Insulin Dose Adjustment Guidelines

Basal Insulin Titration

The American Diabetes Association recommends initiating basal insulin at 10 units per day or 0.1-0.2 units/kg per day for insulin-naive patients 1
Increase basal insulin dose by 2 units every 3 days to reach fasting plasma glucose target without hypoglycemia, as recommended by the American Diabetes Association 1, 2
Set fasting glucose target of 90-150 mg/dL for most patients, according to the American Diabetes Association 3, 4
If 50% of fasting values exceed goal over one week, increase dose by 2 units, as suggested by the American Diabetes Association 3, 4
If more than 2 fasting values per week are <80 mg/dL, decrease dose by 2 units, according to the American Diabetes Association 3, 4
For hypoglycemia without clear cause, lower the dose by 10-20%, as recommended by the American Diabetes Association 1

Start with 4 units per dose or 10% of basal dose with the largest meal or meal with greatest postprandial glucose excursion, according to the American Diabetes Association 1
When adding prandial insulin, reduce basal dose by 4 units or 10%, as recommended by the American Diabetes Association 1
Increase dose by 1-2 units or 10-15% twice weekly based on postprandial glucose, according to the American Diabetes Association 1
Monitor blood glucose 2-3 hours after meals to verify adequate coverage, as suggested by the American Diabetes Association 5

The insulin-to-carbohydrate ratio (commonly 1:10) means 1 unit of insulin covers 10 grams of carbohydrate, according to the American Diabetes Association 5
Calculate bolus dose: (grams of carbohydrate consumed) ÷ (carbohydrate per unit ratio), as recommended by the American Diabetes Association 5
A 50% reduction in carbohydrates requires a 50% reduction in prandial insulin dose, according to the American Diabetes Association 5

Total daily dose for insulin-naive patients: 0.3-0.5 units/kg, as recommended by the Endocrine Society 6
Allocate 50% to basal insulin (given 1-2 times daily) and 50% to prandial insulin (divided before three meals), according to the Endocrine Society 6
Use lower doses (0.3 units/kg) for patients at higher hypoglycemia risk: age >65 years, renal failure, or poor oral intake, as suggested by the Endocrine Society 6

Correction insulin should be added to carbohydrate coverage based on pre-meal glucose if above target, according to the American Diabetes Association 5
Do not use sliding scale insulin alone as the primary regimen in patients with type 1 or type 2 diabetes requiring insulin, as recommended by the Endocrine Society 6
For premeal glucose >250 mg/dL: give 2 units of rapid-acting insulin, according to the American Diabetes Association 3, 4
For premeal glucose >350 mg/dL: give 4 units of rapid-acting insulin, as recommended by the American Diabetes Association 3, 4

Reassess and modify treatment regularly every 3-6 months, according to the American Diabetes Association 1
Adjust insulin dose and/or add glucose-lowering agents every 2 weeks based on finger-stick testing, as recommended by the American Diabetes Association 3, 4
Monitor fasting blood glucose daily to assess basal insulin effect, according to the American Diabetes Association 2

Change basal insulin timing from bedtime to morning for older adults on complex insulin plans, as recommended by the American Diabetes Association 3, 4
If on premixed insulin, use 70% of total dose as basal only in the morning, according to the American Diabetes Association 3, 4
If prandial insulin ≤10 units per dose: discontinue and add noninsulin agent, as suggested by the American Diabetes Association 3, 4

Patients should carry at least 15 grams of fast-acting carbohydrate for hypoglycemia treatment, according to the American Diabetes Association 5
If recurrent hypoglycemia occurs despite correct calculations, reduce insulin dose by 10-20% and consult diabetes care team, as recommended by the American Diabetes Association 5