Appendix 2

Appendix 2. Guide to insulin initiation and titration

For fasting and preprandial blood glucose targets, please refer to the section ‘Glucose monitoring’. Note that the 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. 

The American Diabetes Association recommends:² 

• In adults with type 2 diabetes, initially initiating a glucagon-like peptide-1 receptor agonist (GLP-1RA), including a dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1RA, is preferred before considering insulin. Grade: A 

• In adults with type 2 diabetes, glucose-lowering agents may be continued upon initiation of insulin therapy (unless contraindicated or not tolerated) for ongoing glycaemic and metabolic benefits (ie weight, cardiometabolic or kidney benefits). Grade: A 

• To minimise the risk of hypoglycaemia and treatment burden when starting insulin therapy in adults with type 2 diabetes, reassess the need for and/or dose of glucose-lowering agents with higher hypoglycaemia risk (ie sulfonylureas). Grade: A 

Starting and adjusting basal insulin^1,3,4 

Figure 1. Starting and adjusting basal insulin 

Starting and adjusting pre-mixed (biphasic) and co-formulated insulin^1,3

Figure 2. Starting and adjusting pre-mixed biphasic 

Guide to basal plus insulin intensification schedules 

Figure 3. Guide to basal plus insulin intensification schedules