Basal-Plus Insulin Regimen Example for a 70-kg Adult
For a 70-kg adult, a basal-plus regimen consists of once-daily basal insulin (glargine or detemir) at 14-21 units daily (0.2-0.3 U/kg), plus correctional rapid-acting insulin (lispro, aspart, or glulisine) administered before meals or every 4-6 hours using a sliding scale of 2-4 units for glucose 141-180 mg/dL, escalating to 14-16 units for glucose ≥400 mg/dL. 1
Detailed Dosing Protocol
Basal Insulin Component
- Initial dose: 14-21 units once daily (0.2-0.3 U/kg for 70 kg patient) 2
- Timing: Administer glargine or detemir at the same time each day
- Titration: Increase by 2 units every 2-5 days based on fasting blood glucose 2
- If FBG >180 mg/dL: add 20% of total daily dose
- If FBG 140-180 mg/dL: add 10% of total daily dose
- If FBG 110-139 mg/dL: add 1 unit
Correctional Rapid-Acting Insulin Component
For patients eating meals, use the "usual" column before each meal 1:
| Blood Glucose (mg/dL) | Insulin Dose (units) |
|---|---|
| 141-180 | 4 |
| 181-220 | 6 |
| 221-260 | 8 |
| 261-300 | 10 |
| 301-350 | 12 |
| 351-400 | 14 |
| ≥400 | 16 |
For NPO patients, use the "insulin-sensitive" column every 4-6 hours 1:
| Blood Glucose (mg/dL) | Insulin Dose (units) |
|---|---|
| 141-180 | 2 |
| 181-220 | 4 |
| 221-260 | 6 |
| 261-300 | 8 |
| 301-350 | 10 |
| 351-400 | 12 |
| ≥400 | 14 |
NPO Status Adjustments
When a patient becomes NPO, continue the full basal insulin dose but switch to the insulin-sensitive correctional scale administered every 4-6 hours with rapid-acting insulin (or every 6 hours with regular insulin). 1, 3 This approach maintains glycemic control while minimizing hypoglycemia risk in patients with reduced nutritional intake.
Recent evidence suggests that maintaining basal insulin doses rather than reducing them may be appropriate for NPO patients. A 2020 study found no difference in hypoglycemia rates between patients receiving ≤50% versus >50% of home basal insulin doses while NPO 4, and a 2022 study confirmed similar hypoglycemia rates across various dose reductions 5. Therefore, continuing the established basal dose with appropriate correctional insulin is the preferred strategy. 3
Clinical Rationale
The basal-plus approach offers several advantages over sliding-scale insulin alone or full basal-bolus regimens:
- Efficacy: Achieves glycemic control equivalent to basal-bolus regimens with fewer injections 6, 7
- Safety: Lower hypoglycemia risk compared to basal-bolus (13% vs 16%) while maintaining superior control versus sliding-scale alone 6
- Simplicity: More practical for real-world implementation, particularly in hospitalized patients 3, 6
Important Caveats
Hypoglycemia management: If blood glucose drops below 70 mg/dL, reduce the total daily insulin dose by 10-20%; if below 40 mg/dL, reduce by 20-40% 2
Elderly and renal impairment: Use lower initial doses (0.2-0.3 U/kg) in patients ≥70 years or with GFR <60 mL/min 1
Transition from IV insulin: When converting from continuous IV insulin, calculate the total daily subcutaneous dose as the average hourly IV rate × 24 hours, then distribute as 50% basal and 50% correctional 3
Avoid overbasalization: If basal doses exceed 0.5 U/kg/day without achieving glycemic targets, consider adding scheduled prandial insulin rather than continuing to escalate basal doses 2