Table 6.

Intensification of premix/insulin co-formulation

Modified from [17]

	Therapeutic option	Total daily dose
Step I: add prandial insulin	When glycemic targets are unmet	TDD 0.3–0.5 units/kg (40–50% basal: 50–60% prandial)a
Step II: titrationb (every 2–3 days to reach glycemic goals)	Fixed regimen (prandial insulin)	Increase TDD by 2 units/day
	Adjustable regimen (prandial insulin)
	FPG > 9.99 mmol/L	Increase TDD by 4 units
	FPG 7.77–9.99 mmol/L	Increase TDD by 2 units
	FPG 6.10–7.71 mmol/L	Increase TDD by 1 unit
	2-h PPG or next premeal glucose > 9.99 mmol/L	Increase prandial dose for the next meal by 10%
	When glycemic targets are unmet	TDD 0.3–0.5 units/kg (40–50% basal: 50–60% prandial)*
	FPG/premeal BG > 9.99 mmol/L	Increase TDD by 10%
Step III: monitor for hypoglycemia	Fasting hypoglycemia	Reduce basal insulin dose
	Nighttime hypoglycemia	Reduce basal insulin or reduce short/rapid-acting insulin taken before supper or evening snack
	Between-meal hypoglycemia	Reduce previous premeal short/rapid-acting insulin

BG blood glucose, DPP-4 dipeptidyl peptidase-4 inhibitors, FPG fasting plasma glucose, GLP-1 glucagon-like peptide 1 receptor agonists, NPH neutral protamine Hagedorn, PPG postprandial glucose, SGLT2 sodium glucose cotransporter 2, TDD total daily dose

^aBasal + prandial insulin analogues preferred over NPH + Regular insulin or premixed insulin

^bFor most patients with T2DM taking insulin, glucose goals are HbA1c < 7% (< 53 mmol/mol) and fasting and premeal blood glucose < 6.10 mmol/L in the absence of hypoglycemia. HbA1c and FPG targets may be adjusted on the basis of patient’s age, duration of diabetes, presence of comorbidities, diabetic complications, and hypoglycemia risk