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