INSULIN DOSING























  • 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 more)
  • 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 more)
  • 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 more)
  • If pancreatic autoantibodies are positive, consider starting basal-premeal regimen or insulin pump therapy

  • Reference [27]
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
  • The information below gives general recommendations that can be used for simplifying regimens in appropriate patients
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 noninsulin therapy based on pre-lunch and pre-dinner glucose readings
    • If 50% of premeal blood sugar values are above goal over 2 weeks, increase intensity of noninsulin therapy
    • If > 2 premeal values/week are < 90 mg/dl, decrease intensity of therapy
  • 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, use metformin as noninsulin agent
    • If GFR < 45 ml/min or metformin is already being used, see T2DM treatment recommendations for guidance on other agents






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







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




  • 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








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







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%









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




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, Semglee, Basaglar, Levemir, and Tresiba
  • Dose remains the same when switching between Lantus, Semglee, 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/Semglee and NPH
  • Once-daily NPH to Lantus/Semglee/Basaglar
    • Dose remains the same

  • Twice-daily NPH to Lantus/Semglee/Basaglar
    • Lantus/Semglee/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/Semglee/Basaglar: 60 units X 0.80 = 48 units
      • Daily Lantus/Semglee/Basaglar dose will be 48 units [19]

  • Lantus/Semglee/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/Semglee/Basaglar to twice-daily NPH
    • When switching from Lantus/Semglee/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/Semglee/Basaglar and Toujeo
  • Lantus/Semglee/Basaglar to Toujeo
    • When going from Lantus/Semglee/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/Semglee/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/Semglee/Basaglar
    • When going from Toujeo to Lantus/Semglee/Basaglar, the Lantus/Semglee/Basaglar dose should be started at 80% of the Toujeo dose in order to avoid hypoglycemia
    • Lantus/Semglee/Basaglar is more potent than Toujeo; therefore, an equally effective Lantus/Semglee/Basaglar dose will likely be lower [19,23]
    • Example:
      • Patient's Toujeo dose is 60 units a day
      • To convert to Lantus/Semglee/Basaglar: 60 units X 0.80 = 48 units
      • Daily Lantus/Semglee/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
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
Toujeo and Levemir
  • 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%.
Tresiba and Toujeo
  • 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