Pathophysiology
Clinical meaning
Insulin titration is the systematic process of adjusting insulin doses to achieve glycemic targets while minimizing hypoglycemia. The NP must master titration algorithms for basal insulin, mealtime insulin, and correction doses, as well as complex scenarios including insulin transitions, sick-day management, and steroid-induced hyperglycemia. Basal insulin titration targets fasting glucose. The treat-to-target approach (demonstrated in the PREDICTIVE and AT.LANTUS trials) uses patient-directed titration: increase basal insulin by 2 units every 3 days until fasting glucose is consistently 80-130 mg/dL (ADA target). More aggressive protocols (2-4 units every 3 days) may be used in highly motivated patients with close monitoring. If fasting glucose drops below 70 mg/dL, reduce dose by 10-20%. If nocturnal hypoglycemia occurs, reduce dose by 4 units or 10-20% and evaluate timing. Starting dose: 10 units or 0.1-0.2 units/kg/day for type 2 diabetes. Mealtime insulin titration targets 2-hour postprandial glucose (<180 mg/dL). Initial approach: start with the largest meal (basal-plus strategy). Starting dose: 4 units or 10% of basal dose. Adjust by 1-2 units every 3 days based on 2-hour postprandial glucose. Advanced approach: carbohydrate counting with insulin-to-carb...