By rray, 9 February, 2023 Usually 1 dose w largest meal or meal w greatest PPG excursion prandial insulin can be dosed individually or mixed w NPH
By rray, 9 February, 2023 If A1C still above target add prandial insulin or if on bedtime NPH consider switch to bid NPH regimen4
By rray, 9 February, 2023 If above A1C target and not already on GLP 1 RA or GIP GLP 1 RA consider these classes either in free combo or fixed ratio combo w insulin
By rray, 9 February, 2023 Assess adequacy of basal insulin dose Consider clinical signals to evaluate for overbasalization and need to consider adjunctive tx e g basal dose 0 5 units kg day elevated bedtime morning and or postprandial differential hypoglycemia aware or unaware hig
By rray, 9 February, 2023 Titration Set FPG target choose evidence based titration algorithm e g increasing 2 units q3 days to reach FPG target w o hypoglycemia for hypoglycemia determine cause if no clear reason lower dose by 10 to 20
By rray, 9 February, 2023 If A1C still above target add basal insulin2 basal analog or bedtime NPH insulin3
By rray, 9 February, 2023 Consider insulin as the 1st injectable if evidence of ongoing catabolism wt loss if hyperglycemia sx are present if very high A1C levels 10 or BG levels 300 mg dL or if T1DM dx is a possibility
By rray, 9 February, 2023 If already on GLP 1 RA or GIP GLP 1 RA or if these aren t appropriate or insulin is preferred proceed to basal insulin next step below
By rray, 9 February, 2023 Consider GLP 1 RA1 or GIP GLP 1 RA in most pts prior to insulin initiation Initiate appropriate start dose varies by agent w in class and gradually titrate to maintenance varies by agent