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● You typically start with basal (e.g. NPH) insulin given at a low dose (e.g., 0.1-0.2 U/kg) as a single daily injection. The timing of administration depends on the patient's schedule and the overall glucose profile.
● Up titrate at increments of 5-10% until the fasting glucose levels remain above the target (typically <130 mg/dL). Reduce at persisting hypoglycemic episodes.
● Add prandial (normal) insulin at significant postprandial hyperglycemia (>180 mg/dL), when the fasting glucose is at target but the HbA1c remains above goal after 3-6 months of basal insulin titration, or if large drops in glucose occur during overnight hours or in between meals. In the last case reduce the basal insulin dose as you initiate prandial insulin.
● Note that sulfonylurea should be discontinued at the latest upon intensification of insulin therapy with normal (prandial) insulin, reflecting the termination of secretion. Metformin should be continued, as it reduces the insulin-driven weight gain.