Management of type 2 diabetes: A handbook for general practice

Appendices

Appendix 2. Guide to insulin initiation and titration

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Last revised: 17 Sep 2020

For fasting and preprandial blood glucose targets, please refer to the section ‘Glucose monitoring’. Note that adjustments given below are based on average blood glucose levels over at least 2–3 days.

Principles of insulin titration by regimen1

Basal (intermediate- or long-acting insulin):

  • Adjust the dose based on previous average fasting glucose levels

Premixed insulin at breakfast and dinner:

  • Adjust the breakfast dose based on average previous dinner readings (as long as a dose increase does not cause hypoglycaemia at lunchtime)
  • Adjust the dinner dose based on previous average fasting glucose levels (as long as a dose increase does not cause hypoglycaemia at bedtime)

Basal–bolus:*

  • Adjust the dose at mealtime based on the previous day’s glucose level measured either two hours after the corresponding mealtime or before the next mealtime (eg adjust the breakfast dose based on the previous 2–3 days’ average two-hour post-breakfast value or the pre-lunch value)

*Rapid- or short-acting insulin is used for bolus dose.

Starting and adjusting basal insulin1–3

Figure 1.

Figure 1.

Starting and adjusting basal insulin

Starting and adjusting pre-mixed (biphasic) and co-formulated insulin

Starting and adjusting pre-mixed biphasic

Figure 2.

Starting and adjusting pre-mixed biphasic

Guide to basal plus insulin intensification schedules

Figure 3.

Figure 3.

Guide to basal plus insulin intensification schedules


 
  1. Lau ANC, Tang T, Halapy H, Thorpe K, Yu CHY. Initiating insulin in patients with type 2 diabetes. CMAJ 2012;184(7):767–76.
  2. Wong J, Tabet E. The introduction of insulin in type 2 diabetes mellitus. Aust Fam Physician 2015;44(5):278–83.
  3. Howard-Thompson A, Khan M, Jones M, George CM. Type 2 diabetes mellitus: Outpatient insulin management. Am Fam Physician 2018;97(1):29–37.