dromlakhani Basal Insulin Titration — Proprietary Protocol
Step 1 — Gather the Data Points
Ask for (or confirm):
- Yesterday's fasting blood glucose (FBG₋₁)
- Today's fasting blood glucose (FBG₀)
- Current basal insulin dose (in units)
- Which basal insulin — Lantus (glargine U-100), Basaglar (glargine biosimilar), or Ryzodeg (IDegAsp, used OD as basal)
Step 2 — Determine the Trend
Compare FBG₀ vs FBG₋₁:
| Trend | Definition |
|---|---|
| ↑ Rising | FBG₀ > FBG₋₁ |
| ↓ Falling | FBG₀ < FBG₋₁ |
| → Stable | FBG₀ = FBG₋₁ |
Step 3 — Apply the Titration Rule
🔺 If FBG is RISING (FBG₀ > FBG₋₁) → INCREASE dose
| Today's FBG (FBG₀) | Dose Adjustment |
|---|---|
| > 200 mg/dL | +4 units |
| 90 – 200 mg/dL | +2 units |
| < 90 mg/dL | No change (at/below target — do not increase) |
🔻 If FBG is FALLING (FBG₀ < FBG₋₁) → Usually NO CHANGE
Exception — reduce dose if FBG₀ is in hypoglycaemia range:
| Today's FBG (FBG₀) | Dose Adjustment |
|---|---|
| ≥ 90 mg/dL | No change |
| 70 – 89 mg/dL | −2 units |
| < 70 mg/dL | −4 units |
→ If FBG is STABLE → No change
Step 4 — State the New Dose
New dose = Current dose ± adjustment
State the insulin name and the specific new dose in units. Titrate daily.
Step 5 — Insulin-Specific Notes
| Insulin | Generic Name | Titration |
|---|---|---|
| Lantus | Insulin glargine U-100 | As per protocol above |
| Basaglar | Insulin glargine biosimilar | As per protocol above |
| Ryzodeg | IDegAsp (degludec + aspart) | As per protocol above |
⚠️ Ryzodeg reminder: Contains both IDeg (basal) and IAsp (rapid-acting prandial component). When used OD as basal, the prandial component covers the injection meal. Counsel patient not to skip the meal at injection time.
Step 6 — Clinical Guardrails
- Nocturnal hypoglycaemia masking: A rising FBG₀ may indicate Somogyi-type rebound — check for overnight hypoglycaemia before increasing dose.
- Illness or reduced oral intake: Hold titration; consider empiric dose reduction.
- Renal impairment (eGFR < 30): Use ±2 units as maximum increment; hypoglycaemia risk amplified.
- Elderly patients: Use ±2 units as maximum increment regardless of glucose level.
- Basal insulin only. Prandial insulin titrated separately.
Quick Reference Card
FBG TODAY vs YESTERDAY
─────────────────────────────────────────────
TREND │ FBG₀ VALUE │ DOSE CHANGE
─────────────────────────────────────────────
↑ RISING │ > 200 mg/dL │ + 4 units
↑ RISING │ 90–200 mg/dL │ + 2 units
↑ RISING │ < 90 mg/dL │ No change
→ STABLE │ any │ No change
↓ FALLING │ ≥ 90 mg/dL │ No change
↓ FALLING │ 70–89 mg/dL │ − 2 units
↓ FALLING │ < 70 mg/dL │ − 4 units
─────────────────────────────────────────────
Titrate daily. Applies to Lantus, Basaglar, Ryzodeg.
Protocol: Proprietary — Mellitus Health Tech. For clinical use under physician supervision.