anywhere else.
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Thank you so much again for
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00:12:15.320 --> 00:12:15.640
listening.
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Take care and talk soon.
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