How to adjust Basal (basal) insulin when a large dose of regular (short-acting) insulin is required?

From the Guidelines

When adjusting basal insulin in the context of requiring a large dose of regular insulin, it is crucial to decrease the basal insulin dose by the same amount as the starting mealtime dose to avoid hypoglycemia and optimize glucose control. This approach is supported by the American Diabetes Association's standards of medical care in diabetes, which emphasize the importance of adjusting insulin therapy based on individual patient needs and glucose targets 1. Key considerations include:

• Starting with a safe and simple basal insulin regimen, such as 10 units or 0.1 to 0.2 units/kg of body weight per day, and adjusting as needed to achieve fasting blood glucose targets 1.
• When adding mealtime insulin, starting with a dose of 4 U per meal, 0.1 U/kg per meal, or 10% of the basal insulin dose per meal, and considering a decrease in basal insulin dose to avoid over-insulinization 1.
• Monitoring blood glucose levels closely to adjust insulin doses and prevent hypoglycemia, especially when using concentrated insulin products or adjusting basal and mealtime insulin doses 1.
• Considering the use of premixed insulin products or concentrated insulin preparations for patients who require higher doses of insulin or simpler dosing regimens 1. By taking a patient-centered approach to adjusting basal insulin in the context of large doses of regular insulin, healthcare providers can help optimize glucose control, reduce the risk of hypoglycemia, and improve overall quality of life for individuals with diabetes.

From the FDA Drug Label

Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), during acute illness, or changes in renal or hepatic function. Dosage adjustments should only be made under medical supervision with appropriate glucose monitoring [see Warnings and Precautions (5.2)].

The FDA drug label does not provide specific guidance on adjusting basal insulin when a large dose of regular insulin is required. However, it does mention that dosage adjustments may be needed with changes in meal patterns or during acute illness, and that these adjustments should be made under medical supervision with appropriate glucose monitoring 2.

• Basal insulin adjustments should be individualized based on the patient's metabolic needs and glycemic control goal.
• Medical supervision and glucose monitoring are recommended when making dosage adjustments.

From the Research

Adjusting Basal Insulin with Large Doses of Regular Insulin

• When a large dose of regular (short-acting) insulin is required, adjusting basal (basal) insulin is crucial to maintain good glycemic control and prevent diabetes-associated complications 3, 4.
• The initiation and titration of basal insulins should be managed by primary care providers, who should understand how to correctly manage basal insulin doses and help patients self-manage insulin injections 4.
• Basal insulin is usually initiated at a conservative dose of 10 units/day or 0.1-0.2 units/kg/day, then titrated thereafter over several weeks or months, based on patients' self-measured fasting plasma glucose, to achieve an individualized target (usually 80-130 mg/dL) 4.
• A simple rule is to gradually increase the initial dose by 1 unit per day (NPH, insulin detemir, and glargine 100 units/mL) or 2-4 units once or twice per week (NPH, insulin detemir, glargine 100 and 300 units/mL, and degludec) until FPG levels remain consistently within the target range 4.
• If a large dose of regular insulin is required, the dose of basal insulin should be adjusted accordingly to avoid overbasalization (continuing to escalate dose without a meaningful reduction in fasting plasma glucose) 4, 5.
• The management of postprandial glucose excursions with a rapid-acting insulin, such as insulin glulisine, can provide further improvements in glycemic control when basal insulin is not enough 5.
• A patient-managed insulin intensification strategy with insulin glargine and insulin glulisine can provide similar glycemic control as a physician-managed strategy, allowing patients to self-titrate their insulin doses 6.