Basal Insulin Titration

---
name: basal-insulin-titration
description: Adjust basal insulin dose (Lantus, Basaglar, Ryzodeg/IDegAsp) based on fasting blood glucose trend. Use when a clinician asks how to titrate basal insulin, whether to increase or decrease Lantus/glargine/degludec/Ryzodeg dose, or how to adjust basal insulin based on fasting glucose readings. Triggers include: "adjust basal insulin", "titrate Lantus", "basal dose change", "FBG is high/low", "should I increase/decrease insulin".
---

# Basal Insulin Titration — Proprietary Protocol

## Step 1 — Gather the Data Points

Ask for (or confirm):
1. **Yesterday's fasting blood glucose (FBG₋₁)**
2. **Today's fasting blood glucose (FBG₀)**
3. **Current basal insulin dose** (in units)
4. **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** |

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### → If FBG is STABLE → No change

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## Step 4 — State the New Dose

> **New dose = Current dose ± adjustment**

State the insulin name and the specific new dose in units. Titrate daily.

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## 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.

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## 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.

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## 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.
```

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*Protocol: Proprietary — Mellitus Health Tech. For clinical use under physician supervision.*