Insulin Titration: Evidence-Based Approach
Start basal insulin at 10 units per day (or 0.1-0.2 units/kg/day), then increase by 2 units every 3 days until fasting plasma glucose reaches target without hypoglycemia. 1
Basal Insulin Initiation
Starting dose:
- 10 units per day OR 0.1-0.2 units/kg per day for basal insulin (NPH or long-acting analog) 1
- Administer at the same time daily, with timing based on patient schedule 2
- Continue metformin and consider one additional non-insulin agent 1
Target setting:
- Establish individualized fasting plasma glucose (FPG) goal before titration begins 1
- Typical target: 80-130 mg/dL (4.4-7.2 mmol/L) 3
Basal Insulin Titration Algorithm
Standard titration approach:
- Increase dose by 2 units every 3 days to reach FPG target without hypoglycemia 1
- Alternative: increase by 10-15% or 2-4 units once or twice weekly 1
- For NPH, detemir, and glargine 100 U/mL: can increase by 1 unit daily 3
- For glargine 300 U/mL and degludec: increase by 2-4 units once or twice weekly 3
Hypoglycemia management:
- If hypoglycemia occurs without clear cause, reduce dose by 10-20% 1
- Identify and address reversible causes before dose reduction 1
Recognizing Overbasalization
Stop escalating basal insulin when:
- Dose exceeds approximately 0.5 units/kg/day 1, 4
- Large bedtime-to-morning glucose differential develops 1, 4
- Elevated postprandial-to-preprandial glucose differential appears 1, 4
- Hypoglycemia (aware or unaware) occurs 1, 4
- High glucose variability emerges 1, 4
At this point, do NOT continue increasing basal insulin. Instead, add adjunctive therapy. 4
Adding Prandial Insulin
When to add:
- A1C remains above goal despite optimized basal insulin 1
- Significant postprandial glucose excursions (>180 mg/dL or >10.0 mmol/L) persist 1
- FPG at target but A1C elevated after 3-6 months of basal titration 1
Initiation approach:
- Start with one dose at the largest meal or meal with greatest postprandial excursion 1
- Starting dose: 4 units per meal OR 0.1 units/kg per meal OR 10% of basal dose 1
- If A1C <8%, reduce basal insulin by 4 units or 10% when adding prandial insulin 1
Prandial insulin titration:
- Increase by 1-2 units or 10-15% twice weekly based on postprandial glucose 1
- For hypoglycemia, reduce corresponding dose by 10-20% 1
- Add second and third prandial doses stepwise if A1C remains above target 1
Alternative: GLP-1 Receptor Agonist
Before adding prandial insulin, consider:
- If not already on GLP-1 RA or dual GIP/GLP-1 RA, add these agents in combination with basal insulin 1
- Fixed-ratio combination products (IDegLira or iGlarLixi) are available options 1
- This approach may provide better weight outcomes and lower hypoglycemia risk than prandial insulin 1
NPH-Specific Considerations
Converting from bedtime NPH to twice-daily:
- Total dose = 80% of current bedtime NPH dose 1
- Give 2/3 before breakfast, 1/3 before dinner 1
- Consider switching to basal analog if hypoglycemia develops or adherence issues arise 1
Critical Safety Points
Monitoring requirements:
- Assess insulin adequacy at every visit 1
- Increase blood glucose monitoring frequency during any regimen changes 2
- Daily self-monitoring essential during titration phase 1
Common pitfalls to avoid:
- Never continue escalating basal insulin beyond 0.5-1.0 units/kg/day without reassessing strategy 3
- Avoid months of uncontrolled hyperglycemia while attempting triple oral therapy 1
- Do not delay insulin intensification when basal insulin alone is insufficient 1
- Rotate injection sites to prevent lipodystrophy and localized cutaneous amyloidosis 2
Dose adjustment triggers:
- Changes in physical activity, meal patterns, or acute illness require dose modification 2
- Renal or hepatic impairment necessitates closer monitoring and potential dose reduction 2
Full Basal-Bolus Regimen
When A1C remains above target on basal plus single prandial dose: