Insulin Initiation and Titration Guidelines

Basal Insulin Starting Doses

• The American Diabetes Association recommends starting basal insulin in type 2 diabetes with 10 units once daily or 0.1-0.2 units/kg/day 1, 2
• For patients with severe hyperglycemia, the initial dose can be 0.3-0.4 units/kg/day to achieve targets faster 1, 2
• Metformin should be continued unless contraindicated when initiating basal insulin, as recommended by the American College of Clinical Endocrinologists 3, 4, 2

Premix Insulin Starting Doses

• The American Association of Clinical Endocrinologists suggests administering premix insulin twice daily, with a starting dose of 4 units per injection or 0.1-0.2 units/kg/day divided between the two doses 5
• Premix insulin is appropriate when basal insulin has been titrated to acceptable fasting glucose but A1C remains above target, according to the American Diabetes Association 3, 4, 5

Dose Titration Protocol

• The American College of Clinical Endocrinologists recommends increasing basal insulin by 2 units every 3 days if fasting glucose is 140-179 mg/dL, and by 4 units every 3 days if fasting glucose is ≥180 mg/dL 1, 2
• The target fasting plasma glucose is 80-130 mg/dL, as recommended by the American Association of Clinical Endocrinologists 1, 2

Critical Thresholds and Warning Signs

• When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, prandial insulin or premix should be added rather than continuing to escalate basal insulin alone, according to the American Diabetes Association 1, 2

Special Populations

• For hospitalized patients, the American College of Clinical Endocrinologists recommends a total daily dose of 0.3-0.5 units/kg/day, with half as basal insulin for insulin-naive or low-dose patients 1
• High-dose home insulin (≥0.6 units/kg/day) should be reduced by 20% upon hospitalization to prevent hypoglycemia, as recommended by the American Association of Clinical Endocrinologists 1