Insulin Adjustment for Hyperglycemia

Assessment and Adjustment of Basal Insulin

• The American Diabetes Association recommends adjusting basal insulin dose in small increments for fasting or persistent hyperglycemia, with a starting point of increasing Lantus from 9 units to 11 units 1, 5
• The recommended approach is to follow an evidence-based titration algorithm, increasing basal insulin by 2 units every 3 days until fasting plasma glucose reaches target without hypoglycemia, as suggested by the American Association of Clinical Endocrinologists 3, 4, 5

Monitoring and Avoiding Pitfalls

• The American Diabetes Association recommends monitoring fasting blood glucose daily to assess the effect of basal insulin adjustment, and checking blood glucose before meals and 2 hours after meals to evaluate the adequacy of the carbohydrate ratio 1, 5
• Avoid aggressive dose increases (>2 units at a time) which may lead to hypoglycemia, and be cautious of overbasalization, as warned by the Endocrine Society 4, 7

Considerations for Carbohydrate Ratio and Further Adjustments

• The American Diabetes Association suggests maintaining the current 1:10 carbohydrate ratio initially while assessing the impact of basal insulin adjustment, and considering adjusting the insulin-to-carbohydrate ratio if postprandial hyperglycemia persists after optimizing basal insulin 1, 6
• If blood glucose remains elevated after increasing basal insulin, consider further basal insulin titration, adjusting the carbohydrate ratio, or adding correction doses for persistent hyperglycemia, as recommended by the American Association of Clinical Endocrinologists 1, 5