Table 18.
Recommended Steps for the Intensification of Insulin Therapy When Prandial Control Is Needed
| Therapeutic option | Insulin dose | Notes/caveats |
|---|---|---|
| Step 1. Add prandial therapy: Begin with Step 1A for T2D and Step 1B for T1D | ||
| Step 1A: GLP-1 RA, SGLT2 inhibitor, or DPP-4 inhibitor | If glucose goals remain unmet, add prandial insulin | |
| Step 1B: Prandial insulin | TDD 0.3 to 0.5 units/kg (50% basal; 50% prandial) | Basal + prandial insulin analogs preferred over (NPH + regular insulin) or premixed insulin |
| Step 2. Monitor for hyperglycemia; Titrate insulin every 2–3 days to reach glycemic goalsa | ||
| Fixed regimen | Increase TDD by 2 units/d | |
| Adjustable regimen | ||
| Elevated fasting BG | Increase HS basal doses | Increase dose by 10% to 20% depending on severity of BG elevation |
| Elevated premidday meal BG | Increase breakfast prandial insulin doses | |
| Elevated pre-evening meal BG | Increase midday prandial insulin dose | |
| Elevated bedtime BG | Increase dinner prandial insulin dose | |
| Premixed insulin | ||
| FBG/premeal BG >180 mg/dL | Increase AM or PM dose depending on times of BG elevation | Increase dose by 10% to 20% depending on severity of BG elevation |
| Step 3. Monitor for hypoglycemia | ||
| Adjustable regimen | ||
| Low fasting BG | Reduce HS basal dose | Decrease dose by 10% to 20% depending on severity of hypoglycemia |
| Low premidday meal BG | Reduce breakfast prandial dose | |
| Low pre-evening meal BG | Reduce midday prandial dose | |
| Low bedtime BG | Reduce evening prandial dose | |
| Premixed insulin | ||
| Low BGs in AM or PM | Reduce AM or PM dose depending on times of BG elevation | Reduce dose by 10% to 20% depending on severity of BG elevation |
Abbreviations: A1C = hemoglobin A1c; AM = morning; BG = blood glucose; DPP-4 = dipeptidyl peptidase 4; FBG = fasting blood glucose; GLP-1 RA = glucagon-like peptide 1 receptor agonist; HS = at bedtime; NPH = Neutral Protamine Hagedorn; PM = evening; PPG = postprandial glucose; SGLT2 = sodium glucose cotransporter 2; T1D = type 1 diabetes; T2D = type 2 diabetes; TDD = total daily dose
For most persons with T2D taking insulin, glucose goals are A1C <7% and fasting and premeal blood glucose <110 mg/dL in the absence of hypoglycemia. A1C and FBG targets may be adjusted based on a person’s age, duration of diabetes, presence of comorbidities, diabetic complications, and hypoglycemia risk.