How do I safely increase a patient's insulin dose?

Safe Insulin Dose Adjustment Protocol

When increasing a patient's insulin dose, follow a structured titration approach based on blood glucose monitoring, with adjustments of 2 units at a time for basal insulin when fasting glucose values remain above target range. 1

Basal Insulin Titration

• Starting point: Begin with basal insulin at 0.1-0.2 units/kg/day or 10 units once daily for insulin-naive patients with type 2 diabetes 2
• Monitoring frequency: Check fasting blood glucose daily for one week
• Target range: 90-150 mg/dL (5.0-8.3 mmol/L) 1
• Adjustment protocol:
  • If 50% of fasting glucose values over one week are above target: Increase dose by 2 units
  • If >2 fasting glucose readings per week are <80 mg/dL: Decrease dose by 2 units
  • Make adjustments every 3-4 days until target range is achieved 1

Prandial (Mealtime) Insulin Titration

• For patients on prandial insulin >10 units/dose:
  • Consider decreasing dose by 50% and adding a non-insulin agent 1
  • Titrate prandial doses down as non-insulin agents are increased 1
• Simplified correction scale:
  • For premeal glucose >250 mg/dL: Add 2 units of rapid/short-acting insulin
  • For premeal glucose >350 mg/dL: Add 4 units of rapid/short-acting insulin 1
• Important safety note: Do not use rapid or short-acting insulin at bedtime due to hypoglycemia risk 1

Special Considerations

• Timing: When using basal insulin, consider changing from bedtime to morning administration for better monitoring of hypoglycemia risk 1
• Premixed insulin conversion: If patient is on premixed insulin, use 70% of total dose as basal only in the morning 1
• Medication errors: Always check insulin labels before administration to avoid mix-ups between different insulin products 2
• Injection technique:
  • Rotate injection sites within the same region (abdomen, thigh, or deltoid)
  • Avoid areas of lipodystrophy 2

Hypoglycemia Prevention and Management

• High-risk periods: Increase monitoring frequency during:
  • Initial weeks after changing insulin regimen
  • Changes in physical activity
  • Changes in meal patterns
  • Acute illness
  • Changes in renal or hepatic function 2
• Hypoglycemia management: If blood glucose <70 mg/dL:
  • Treat with 15g fast-acting carbohydrate
  • Recheck in 15 minutes
  • If persistent, consider reducing insulin dose by 10-20% 3

Common Pitfalls to Avoid

• Overly aggressive titration: Can lead to severe hypoglycemia, which poses greater immediate risk than moderate hyperglycemia
• Insufficient monitoring: Always increase blood glucose monitoring frequency when adjusting insulin doses
• Ignoring pattern recognition: Look at patterns over several days rather than reacting to single readings
• Failure to adjust for lifestyle factors: Consider exercise, meal timing, and carbohydrate content when adjusting insulin doses
• Medication interactions: Be aware that antiadrenergic drugs (beta-blockers, clonidine) may mask hypoglycemia symptoms 2

By following this systematic approach to insulin dose adjustment, you can safely optimize glycemic control while minimizing the risk of hypoglycemia, which is crucial for reducing morbidity and mortality in patients requiring insulin therapy.