Basal insulin initiation
Practical starting doses and titration for basal insulin in type 2 diabetes.
Last reviewed January 5, 2026
Contraindications
- Do not initiate basal insulin during active hypoglycemia.
- Defer routine outpatient starts when severe acute illness or ketosis concern is present.
- Verify insulin product and concentration carefully to avoid dosing errors.
Dosing
Insulin glargine (U100)
- Starting dose
- 10 units at bedtime or 0.1-0.2 units/kg
- Typical titration / target
- Increase by 2 units every 3 days to fasting target
- Monitoring / notes
- Review hypoglycemia risk and injection technique.
Insulin NPH
- Starting dose
- 10 units at bedtime
- Typical titration / target
- Increase by 2 units every 3 days to fasting target
- Monitoring / notes
- Higher nocturnal hypoglycemia risk; consider SMBG overnight.
| Medication (generic) | Starting dose | Typical titration / target | Monitoring / notes |
|---|---|---|---|
| Insulin glargine (U100) | 10 units at bedtime or 0.1-0.2 units/kg | Increase by 2 units every 3 days to fasting target | Review hypoglycemia risk and injection technique. |
| Insulin NPH | 10 units at bedtime | Increase by 2 units every 3 days to fasting target | Higher nocturnal hypoglycemia risk; consider SMBG overnight. |
Renal and hepatic considerations
- Start conservatively and titrate carefully when renal function is reduced.
- Use additional caution in significant hepatic impairment due to altered glucose handling.
- Reassess dosing pace when oral intake is inconsistent or frailty is present.
Pregnancy and lactation cautions
- Pregnancy requires individualized glycemic targets and medication planning.
- Review preconception goals and coordinate early obstetric/diabetes support when relevant.
- During lactation, reinforce hypoglycemia prevention and individualized dose reassessment.
Monitoring checkpoints
- Titrate slowly with fasting SMBG; pause titration if hypoglycemia occurs.
- Ensure patients understand sick day management and hypoglycemia treatment.
- Reassess A1C in 3 months and adjust prandial therapy if needed.
Stop or escalate criteria
- Escalate urgently for recurrent or severe hypoglycemia.
- Escalate if fasting targets remain persistently above goal despite appropriate titration and adherence support.
- Escalate immediately when ketosis symptoms or significant clinical deterioration appear.
References
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