The Basal/Bolus Insulin Concept

Basal insulin

The dose of insulin used to create a constant background level of insulin in the blood is called the basal dose

Suppresses glucose production between meals and overnight

40% to 50% of daily needs

Bolus/Prandial insulin (mealtime)

The dose of insulin used to cover the need of each meal is the prandial dose of insulin

Limits hyperglycemia after meals

10% to 20% of total daily insulin requirement at each meal which then equals a total of approximately 40% to 50% of daily needs

Basal-Bolus vs. Sliding Scale Insulin Regimens

What’s wrong with Sliding Scale by itself?

Reactive Approach- waiting until BG elevates

Causes rollercoaster effect for patient

Basal/bolus approach is proactive; more like normal insulin delivery

Basal bolus with correction should be used, not correction by itself in most cases.

Basal-Bolus vs. Sliding Scale Insulin Regimens

During Hospitalization Patients are best served by conversion from oral diabetes

agents to basal-bolus insulin therapy.

Insulin is more versatile and easily titrated.

IV insulin infusions are preferable in the rapidly changing environment of acute illness, DKA or surgery.

IV insulin has a half life of 5 minutes.

Moghissi E, Korytkowski M, DiNardo M, Einhorn,D et al. AACE consensus statement on inpatient glycemic control. Endocrine Practice. 2009:15(4):1-17.

Basal-Bolus vs. Sliding Scale Insulin Regimens

Launch into Hyperspace

Starting Basal Bolus Insulin Regimen

Dosing - TDD

• Calculating Total Daily Dose (TDD) of insulin for patients with unknown insulin requirements: • Type 1 diabetics, 0.5–0.7 units/kg insulin/24-h period• Type 2 diabetics, 0.4–1.0 units/kg or more• If NPO or low intake:

• Type 1 diabetics, reduce TDD by 50% • Type 2 diabetics, only correctional insulin is usually sufficient

Starting Basal Bolus Insulin Regimen

Dosing – basal/bolus

• Basal Insulin = ½ TDD TDD=total daily dose• Give All of Calculated Glargine (Lantus) Dose Q 24h• We usually give at 9:00 PM. It can be given in the am if the patient routinely takes it

at this time. It is most important to give it at the same time every day• Goal: Fasting blood sugar And Pre-Meal blood sugar should = 110-140. Fasting is

used to determine dose adjustments of Lantus• Bolus Doses = ½ TDD divided into the 3 meals

• We give prandial doses before each meal• Prandial doses are given when the patient is eating. They are the dose that is held if

the patient is NPO. Prandial = meal.• Correction scale

-We usually give correction doses before each meal added to the prandial dose however they can and should be given independent of the prandial dose when warranted.-Correction doses should always be given even when the patient is NPO and even if the prandial portion is being held.

NEVER discontinue basal insulin on a patient with Type 1 Diabetes unless on an IV insulin infusion or an insulin pump. Holding even a single dose can result in DKA.

Lantus should still be given when patient is NPO.

Renal impairment dose for Lantus should be used for creatinine clearance of less than 30

Lantus is not currently approved for use in pregnancy.

You may still see Lantus used in pregnancy or you see NPH dosed BID or an insulin pump with HumaLOG or NovoLOG

Basal Guidelines

Basal Insulin

Prandial Insulin

Glucose

mg/dl

Low

type 1, very insulin

sensitive, TDD less than 40

units/day

Medium

usual type 2 starting dose,

home TDD of 40-80

units/day)

High

type 2 insulin resistant,

TDD of over 80 units/day,

IV steroid pts

Individual

(pts that high correction is not

high enough consider adding

additional units

120-139 0 units 0 units 0 units ____

140-199 1 units 2 units 3 units ____

200-249 2 units 4 units 6 units ____

250-299 3 units 6 units 9 units ____

300-349 4 units 8 units 12 units

350-399 5 units 10 units 15 units ____

400 or greater 6 units 12 units 18 units ____

Correction Insulin algorithm

Correction Insulin

Correction insulin should still be given when patient is NPO

Give with prandial insulin based on the pre-meal blood glucose value when patient is eating.

Bedtime Correction: Is a lesser dose than day time correction.

IF patient is on continuous tube feedings/TPN bedtime correction dose is based on blood glucose result with no reduction in dose of insulin

Correction Insulin Guidelines

Hypoglycemia Protocol

Basal Dose (Give It!) Type 1 = (Give It!) 100% dose Type 2 = (Give It!) but can call MD

to get dose decreased if needed

Prandial Dose: No prandial insulin (It’s the only insulin held when NPO)

Correction Dose: (Give It!) Should give Correction insulin!

What if the patient is NPO??

•Call physician if blood sugar less than 70mg/dL or greater than 400mg/dL.

•Verify results with STAT venipuncture if less than 40mg/dL or greater than 600 mg/dL.

•Call physician for 3 blood glucoses over 180.

•Nursing to notify pharmacy of changes in diet orders to NPO or from NPO to eating.

•Finger stick frequency will be adjusted to reflect patient nutrition status.

Nursing – Notification Guidelines