Self-Titration Protocol for Long-Acting Insulin at Night
Patients can safely self-titrate long-acting insulin at night using an evidence-based algorithm that increases the dose by 2 units every 3 days until reaching target fasting glucose levels without hypoglycemia. 1
Initial Setup and Starting Dose
- For insulin-naïve patients with type 2 diabetes, start with 10 units once daily at bedtime or 0.1-0.2 units/kg body weight 1, 2
- Set a specific fasting plasma glucose (FPG) target, typically 90-150 mg/dL (5.0-8.3 mmol/L) for most adults, which may be adjusted based on individual health status and goals of care 1
- Provide patients with a glucose monitoring device and a simple titration algorithm chart to record morning glucose readings 1
Self-Titration Algorithm
- Instruct patients to check fasting blood glucose daily 1
- Follow an evidence-based titration algorithm: increase dose by 2 units every 3 days if fasting glucose remains above target 1
- As target glucose is approached, make more modest adjustments (1 unit increments) and less frequently 1
- For hypoglycemia (glucose <70 mg/dL or symptomatic): determine cause; if no clear reason, reduce dose by 10-20% 1
Patient Education Components
- Teach proper insulin injection technique and site rotation (abdomen, thigh, upper arm) 2
- Educate on recognition and management of hypoglycemia symptoms 1
- Provide clear written instructions on when to contact healthcare providers (severe hypoglycemia, persistent hyperglycemia despite titration) 3
- Consider technology support such as SMS reminders or digital tracking tools to improve adherence 4
Monitoring and Follow-up
- Weekly phone/virtual check-ins during the initial titration period 1
- More frequent monitoring for elderly patients or those with hypoglycemia unawareness 1
- Schedule follow-up visits at 2-4 weeks after initiation, then every 3 months once stable 1
- Assess adequacy of basal insulin dose and consider clinical signals of overbasalization (basal dose >0.5 units/kg/day, elevated bedtime-morning glucose differential, hypoglycemia) 1
Special Considerations
- For elderly patients: consider higher glucose targets (100-180 mg/dL) and more conservative titration (1 unit increments) 1
- If NPH insulin is being used at bedtime and patient experiences nocturnal hypoglycemia, consider switching to a long-acting analog (glargine or detemir) 1
- For patients with significant postprandial excursions despite optimized basal insulin, consider adding prandial insulin or GLP-1 RA 1
Practical Tips for Success
- Lower FPG targets (70-90 mg/dL) may lead to better overall glycemic control but require more careful monitoring 3
- Patient-directed titration can achieve similar or better outcomes compared to physician-directed titration 5, 3
- Consider using a fixed titration schedule (e.g., dose adjustments on specific days of the week) to improve adherence 6
- Insulin detemir may require twice-daily dosing in some patients to achieve optimal control 7
Common Pitfalls to Avoid
- Therapeutic inertia: failing to adjust insulin doses frequently enough to reach glycemic targets 1
- Overbasalization: using excessive basal insulin (>0.5 units/kg/day) rather than adding mealtime insulin when appropriate 1
- Inadequate monitoring during illness, which may require temporary dose adjustments 1
- Forgetting to reduce basal insulin dose when adding prandial insulin (typically reduce basal by 4 units or 10%) 1