Quality Standards for Diabetes Care Toolkit

Dose titration

BPAC (2012) states that:

Patients require adequate education and training before they begin SMBG and self-administering insulin. It should be made clear that the initial dose of insulin is merely a starting point from where titration will be based – a common error is to initiate but not to titrate the dose effectively. Patients can be safely taught to self-adjust insulin doses in response to blood glucose levels, however, follow-up is essential. The need for continued exercise to prevent weight gain should also be emphasised. Practice staff training patients with type 2 diabetes to self-administer insulin need to have a thorough working knowledge of all the practical aspects of insulin treatment. In some DHBs training programmes for health professionals are run by diabetes nurse educators. In some cases it may be necessary for practices to contact manufacturers for specific product training.

After the initiation of insulin, twice weekly phone calls to the patient are recommended in combination with face-to-face meetings as required, until satisfactory glycaemic control is achieved. From this point, regular contact between the patient and the practice should be maintained, as blood glucose levels may be affected by other illnesses and insulin dose adjustments may be required. A face-to-face meeting approximately one month after initiation is also recommended to assess the need for regimen adjustment.

It should be emphasised to all patients, before they begin taking insulin, that medication is not a substitute for a healthy lifestyle and that behavioural strategies such as exercise, healthy eating and smoking cessation should still continue. Alcohol consumption should be moderate as this increases the risk of hypoglycaemia in patients taking insulin (p 25).

A guide to dose titration following the initiation of insulin is provided on page 62 of the New Zealand Primary Care Handbook 2012.