Insulin Dose Adjustment for Elevated Bedtime Glucose
Increase your evening long-acting insulin dose by 2-4 units every 3 days until bedtime glucose reaches 80-130 mg/dL, while continuing pioglitazone and metformin (if on it). 1
Understanding Your Current Situation
Your fasting blood sugar (100-120 mg/dL) is well-controlled, indicating your morning insulin dose is appropriate. However, bedtime glucose in the 160s mg/dL suggests your evening basal insulin dose needs titration upward. 1
Specific Titration Protocol
Adjust your evening insulin dose as follows:
- Since bedtime glucose is 140-179 mg/dL, increase the evening dose by 2 units every 3 days 1
- If bedtime glucose were ≥180 mg/dL, you would increase by 4 units every 3 days 1
- Continue adjustments until bedtime glucose consistently reaches 80-130 mg/dL 1
Monitor for hypoglycemia: If you experience low blood sugar, reduce the dose by 10-20% immediately 1
Foundation Therapy Considerations
Ensure you are on metformin (unless contraindicated), as it should be continued when using insulin therapy for ongoing glycemic and metabolic benefits. 2 Metformin remains the foundation of type 2 diabetes therapy even when intensifying insulin. 1
Continue pioglitazone 15mg as currently prescribed. Pioglitazone can be helpful when used adjunctively with insulin, potentially reducing the total insulin dose needed while improving glycemic control. 2
Critical Threshold to Watch
Be vigilant for "overbasalization" if your total daily insulin dose approaches 0.5 units/kg/day (approximately 60 units daily for a typical adult). 2 Clinical warning signs include:
- Basal insulin dose >0.5 units/kg/day 1
- Large bedtime-to-morning glucose differential (≥50 mg/dL) 1
- Episodes of hypoglycemia 1
- High glucose variability 2
If these signs appear, adding prandial (mealtime) insulin becomes more appropriate than continuing to escalate basal insulin alone. 2, 1
When to Advance Beyond Basal Insulin
If after 3-6 months of optimizing your basal insulin doses (achieving fasting and bedtime targets), your HbA1c remains above goal, you will need to add either:
- Prandial insulin (4 units before the largest meal, or 10% of your total basal dose) 1
- GLP-1 receptor agonist (preferred option to minimize weight gain and hypoglycemia risk) 2