INSULIN TITRATION 

 

TAKE HOME MESSAGES

1.  Insulin is only useful if the doses are titrated.

2.  Make adjustments of 10-20% of a dose if glycemic targets are not attained

3.  Unless there are severe abnormalities (BG < 4 or > 15), generally:

        - see if a trend is consistent across 2-3 days before making a change

        - be aware of how adjusting one dose could affect the impact other doses given later in the day

 

Adjusting different types of insulins:

  basal insulin given at bedtime

        - titrate based on fasting BG.  If consistently high, increase dose of bedtime basal insulin by 1-2 units until fasting BG reaches target.

premixed insulin

- if given in morning, titrate based on lunch and supper BG values.  If given at supper, titrate based on bedtime and next morning’s BG.  Remember, with premixed insulin you can NOT affect BG at one time of the day (e.g. lunch) without affecting BG at the other relevant time (e.g. supper)

rapid acting insulin with meals

        - prandial (mealtime) insulin is titrated based on the blood glucose level measured at the following meal or at bedtime in the case of suppertime insulin

 

Example 1:

A 58 yr old male with Type 2 diabetes takes basal insulin 30 units qhs and prandial insulin (e.g. aspart or lispro) 12 units acb, 10 units acl and 14 units acs.  His average daily BG are as follows:

  

Fasting

Before lunch

Before supper

Bedtime

6.5 mmol/L

15.2 mmol/L

12.8 mmol/L

9.2 mmol/L

 

Question:

How would you adjust this patient's insulin regimen?

Answer:

His morning BG are acceptable, but his average lunchtime BG is higher than the target level of 4-7 mmol/L.  Thus, breakfast insulin should be increased by 10-20% from his baseline 12 unit dose.  Even though his supper BG is also high, it would be safest to first see what impact the change in his morning insulin has on his lunch BG (which in turn could affect his supper BG) before making adjustments to his lunch insulin.

 

Ex 2:

A 73 yr old woman with type 2 diabetes takes premixed insulin 30/70, 20 units acb and 10 units acs.  Her average daily BG are as follows:

 

Fasting

Before lunch

Before supper

Bedtime

7.0 mmol/L

12.7 mmol/L

11.9 mmol/L

6.8 mmol/L

 

Question:

How would you adjust this pt's insulin regimen?

 

Answer:

Note that her average lunchtime and suppertime BG values are higher than target.  Thus, the breakfast 30/70 (which will impact the lunchtime and suppertime blood glucose) should be increased by 2-4 units (10-20%).  However, notice that her bedtime BG drops from supper to bedtime using her existing dose of insulin at supper (10 units).  Therefore, when her supper BG improves with the change in the morning dose, you may need to adjust her supper dose to ensure that bedtime or next morning’s BG do not go low.

 

Ex 3:

You are following a 34 yr old woman with type 1 diabetes.  She takes basal insulin (e.g. glargine or detemir) 15 units qhs and rapid-acting insulin 5 units with meals.  Her average daily blood sugars are:

 

Fasting

Before lunch

Before supper

Bedtime

12.2 mmol/L

5.8 mmol/L

6.1 mmol/L

7.6 mmol/L

 

Question:

How would you adjust this pt's insulin regimen?

 

Answer:

Note the high fasting BG.  This may either be due to insufficient doses at bedtime, or possibly due to excess bedtime insulin resulting in the Somogyi phenomenon (rebound hyperglycemia from counter-regulatory overcompensation to nocturnal hypoglycemia).  Thus, this patient should have her BG checked at ~ 3 AM.  If not hypoglycemic at 3 AM, increase bedtime basal insulin 10-20%.  If hypoglycemic at 3 AM, decrease bedtime basal insulin by 10-20%.

 

Housekeeping:

 if patient’s insulin dose is changed, don’t forget to provide written instructions regarding updated insulin regimen to the patient prior to discharge

ensure patient has adequate diabetes f/u (family physician or endocrinologist)

  

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