From the Guidelines
Overbasalization of insulin should be addressed by reducing the basal insulin dose and redistributing insulin therapy to prevent potential complications, such as hypoglycemia and high glycemic variability, as recommended by the most recent guidelines 1. To identify overbasalization, healthcare providers should monitor for signs such as basal dose exceeding 0.5 units/kg/day, significant bedtime-to-morning or postprandial-to-preprandial glucose differential, occurrences of hypoglycemia, and high glycemic variability 1. When overbasalization is suspected, a thorough reevaluation should occur promptly to further tailor therapy to the individual’s needs 1. Key factors to consider when adjusting insulin therapy include:
- Reducing the basal insulin dose by 10-20% if the patient is experiencing frequent hypoglycemia, especially overnight or during fasting periods 1
- Aiming for approximately 50% of total daily insulin as basal insulin, with the remainder as bolus (mealtime) insulin for patients on basal-bolus regimens
- Monitoring blood glucose more frequently during the adjustment period, particularly before meals and at bedtime The goal of insulin therapy is to mimic normal pancreatic function, where basal insulin maintains glucose homeostasis between meals and bolus insulin handles carbohydrate intake, making a balanced approach more effective for glucose management 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Effects of Over-Basalization of Insulin
- Over-basalization, or continuing to escalate the dose of basal insulin without a meaningful reduction in fasting plasma glucose, is not recommended 2
- This approach can lead to unnecessary increases in insulin dosage, potentially resulting in hypoglycemia or other adverse effects
- Instead, re-evaluation of individual therapy, including consideration of more concentrated basal insulin preparations and/or short-acting prandial insulin, as well as other glucose-lowering therapies, is suggested 2
Risks Associated with Basal Insulin
- Severe hypoglycemia is a potential risk associated with basal insulin therapy, particularly with certain types of insulin such as NPH 3
- The risk of severe hypoglycemia can be lower with certain long-acting basal insulin analogs, such as detemir, compared to NPH 3
- Hyperglycemia can also occur, particularly if the basal insulin dose is reduced too much, such as in hospitalized patients who are unable to eat 4
Management of Basal Insulin Therapy
- Basal insulin should be initiated at a conservative dose, such as 10 units/day or 0.1-0.2 units/kg/day, and titrated thereafter based on patient self-measured fasting plasma glucose 2
- The dose of basal insulin should be increased as required, up to approximately 0.5-1.0 units/kg/day in some cases, but over-basalization should be avoided 2
- Switching between basal insulins can be done using simple regimens, but pharmacokinetic and pharmacodynamic differences between formulations require explicit guidance to patients 2