Insulin Initiation and Adjustment Program

Medical Directive ID: 
Lead Contact Person: 
Mary Biro
Physician/Nurse Lead: 
Dr. Tamara Spaic
Medicine - Diabetes Education Centre
Approval By: 
Medical Advisory Committee
Original Effective Date: 
Wednesday, June 3, 2009
Revised Date: 
Friday, September 17, 2021
To Be Reviewed Date: 
Tuesday, September 17, 2024
This Medical Directive Applies to the following sites: 
St. Joseph’s
This Medical Directive Applies to the following patient population: 

**This directive is a renewal and replaces directive #MED-2014-007

Registered nurses, registered dietitians, and pharmacists may initiate or adjust insulin based on the following criteria:

 A written or verbal order is required from the prescriber for initial insulin orders specifying the type, dose and timing of the insulin (verbal orders shall comply with the “Telephone and Verbal Orders” policy).

 Insulin adjustments will be made on the basis of documented self-monitored glucose values and reported hypoglycemic episodes. The adjustments will be based on detected patterns seen in the reported glucose values.

 Each dose of insulin may be adjusted by a maximum of 4 units or 15%, whichever is greater. This applies to all insulin containing products except Tresiba® (insulin degludec), Xultophy® (insulin decludec/liraglutide), Soliqua™ (insulin glargine/lixisenatide) and insulin pumps. Specific adjustment criteria are listed below for each of these products.

 Tresiba® (insulin degludec) may adjusted by 4 units no more than once a week based on that morning’s fasting glucose value.

 Xultophy® (insulin degludec/liraglutide) may be adjusted by 2 units every three to four days until target fasting sugar (based on self-monitoring report) is achieved while avoiding hypoglycemia. Do not exceed maximum dose of 50 units once a day. Consider alternative treatment option if patient requires less than 16 units or greater than 50 units per day. The dosage may be temporarily down titrated to below 16 units (i.e., 0 to 15 units). However, if patients require persistent dosages below 16 units of Xultophy® discontinue and use alternative therapy.

 Soliqua™ (insulin glargine/lixisenatide) may be adjusted by 2 to 4 units once a week until target fasting sugar (based on self-monitoring report) is achieved while avoiding hypoglycemia. Do not exceed maximum dose of 60 units / day. Consider alternative treatment option if patient requires less than 15 units or greater than 60 units per day.

 Insulin pump, may increase or decrease the rate by 15% of the total 24-hour basal amount.

 Adjustments in excess of the above are acceptable:

1. During patient illness, as outlined for sick day management.

2. Within the context of exercise management. Insulin will usually be adjusted on the basis of preprandial glucose values. However, when very tight control is desired and /or insulin analog is used, insulin may be adjusted within the above parameters according to both the pre and post-prandial glucose values.

Click the link to view the entire medical directive in detail: 


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