How Much to Increase Insulin at a Time
Increase basal insulin by 2-4 units every 3 days based on fasting glucose levels, or by 10-15% for higher doses, while prandial insulin should be increased by 1-2 units or 10-15% every 3 days based on postprandial readings. 1
Basal Insulin Titration Algorithm
The titration schedule depends on your fasting glucose readings:
- If fasting glucose is 140-179 mg/dL: Increase basal insulin by 2 units every 3 days 1
- If fasting glucose is ≥180 mg/dL: Increase basal insulin by 4 units every 3 days 1
- Target fasting glucose: 80-130 mg/dL 1
For patients already on higher basal insulin doses, an alternative approach is to increase by 10-15% of the current dose once or twice weekly until fasting glucose targets are met 1. This percentage-based approach becomes more practical when doses exceed 20-30 units, as it maintains appropriate proportional increases.
Prandial (Mealtime) Insulin Titration
When adjusting rapid-acting insulin given before meals:
- Increase by 1-2 units every 3 days if postprandial glucose remains elevated 1, 2
- Alternatively, increase by 10-15% every 3 days for higher doses 1, 2
- Base adjustments on 2-hour postprandial glucose readings 1
Critical Threshold: When to Stop Escalating Basal Insulin
Stop increasing basal insulin when the dose exceeds 0.5 units/kg/day and instead add prandial insulin rather than continuing to escalate basal insulin alone. 1 This threshold prevents "overbasalization," a dangerous pattern where excessive basal insulin masks the need for mealtime coverage and increases hypoglycemia risk without improving control 1.
Clinical signs of overbasalization include:
- Basal insulin dose >0.5 units/kg/day 1
- Bedtime-to-morning glucose differential ≥50 mg/dL 1
- Episodes of hypoglycemia 1
- High glucose variability throughout the day 1
Hypoglycemia Response
If hypoglycemia occurs without a clear cause, immediately reduce the insulin dose by 10-20%. 1, 2 Do not wait for the next scheduled adjustment—this requires immediate action to prevent recurrent episodes.
Special Populations Requiring Modified Titration
Hospitalized Patients
For hospitalized patients with severe hyperglycemia, a weight-based approach may be used with increments of 0.1 units/kg daily 3. This user-friendly regimen achieved target fasting glucose in 3.2 days compared to 4.8 days with standard dose-based titration 3.
High-Risk Patients
For elderly patients (>65 years), those with renal failure, or poor oral intake, use lower starting doses (0.1-0.25 units/kg/day) and more conservative titration increments 1, 2. These patients have higher hypoglycemia risk and may require slower dose escalation.
Patients on High-Dose Home Insulin
When admitting hospitalized patients already on ≥0.6 units/kg/day at home, reduce the total daily dose by 20% upon admission to prevent hypoglycemia 1.
Timing of Adjustments
Adjust basal insulin every 3 days after a change is made, even when patients are concurrently receiving short-acting correctional insulin 1. The two components (basal and correctional) can be adjusted independently on their respective schedules because basal insulin addresses fasting and between-meal glucose levels while correctional insulin addresses acute hyperglycemic excursions 1.
For ultra-long-acting basal insulins (such as degludec), some experts recommend waiting at least 1 week before making subsequent dose adjustments to fully assess glucose outcomes 1.
Common Pitfalls to Avoid
- Do not wait longer than 3 days between basal insulin adjustments in stable patients, as this unnecessarily prolongs time to achieve glycemic targets 1
- Do not continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia—this leads to overbasalization with increased hypoglycemia risk 1, 2
- Do not use sliding scale insulin as monotherapy—scheduled basal-bolus regimens are superior 1, 2
- 75% of hospitalized patients who experienced hypoglycemia had no basal insulin dose adjustment before the next administration, demonstrating the danger of both under-adjusting and failing to respond to hypoglycemia 1