Timing Glucose goal (mg/dl)
Fasting
(no calories for 8 hours)
75 - 99
Premeal 80 - 120
2 hours post-meal < 140




  • Reference [24]
ADA algorithm for initiating insulin in type 2 diabetes
Step 1 - start with basal insulin

  • 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
  • If hypoglycemia occurs: decrease dose by 10 - 20% or 4 units

  • If blood sugars are still uncontrolled after fasting target is achieved or if insulin dose is > 0.5 units/kg/day, proceed to Step 2
    • Alternatively, may consider adding GLP-1 analog

Step 2 - add premeal insulin before largest meal

  • Initial dose: 4 units OR 0.1 units/kg 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% once or twice weekly to achieve pre- and postprandial goals
  • If hypoglycemia occurs: decrease dose 2 - 4 units or 10 - 20%

    Alternative regimen - change basal insulin to twice daily premixed insulin
    • Initial dose: divide basal dose and give as premixed insulin twice daily (2/3 AM and 1/3 PM OR 1/2 AM and 1/2 PM)
    • Adjust dose: increase dose by 1 - 2 units or 10 - 15% once or twice weekly to achieve pre- and postprandial goals
    • If hypoglycemia occurs: decrease dose 2 - 4 units or 10 - 20%

  • If blood sugars are still uncontrolled, proceed to Step 3

Step 3 - add premeal insulin before ≥ 2 meals

  • Initial dose: 4 units OR 0.1 units/kg OR 10% of basal dose before each meal
    • If A1C < 8%, consider decreasing basal insulin dose by same amount
  • Adjust dose: increase dose by 1 - 2 units or 10 - 15% once or twice weekly to achieve pre- and postprandial goals
  • If hypoglycemia occurs: decrease dose 2 - 4 units or 10 - 20%












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

















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