INSULIN DOSING

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• Overview
• There are many different ways to dose insulin, and no single regimen fits every patient. Patient variables, including education, motivation, diabetes control, and resources, must all be considered when determining which method works best for each individual.


• Low blood sugar (Hypoglycemia)
• In most patients, the main concern when initiating insulin is the risk of hypoglycemia. To help lower the risk, blood sugar monitoring should be increased, and all patients should be aware of the signs, symptoms, and treatment of hypoglycemia (see hypoglycemia for more).


• Measures to help prevent low blood sugars
• Insulin-naïve patients should start at the lower end of dosing ranges and titrate slowly
• Patients should try to avoid insulin doses outside of their prescribed regimens as this may lead to incorrect adjustments
• Patients should attempt to consume a consistent diet of three meals a day while keeping meals as uniform as possible in size and carbohydrate content. Patients should notify their provider and increase monitoring if they decide to make significant changes to their diet (e.g. start a keto diet, drastically reduce calorie intake).
• When using a multidose regimen (basal and premeal), adjust one regimen at a time and alternate between the two (see alternating regimens for more)

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• For dosing purposes, insulins can be divided into two categories:
• Basal insulins - basal insulins provide a steady amount of background insulin activity over the course of a day
• Premeal insulin (prandial insulin) - premeal insulins provide a burst of insulin that acts quickly to abate the rise in blood glucose that is seen after consuming a meal
• See insulin chart for a review of available insulins including their pharmacokinetics, dosage forms, storage, and more

• Basal insulins
• Intermediate-acting insulins
• Humulin® N (NPH)
• Novolin® N (NPH)
• Long-acting insulins
• Basaglar® (insulin glargine)
• Lantus® (insulin glargine)
• Levemir® (insulin detemir)
• Rezvoglar® (insulin glargine)
• Semglee® (insulin glargine)
• Toujeo® (insulin glargine)
• Tresiba® (insulin degludec)

• Premeal insulins
• Rapid-acting insulins
• Admelog® (insulin lispro)
• Afrezza® (inhaled insulin)
• Apidra® (insulin glulisine)
• Fiasp® (insulin aspart)
• Humalog® (insulin lispro)
• Lyumjev® (insulin lispro-aabc)
• Novolog® (insulin aspart)
• Short-acting insulins
• Humulin® R (regular)
• Novolin® R (regular)

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• See ADA blood sugar goals in DM

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• ADA general treatment recommendations for T1DM
• T1DM patients should receive multidose injections (3 - 4 a day) of basal and premeal insulin or insulin pump therapy
• Most individuals with T1DM should use rapid-acting insulin analogs to reduce hypoglycemia risk
• Patients should match premeal insulin to carbohydrate intake, premeal blood glucose levels, and anticipated activity [26]


• Starting therapy
• Insulin dosing in T1DM will vary based on patient's age, weight, and residual pancreatic insulin activity
• T1DM patients will typically require a total daily insulin dose of 0.4 - 1.0 units/kg/day
• A typical starting dose in metabolically-stable patients is 0.5 units/kg/day
• After calculating the total daily dose, it should be given as follows:
• Basal insulin - given as half of the total daily dose ^✝
• Premeal insulin - half of the total daily dose divided into thirds and given before each meal
• ^✝ When first starting therapy, it is recommended that the initial basal dose be reduced by 20 - 30% to prevent hypoglycemia [11,19]
• T1DM patients may experience a "honeymoon phase" after starting insulin therapy where the initial effects of insulin are greater than what is seen later in the disease [7,13,26]
• Example
• Patient weighs 80 kg
• Total daily dose = 80 kg X (0.5 units/kg/d) = 40 units per day
• Basal insulin = 1/2 X 40 units = 20 units of basal per day^✝
• Premeal Insulin = 1/2 X 40 units = 20 units / 3 = approximately 7 units before each meal
• ^✝ If patient is just starting therapy, the initial basal dose should be reduced by 20 - 30%. In our example: 20 units X 0.20 = 4 units, so initial basal dose would be 20 - 4 = 16 units


• Adjusting therapy
• See adjusting basal insulin and adjusting premeal insulin below

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• Reference [27]

ADA Insulin Dosing Recommendations for Adults with T2DM
Step 1 - start with long-acting insulin or bedtime NPH Initial dose: 10 units/day or 0.1 - 0.2 units/kg/day Adjust dose: increase dose by 10 - 15% or 2 - 4 units once or twice weekly to achieve fasting blood sugar goal (see adjusting basal insulin and NPH dosing for other recommendations) If hypoglycemia occurs: decrease dose by 10 - 20% or 4 units If A1C is still above target despite achieving fasting blood sugar goal, or if A1C is not at target and insulin dose is > 0.7 - 1.0 units/kg, proceed to Step 2
Step 2 - add premeal insulin before largest meal Initial dose: 4 units or 10% of basal dose If A1C < 8%, consider decreasing basal insulin dose by same amount Adjust dose: increase dose by 1 - 2 units or 10 - 15% twice weekly to achieve pre- and postprandial goals (see adjusting premeal insulin for other recommendations) If hypoglycemia occurs: decrease dose 2 - 4 units or 10 - 20% For patients using bedtime NPH: Consider switching to twice daily NPH by taking 80% of current bedtime NPH dose and giving 2/3 in the morning and 1/3 at bedtime. See NPH dosing for more. Example: Current bedtime NPH dose is 30 units 0.80 X 30 = 24 units 2/3 of 24 = 16 units in the morning 1/3 of 24 = 8 units in the evening If A1C still not at target, proceed to Step 3
Step 3 - add premeal insulin before other meals in stepwise fashion Add prandial insulin to an additional meal and use the guidelines in Step 2 to adjust If not controlled with 2 preprandial doses, add to a third meal Stepwise addition of prandial insulin every 3 months is associated with a lower risk of hypoglycemia and greater patient satisfaction

• Reference [27]

ADA Insulin Recommendations for Youth with T2DM
Basal insulin Initial dose: 0.5 units/kg/day Adjust dose: Increase every 3 - 5 days based on blood sugar readings to a maximum of 1.5 units/kg/day (see adjusting basal insulin for other recommendations) If pancreatic autoantibodies are positive, consider starting basal-premeal regimen or insulin pump therapy

• Reference [27,36]

ADA Insulin Recommendations for Elderly with T2DM
Overview In order to avoid hypoglycemia, the ADA recommends that insulin regimens be simplified in elderly patients who have cognitive impairment, multiple coexisting chronic illnesses, and/or functional dependence Continuous glucose monitoring is recommended in older adults with T1DM and those with T2DM receiving multiple daily doses of insulin
Basal insulin Change timing from bedtime to morning When titrating basal insulin, use a fasting blood sugar goal of 90 - 150 mg/dl and make adjustments based on a week of values If 50% of fasting blood sugar values are above goal, increase basal dose by 2 units If > 2 fasting blood sugar values/week are < 80 mg/dl, decrease basal dose by 2 units
Premeal (prandial) insulin Initial therapy Do not use short-acting insulin at bedtime If premeal insulin dose is ≤ 10 units, discontinue premeal insulin and add noninsulin agent If premeal insulin dose is > 10 units, decrease dose by 50% and add noninsulin agent. Titrate noninsulin agent while decreasing premeal insulin dose with goal of stopping premeal insulin. Adjusting therapy Use a blood glucose premeal goal of 90 - 150 mg/dl Every 2 weeks, adjust insulin dose and/or add noninsulin therapy based on pre-lunch and pre-dinner glucose readings If 50% of premeal blood sugar values over 2 weeks are above goal, increase the dose or add another agent If > 2 premeal values/week are < 90 mg/dl, decrease the dose of medication Sliding scale for premeal blood sugar values Blood sugar > 250 mg/dl: give 2 units of short- or rapid-acting insulin Blood sugar > 350 mg/dl: give 4 units of short- or rapid-acting insulin Noninsulin agents If GFR ≥ 45 ml/min, start metformin 500 mg daily and increase dose every 2 weeks, as tolerated If GFR < 45 ml/min, metformin is already being used, or metformin is not tolerated, proceed to second-line agent (see T2DM treatment recommendations)

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• Overview
• ADA basal insulin recommendations for T2DM are provided above (see ADA T2DM insulin recommendations). The three-day method discussed below can be used in type one and type two diabetes and has been proven effective in clinical trials.
• When NPH is used as the basal insulin, other considerations should be taken into account. See NPH dosing for more.

• Three-day method for adjusting basal insulin
• 1. Measure fasting blood sugar (no calories for 8 hours) for previous three consecutive days
• 2. Calculate the average of the three fasting blood sugars
• 3. Adjust basal insulin dose based on the table below
• 4. Repeat steps 1-3 until target range (80 - 99) is achieved

Reference [12]

Fasting blood sugar (mg/dl) average over 3 days	Adjustment to basal insulin dose (units of insulin)
≥ 180	add 8 units
160 - 179	add 6 units
140 - 159	add 4 units
120 - 139	add 2 units
100 - 119	add 1 unit
80 - 99	no change
60 - 79	subtract 2 units
< 60	subtract 4 or more units

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• Overview
• There are several ways to adjust premeal insulin. The scale method and the carb counting method are detailed below. These methods are appropriate for type 1 diabetics and highly-motivated type 2 diabetics. ADA recommendations for type 2 diabetics are presented above (see ADA T2DM insulin recommendations).

• Scale method
• With the scale method, premeal insulin is adjusted based on a scale
• Patients should try to consume the same amount of carbohydrates at each meal (a typical amount is about 60 grams a meal and 15 grams for a bedtime snack)
• Carbohydrate goals vary by individual (see carbohydrate information below)


• Steps:
• 1. Measure blood sugar fasting (pre-breakfast), pre-lunch, pre-dinner, and pre-bedtime snack for previous three consecutive days
• 2. Average the pre-lunch, pre-dinner and pre-bedtime values separately
• 3. Adjust the premeal insulin dose based on the table below
• 4. Repeat steps 1-3 until target range is achieved
• 5. A Correction Factor (see below) should also be incorporated when blood sugars are checked

Reference [12]

If pre-lunch average is not in desired range, adjust pre-breakfast dose If pre-dinner average is not in desired range, adjust pre-lunch dose If pre-bedtime snack average is not in desired range, adjust pre-dinner dose
Premeal blood sugar (mg/dl) average over 3 days	Adjustment to premeal insulin dose
≥ 180	add 3 units
160 - 179	add 2 units
140 - 159	add 2 units
120 - 139	add 1 units
100 - 119	maintain dose (desired range)
80 - 99	subtract 1 unit
60 - 79	subtract 2 units
< 60	subtract 4 or more units

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• Carbohydrate counting
• In carbohydrate counting, premeal insulin is adjusted based on the amount of carbohydrates to be consumed in each meal
• The carbohydrate counting method is used to determine the amount of carbohydrates in a meal
• An insulin to carbohydrate ratio (ex. 1 unit/10g of carb) is used to calculate the premeal insulin dose
• A typical starting ratio is 1 unit of premeal insulin for every 10 grams of carbs to be consumed
• An individual may have different carbohydrate ratios for breakfast, lunch, and dinner because a person's response to insulin may vary throughout the day
• Example:
• 60 grams of carbs to be consumed for lunch
• Patient's ratio is 1 unit of insulin for every 10 grams of carbs
• Patient injects 6 units of premeal insulin before eating meal


• Steps for adjusting an insulin-to-carb ratio
• 1. Calculate the number of carbs to be consumed in a meal using carbohydrate counting
• 2. Dose premeal insulin based on number of carbs in a meal (typical starting point is 1 unit of premeal insulin for every 10 grams of carbs)
• 3. Measure blood sugar fasting (pre-breakfast), pre-lunch, pre-dinner, and pre-bedtime snack for previous three consecutive days
• 4. Average the pre-lunch, pre-dinner and pre-bedtime snack blood sugar values separately
• 5. Adjust the carbohydrate to insulin ratio as instructed in the table below
• 6. Repeat steps 1-5 until appropriate ratios are determined [3,4]
• 7. A Correction Factor (see below) should also be incorporated when blood sugars are checked

If pre-lunch average is not in desired range (80 - 120 mg/dl), adjust breakfast ratio If pre-dinner average is not in desired range (80 - 120 mg/dl), adjust lunch ratio If pre-bedtime snack average is not in desired range (80 - 120 mg/dl), adjust dinner ratio

If average blood sugar is > 120 mg/dl, adjust ratio by subtracting 2 - 3g of carbohydrate Example: Current ratio 1 unit / 10g of carb Pre-lunch average > 120 mg/dl Change breakfast ratio to 1 unit / 7g of carb

If average blood sugar is < 80 mg/dl, adjust ratio by adding 2 - 3g of carbohydrate Example: Current ratio 1 unit / 10g of carb Pre-bedtime snack average < 80 mg/dl Change dinner ratio to 1 unit / 13g of carb

If average blood sugar is 80 - 120 mg/dl, do not adjust ratio

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• Overview
• When adjusting premeal and basal insulins concurrently, adjustments to one regimen may affect the other. This can lead to overcorrections and hypoglycemia. Alternating between regimens can help to prevent these issues.


• Example:
• Day 3 - adjust basal
• Day 6 - adjust premeal
• Day 9 - adjust basal
• Day 12 - adjust premeal, and so on...

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• Overview
• When premeal blood sugar checks are high, a correction factor should be used with premeal insulin
• The correction factor supplies supplemental insulin to account for the elevated blood sugar
• Insulin used in the correction factor should not be included in calculations for adjusting premeal or basal insulin
• There are several methods for determining the correction factor. The flat method uses a simple ratio, and the individual method incorporates the patient's total daily insulin dose.
• When initiating therapy, the flat method is preferred since the appropriate total daily insulin dose will be unknown

• Flat method
  • One unit of insulin is added to the premeal dose for every 25 mg/dl that the blood sugar is above the upper limit of the desired range
  • Example:
  • Pre-lunch blood sugar is 200 mg/dl
  • Upper limit of desired range is 120 mg/dl
  • 200 - 120 = 80 mg/dl above desired range
  • 80 mg/dl ÷ 25 mg/dl = approximately 3
  • Add 3 extra units to premeal dose
  
  
• Individual method
• The individual method uses a patient's total daily insulin dose to calculate a correction factor
• The correction factor is calculated differently for regular insulins (Humulin R, Novolin R) and rapid insulins (Novolog, Humalog, Apidra, Fiasp)

Step 1 - calculate the correction factor For Regular insulin (Humulin R, Novolin R) 1. Divide 1500 by the patient's total daily dose of insulin 2. The result will equal the estimated drop in blood sugar (in mg/dl) from 1 unit of regular insulin For Rapid insulin (Novolog, Humalog, Apidra, Fiasp, Admelog)> 1. Divide 1800 by the patient's total daily dose of insulin 2. The result will equal the estimated drop in blood sugar (in mg/dl) from 1 unit of rapid insulin [4,12] Example: Patient's total daily dose of insulin (premeal + basal) is 60 units Patient uses regular insulin as premeal insulin 1500/60 = 25 Patient can expect that for every 1 unit of regular insulin they inject, their blood sugar will come down 25 mg/dl

Step 2 - Once the correction factor is calculated, the patient can then figure out how much insulin to supplement Example: Patient from above: correction factor is 25 mg/dl Patient checks pre-lunch blood sugar and it is 175 mg/dl (desired range 80 - 120 mg/dl) 175 - 120 = 55 mg/dl 55/25 = approximately 2 Patient would add 2 extra units of regular insulin to premeal dose

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• NPH properties
• NPH insulin is an intermediate-acting insulin that can be used as a basal insulin. Newer long-acting insulin analogs have largely supplanted NPH as first-line basal insulins, but NPH remains the most affordable insulin available at $25/vial and is, therefore, still an important option for patients without insurance and/or those who are cost-sensitive.
• When using NPH, it's essential to understand how its pharmacokinetic properties differ from other basal insulins. Long-acting insulins provide a steady state of insulin that does not have a peak. NPH insulin has a peak effect that occurs between 4 - 10 hours after dosing. Because of this, NPH carries a higher risk of hypoglycemia. In addition, NPH's duration of effect is around 16 - 20 hours, which is shorter than the 24+ hours seen with long-acting insulins. This means NPH often has to be dosed twice daily to achieve sustained control over 24 hours.
• The diagram below illustrates the different pharmacokinetics of NPH and long-acting insulins [11,29]

• Important points about NPH dosing
• NPH is a suspension, and it must be resuspended before dosing. Failure to resuspend NPH properly can result in dosing irregularities. The vials and the pens contain directions on how to resuspend each product. NPH should appear uniformly white and cloudy after proper resuspension.
• Since NPH has a peak effect, patients should keep the timing of their injections and meals consistent to help prevent hypoglycemia. Patients should also try to consume meals that are uniform in size and carbohydrate content.
• Patients who are also using premeal insulins should be aware that NPH may potentiate the effect of their premeal insulin. For example, a patient who injects NPH and a rapid-acting insulin before breakfast will see a peak effect from the rapid insulin around 1 - 3 hours after injection. The NPH will start to have its effect around 2 - 3 hours after injection, and the combined peak actions may lead to hypoglycemia. More frequent blood sugar checks and/or dose adjustments may be necessary when initiating therapy.
• In the evening, NPH should typically be dosed at bedtime (as opposed to dinner), as this has been shown to decrease the incidence of nighttime hypoglycemia [11,28]

• Twice-daily NPH
• Twice-daily NPH regimens divide the daily dose between a morning and evening dose. In studies, dose distribution has varied widely, with some splitting the dose 50-50, some giving 2/3 in the morning and 1/3 in the evening, and others giving 1/3 in the morning and 2/3 in the evening. [30,31,32,33,34,35]
• The steps below are derived from clinical trials and guidelines. They are intended to provide a starting point for initiating and adjusting twice-daily NPH in type 2 diabetics. The recommendations should be individualized as some patients may require more aggressive adjustments (e.g. poorly-controlled morbidly obese diabetics), and others may need minor adjustments (e.g. elderly, hypoglycemia concerns). For recommendations in patients who are switching from another insulin to NPH, see converting from other insulins to NPH below.

Dosing NPH Insulin in T2DM
Step 1 - Initial dose If A1C > 10% and no blood sugars < 126 mg/dl in last 2 weeks ✝ Start with NPH 10 units twice daily If A1C < 10% or any blood sugars < 126 mg/dl in last 2 weeks ✝ Start with NPH 6 units twice daily Morning dose should be given at approximately the same time each day upon awakening Evening dose should be given at bedtime ✝If patient has not been checking blood sugars, have them check and report a fasting blood sugar once they obtain a monitor
Step 2 - Monitor blood sugars Check fasting blood sugar in the morning and predinner blood sugar in the evening on a daily basis
Step 3 - Determine insulin adjustment After 3 consecutive days of readings, average all the blood sugars (fasting and predinner) together Use this average and the table below to determine how much insulin will be added (or subtracted) to the total daily dose Reference [12] Blood sugar average (fasting and predinner) over 3 days Adjustment to total daily NPH dose ≥ 180 add 8 units 160 - 179 add 6 units 140 - 159 add 4 units 120 - 139 add 2 units 100 - 119 add 1 unit 80 - 99 no change 60 - 79 subtract 2 units < 60 subtract 4 or more units
Step 4 - Distributing the insulin adjustment Average the fasting and predinner blood sugars over the last 3 days separately Determine a range for each average (fasting and predinner) from the two tables below Fasting blood sugar ranges Average blood sugar (mg/dl) Range > 160 3 101 - 160 2 ≤ 100 1 Predinner blood sugar ranges Average blood sugar (mg/dl) Range > 160 3 131 - 160 2 ≤ 130 1 Use the table below to distribute the additional insulin dose For fractions of a unit, round up or down. Example: 5.2 units would be 5 units and 2.8 units would be 3 units If insulin is being subtracted, remove the insulin from the dose or doses that precede the low blood sugar readings Repeat this process every 3 days until the appropriate blood sugar range is achieved See the example below for an illustration of how to perform the steps Fasting range Predinner range Dose distribution 1 1 Do not add any NPH insulin 1 2 - 3 Morning - 100% Bedtime - 0% 2 3 Morning - 67% Bedtime - 33% 2 2 Morning - 50% Bedtime - 50% 3 3 Morning - 50% Bedtime - 50% 3 2 Morning - 33% Bedtime - 67% 2 - 3 1 Morning - 0% Bedtime - 100%

• Twice-daily NPH example:
• Patient initiates NPH insulin at 10 units twice daily
• Patient blood sugar readings from 3 consecutive days are as follows:
• Fasting: 185, 133, 156
• Predinner: 256, 300, 190
• Average of all blood sugars = (185 + 133 + 156 + 256 + 300 + 190) / 6 = 203
• Based on table in Step 3, patient will add 8 units to the total daily NPH dose
• Average of fasting blood sugars is = (185 + 133 + 156)/3 = 158
• Average of predinner blood sugars is = (256 + 300 + 190)/3 = 249
• Based on tables in Step 4, fasting blood sugars are range 2, and predinner blood sugars are range 3
• Based on dose distribution table in Step 4, patient will add 67% of the 8 additional units to his morning dose and 33% to the bedtime dose
• 67% of 8 = 0.67 X 8 = 5.36 rounded down to 5 units
• 33% of 8 = 0.33 X 8 = 2.64 rounded up to 3 units
• Patient's new NPH dose is 15 units in the morning and 13 units at night

• Once-daily NPH
• The ADA guidelines list once-daily bedtime NPH as an option in type 2 diabetics (see ADA T2DM insulin recommendations). Patients with normal fasting AM blood sugars may want to give their NPH dose in the morning instead of night.
• Once-daily dosing may work for some people, but others may require twice-daily NPH to reach their goals.

• Converting from long-acting insulins to NPH
• When converting from long-acting insulins to NPH, patients should know how NPH properties differ and review important points about NPH dosing.
• In trials with type 1 diabetics who were switching from other basal insulins to NPH and vice versa, the total daily basal insulin dose was reduced by 25 - 30% upon initiation. This approach helps prevent hypoglycemia but may require significant up-titration after switching. Patients who are also receiving premeal insulin should be particularly cautious because NPH may potentiate the peak effect of short-acting insulins.
• Recommendations from manufacturers for converting between NPH and other insulins are provided below (see converting between insulin brands and types) [11]

• Dosing 70/30 insulin
• Novolin 70/30 and Humulin 70/30 contain 70% NPH and 30% regular insulin. Insulin mixes like 70/30 are more difficult to adjust because the premeal and basal insulin must be given simultaneously and in a 7:3 ratio. Given these constraints, insulin mixes are not widely used anymore.
• In studies with type 2 diabetics, 70/30 has typically been initiated at doses of 0.2 - 0.6 units/kg/day, with two-thirds of the daily dose given before breakfast and one-third before dinner. The daily dose can then be adjusted up or down in increments of 10%, depending on blood sugar readings. [34,35]

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• Sliding scale insulin is rapid or short-acting insulin doses given to treat elevated blood sugar readings. The insulin dose is based on the glucose value.
• Different scales can be used depending on the patient and their insulin sensitivity. The example below is a typical starting point.

Blood sugar (mg/dl)	Insulin dose in units of rapid or short-acting
< 150	0
150 - 200	2
201 - 250	4
251 - 300	6
301 - 350	8
351 - 400	10
401 - 450	12
> 450	14

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• Overview
• Caution should be exercised when converting between insulin products because glucose effects may vary between individuals. Insulin manufacturers make some recommendations, but they do not cover every scenario, and there are few trials directly comparing the effects of different insulins.
• When switching, patients at high risk for hypoglycemia should reduce their daily basal insulin dose by 20 - 30% and re-titrate. All patients should increase blood sugar monitoring until they know how the new insulin will affect them.

• NOTE: Recommendations for Semglee and Rezvoglar are the same as Lantus

Converting between insulin brands and types
Rapid-acting and short-acting insulin When converting between rapid-acting and short-acting insulins, the dose typically remains the same Rapid-acting insulins act quicker (within 10 - 30 minutes) than short-acting insulins (within 30 - 60 minutes), therefore, the timing of the dose should be adjusted Rapid-acting insulins have a shorter duration of action than short-acting insulins (3 - 5 hours vs 6 - 8 hours). Because of this, patients switching to rapid-acting insulins from short-acting insulins may require more basal insulin to maintain blood sugar control, and vice versa. Conversions for inhaled insulin are discussed here - inhaled insulin dosing
Lantus, Basaglar, Levemir, and Tresiba Dose remains the same when switching between Lantus, Basaglar, Levemir, and Tresiba Patients at high risk for hypoglycemia may want to reduce the initial dose of the new insulin by 10 - 30% In trials comparing Tresiba to Lantus and Levemir, the glucose-lowering effect of Tresiba was equivalent to both insulins [22]
Lantus/Basaglar ⇄ NPH Once-daily NPH to Lantus/Basaglar Dose remains the same Twice-daily NPH to Lantus/Basaglar Lantus/Basaglar dose is 80% of total daily NPH dose Example: Patient's NPH dose is 30 units twice daily Total daily NPH dose is 60 units To convert to Lantus/Basaglar: 60 units X 0.80 = 48 units Daily Lantus/Basaglar dose will be 48 units [19] Lantus/Basaglar to once-daily NPH Dose remains the same For patients who are at risk for hypoglycemia, consider an initial dose reduction of 20 - 30% to account for the peak effect that occurs with NPH. See converting from long-acting insulin to NPH for more. Lantus/Basaglar to twice-daily NPH When switching from Lantus/Basaglar to twice-daily NPH, it can be anticipated that a higher amount of NPH may be needed in order to achieve an equivalent effect In most patients, leaving the dose the same and retitrating as needed will be appropriate. Patients at high risk for hypoglycemia (e.g. concomitant premeal insulin) may want to reduce their initial NPH dose by 10 - 30%. See converting from long-acting insulin to NPH and twice-daily NPH for other considerations when changing to NPH insulin
Lantus/Basaglar ⇄ Toujeo Lantus/Basaglar to Toujeo When going from Lantus/Basaglar to Toujeo, the daily dose remains the same Expect that a higher daily dose of Toujeo will be needed to maintain the same level of glycemic control as an equivalent dose of Lantus/Basaglar In a multidose study, the glucose-lowering effect of Toujeo was about 27% lower than that of an equivalent dose of Lantus [21] Toujeo to Lantus/Basaglar When going from Toujeo to Lantus/Basaglar, the Lantus/Basaglar dose should be started at 80% of the Toujeo dose in order to avoid hypoglycemia Lantus/Basaglar is more potent than Toujeo; therefore, an equally effective Lantus/Basaglar dose will likely be lower [19,23] Example: Patient's Toujeo dose is 60 units a day To convert to Lantus/Basaglar: 60 units X 0.80 = 48 units Daily Lantus/Basaglar dose will be 48 units
Levemir and NPH NPH to Levemir Daily dose remains the same Levemir to once-daily NPH Dose remains the same For patients who are at risk for hypoglycemia, consider an initial dose reduction of 20 - 30% to account for the peak effect that occurs with NPH. See converting from long-acting insulin to NPH for more. Levemir to twice-daily NPH When converting from Levemir to twice-daily NPH, an initial dose reduction of 20 - 30% may be appropriate in some type 2 diabetics. In a study where twice-daily Levemir was compared to twice-daily NPH, NPH doses of 0.52 units/kg had the same effect as Levemir doses of 0.77 units/kg. [20] See converting from long-acting insulin to NPH and twice-daily NPH for other considerations when changing to NPH insulin
Levemir and Toujeo Once-daily Levemir to Toujeo Daily dose remains the same [21] Twice-daily Levemir to Toujeo Toujeo dose is 80% of total daily Levemir dose Example: Patient's Levemir dose is 30 units twice daily Total daily Levemir dose is 60 units To convert to Toujeo: 60 units X 0.80 = 48 units Daily Toujeo dose will be 48 units [21] Toujeo to once-daily Levemir Daily dose remains the same [21] Toujeo to twice-daily Levemir Daily dose remains the same. Patients at high risk for hypoglycemia (e.g. concomitant premeal insulin) may want to reduce their initial Levemir dose by 10 - 30%.
Toujeo and NPH Once-daily NPH to Toujeo Dose remains the same Twice-daily NPH to Toujeo Toujeo dose is 80% of total daily NPH dose Example: Patient's NPH dose is 30 units twice daily Total daily NPH dose is 60 units To convert to Toujeo: 60 units X 0.80 = 48 units Daily Toujeo dose will be 48 units [19] Toujeo to once-daily NPH Dose remains the same For patients who are at risk for hypoglycemia, consider an initial dose reduction of 20 - 30% to account for the peak effect that occurs with NPH. See converting from long-acting insulin to NPH for more. Toujeo to twice-daily NPH Daily dose remains the same. Patients at high risk for hypoglycemia (e.g. concomitant premeal insulin) may want to reduce the initial NPH dose by 10 - 30%. See converting from long-acting insulin to NPH and twice-daily NPH for other considerations when changing to NPH insulin
Toujeo and Tresiba Tresiba to Toujeo Dose remains the same when switching from Tresiba to Toujeo Expect that a higher daily dose of Toujeo will be needed to maintain the same level of glycemic control as an equivalent dose of Tresiba In a multidose study, the glucose-lowering effect of Toujeo was about 27% lower than that of an equivalent dose of Lantus. Lantus and Tresiba have similar glucose-lowering effects. [21] Toujeo to Tresiba Reduce initial Tresiba dose by 20 - 30% to avoid hypoglycemia. In trials, the glucose-lowering effect of Toujeo was about 27% lower than that of Lantus. Lantus has a similar effect to Tresiba.
Tresiba and NPH NOTE: the manufacturer of Tresiba makes no specific recommendations when switching between NPH and Tresiba. The recommendations presented here are based on the fact that Tresiba has similar glucose-lowering effects as Lantus. Once-daily NPH to Tresiba Dose remains the same Twice-daily NPH to Tresiba Tresiba dose is 80% of total daily NPH dose Example: Patient's NPH dose is 30 units twice daily Total daily NPH dose is 60 units To convert to Tresiba: 60 units X 0.80 = 48 units Daily Tresiba dose will be 48 units [19] Tresiba to once-daily NPH Dose remains the same For patients who are at risk for hypoglycemia, consider an initial dose reduction of 20 - 30% to account for the peak effect that occurs with NPH. See converting from long-acting insulin to NPH for more. Tresiba to twice-daily NPH When switching from Tresiba to twice-daily NPH, it can be anticipated that a higher amount of NPH may be needed in order to achieve an equivalent effect In most patients, leaving the dose the same and retitrating as needed will be appropriate. Patients at high risk for hypoglycemia (e.g. concomitant premeal insulin) may want to reduce their initial NPH dose by 10 - 30%. See converting from long-acting insulin to NPH and twice-daily NPH for other considerations when changing to NPH insulin

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• Carbohydrates and insulin
• Carbohydrates have the most direct effect on blood sugars; therefore, patients receiving insulin should monitor their intake and understand their properties. Extensive information on carbohydrates is available at the links below.


• Carbohydrate counting - review of carbohydrate counting used in dosing premeal insulin
• Glycemic index - a method of determining the effects of different foods on blood sugars
• Carbohydrates - review of the different types of carbohydrates found in foods
• Calories - review on calculating caloric requirements
• Diabetic diet - diabetic diet recommendations

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• 5 - Kulkarni K: Carbohydrate Counting: A Practical Meal-Planning Option for People With Diabetes. Clinical Diabetes Vol 23:3 p120-122 2005
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• 12 - PMID 16847295
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• 17 - PMID 12766131
• 18 - Glucagon PI
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• 21 - Toujeo PI
• 22 - Tresiba PI
• 23 - Basaglar PI
• 24 - ADA 2015 Standards of Medical Care in Diabetes, Vol 38, Supplement 1, p. S46
• 25 - PMID 29222370 - ADA 2018 Standards of Medical Care in Diabetes
• 26 - ADA 2019 Standards of Medical Care in Diabetes
• 27 - ADA 2020 Standards of Medical Care in Diabetes
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• 29 - PMID 16160867 - Pharmacokinetic and glucodynamic variability: assessment of insulin glargine, NPH insulin and insulin ultralente in healthy volunteers using a euglycaemic clamp technique, Diabetologia (2005)
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• 36 - ADA 2023 Standards of Medical Care in Diabetes, Diabetes Care (2023)