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Diabetes care in Reading, Wokingham and West Berkshire

Insulin titration and adjustment

Guidance for titrating and adjusting insulin in Type 2 diabetes

Guideline for Insulin dose titration

(Adapted from NICE CKS)[i]

 

Starting insulin therapy.

  1. Review blood glucose results. Do not adjust the insulin dose based on a single high blood glucose result. Assess the overall picture.
  2. If blood glucose targets have not been reached: Titrate the insulin dose, and review every 3–7 days or weekly depending on response. Continue to titrate the dose until the individually-agreed blood glucose target is reached, or hypoglycaemia limits further titration.
  3. Consider every dose adjustment as a trial. Monitor the response.
  4. Once-daily regimen (usually taken at bedtime) Review pre-breakfast (fasting) blood glucose levels, as this usually gives a good indication of effectiveness. Titrate the individual insulin dose, increasing it by 10% when appropriate (although this can vary from 5–20%, depending on the individual, for example a smaller increase for frail elderly people and a higher increase for obese people,

 

Titration in once daily Isophane injection

Average fasting blood glucose

Insulin dose increase

Greater than 10 mmol/L

Increase daily dose by 8 units

8–10 mmol/L

Increase daily dose by 4–6 units

6–8 mmol/L

Increase daily dose by 2–4 units

<5

Reduce daily dose by 2–4 units

After a period of time, the insulin dose can then be increased by 10% if three consecutive fasting blood glucose results are higher than the agreed blood glucose target.

 

Twice-daily regimen

 

  1. Adjust pre-breakfast insulin dosages based on the pre-dinner glucose level (for example, based on average records from 3 consecutive days).
  2. Adjust pre-dinner insulin dosages based on pre-breakfast glucose level (for example, based on average records from 3 consecutive days).
  3. Titrate the individual insulin dose, increasing it by 10% when appropriate (although this can vary from 5–20%, depending on the individual, for example a smaller increase for frail elderly people and a higher increase for obese people.
  4. Alternatively, titrate the dose using the schedule shown in Table 1.
  5. If hypoglycaemia becomes a problem: a reduction in insulin dose is indicated, consider reduce the insulin dose by 20%.
  6. Consider switching to a long-acting insulin analogue if hypoglycaemia is a significant problem

 

Dr Ian Gallen, Consultant Community Specialist, October 2015



[i] http://cks.nice.org.uk/insulin-therapy-in-type-2-diabetes#!scenariorecommendation:19/A-466525:1

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