Box 1A: 2017 recommendations by the panel for basal insulin dose and titration

	Panel recommendations	Comments
The initial dosea	10 U/day [19, 22, 59] http://guidelines.diabetes.ca/browse/appendices/appendix3 Other considerations:   0.2 U/kg/day [68, 82]   Using FBG as starting point: e.g., if FBG is 16 mmol/L start at 16 U [59]	May need to be lower for some patients—recall that the starting dose should be individualized [14] http://guidelines.diabetes.ca/cdacpg_resources/CPG_Quick_Reference_Guide_WEB.pdf The lower dosages have the advantage of decreasing the risk of a hypoglycemic reaction with the first injection, but make the titration period a bit longer Discuss and negotiate your patient’s expectation
Fasting SMBG target	Target should be 4.0–7.0 mmol/L for most people   Patient/HCP contact recommended at 7.0 mmol/L. HCP may then suggest continuing to 4.0–5.5 mmol/L [19, 20, 59, 80, 83–85]	Individualize target with a step approach (within 3 months) [14] http://guidelines.diabetes.ca/cdacpg_resources/CPG_Quick_Reference_Guide_WEB.pdf Important to educate that diabetes is a progressive disease and this is a moving target [4]
Dose adjustments	Select a simple titration algorithm that matches patient lifestyle [57] The following dose adjustment algorithms have been shown to be safe and effective. Select the one that is easiest for the patient to follow: One easy titration algorithm is 1 unit every dayb [19, 63, 64, 66] Other titration algorithms include: 2 units twice weekly based on lowest fasting SMGB value of the last 3 days [26, 27, 62, 86] Every week, based on lowest fasting SMGB value of the last 3 days [26, 63, 64] Other considerations:   If (nocturnal) hypoglycemia occurs (BG < 4.0 mmol/L) reduce the dose by 2–4 units, or 10% of the basal dose based on clinical judgement [57]   For other considerations, see Table 6	Measure glucose level at least every morning before breakfastc [57] http://guidelines.diabetes.ca/browse/appendices/appendix3 Remind patient to adjust the basal insulin based on morning glucose not bedtime glucosec [57] Assess for possible hypoglycemia (< 4.0 mmol/L) and decrease titration [52] http://guidelines.diabetes.ca/fullguidelines/chapter14 Recognize that patient fear of hypoglycemia is easily elicited (hypoglycemia is a traumatic stress) and that providers underestimate the psychological impact of nonsevere hypoglycemia [51] Mitigating hypoglycemia: Is there an identifiable cause? [52] http://guidelines.diabetes.ca/fullguidelines/chapter14 Teach patients how to prevent, recognize, and treat hypoglycemia [52] http://guidelines.diabetes.ca/fullguidelines/chapter14 Confirm with patient that it is not “pseudo-hypoglycemia”. Explain what pseudo-hypoglycemiad is and ways to mitigate it [54] If no identifiable and preventable cause is identified, reduce the dose Confirm patient is using an accurate glucometer
Optimal/maximum basal insulin dose	Educate the patient of their expected dose [3, 57] In most studies: 40 to 50 units is needed [8, 19, 26, 27, 66] Communicate how long it will take them to reach target (e.g., if the expected dose is 60 units at 1 U/day increase, then it will take on average 6 weeks)	Indication that basal insulin is not enough includes: Up-titrations without a corresponding drop on BG (verify patient adherence and check injection sites). http://www.fit4diabetes.com/canada-english/fit-recommendations/ Patient has surpassed 1 U/kg/day of basal insulin without sufficient FBG control [87] FBG in target, but A1C above target

BG blood glucose, FBG fasting blood glucose, SMBG self-monitored blood glucose

^aFor more information on how to handle any oral agents and other FAQs, see Tables 6 and 7

^bAlgorithm proven safe and effective with insulin glargine 100 units/mL (Lantus^®) and 300 units/mL (Toujeo™)

^cAdjust accordingly if shift worker

^dPseudo-hypoglycemia: an event in which the patient experiences symptoms of hypoglycemia with a BG > 3.9 mmol/L but approaching that level [54]