A 45-year-old man with type 1 diabetes has recurrent hypoglycemia unawareness despite optimized insulin therapy. Continuous glucose monitoring (CGM) confirms nocturnal hypoglycemia. Which insulin formulation offers the most physiologic basal coverage with least nocturnal hypoglycemia risk?
- A NPH insulin (isophane) given at bedtime
- B Premixed insulin 70/30 given twice daily
- C Insulin glargine U-300 or insulin degludec ✓
- D Insulin detemir given once daily at breakfast
Correct answer: C. Insulin glargine U-300 or insulin degludec
Explanation
Ultra-long-acting basal insulins — degludec (t½ ~25 hours) and glargine U-300 — provide near-peakless, stable basal coverage over 24+ hours, significantly reducing nocturnal hypoglycemia compared to NPH or glargine U-100 (SWITCH trial, BEGIN trials). NPH has a peak action making nocturnal hypoglycemia more likely. Premixed insulins have fixed ratios unsuitable for type 1 and cause hypoglycemia. Detemir given once daily does not provide full 24-hour coverage in all patients.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.