What is the recommended calculation or percentage to increase basal-bolus insulin (basal insulin and bolus insulin) by for uncontrolled hyperglycemia (high blood sugar)?

Insulin Dose Adjustment for Uncontrolled Hyperglycemia on Basal-Bolus Therapy

For uncontrolled hyperglycemia on basal-bolus insulin, increase the insulin dose by 10-15% (or 2-4 units for lower doses) every 3 days, targeting the specific insulin component (basal or bolus) based on which glucose values are elevated. 1, 2

Algorithmic Approach to Dose Adjustment

Step 1: Identify Which Component Needs Adjustment

Basal insulin adjustment is indicated when:

• Fasting blood glucose remains elevated 1
• Increase by 4 units every 3 days if fasting glucose ≥180 mg/dL 3
• Increase by 2 units every 3 days if fasting glucose is 140-179 mg/dL 3
• Continue titration until fasting glucose reaches 80-130 mg/dL 2, 3

Bolus insulin adjustment is indicated when:

• Pre-meal or 2-hour postprandial glucose values are elevated despite controlled fasting glucose 3, 4
• Increase prandial insulin by 1-2 units or 10-15% every 3 days based on pre-meal and postprandial readings 3

Step 2: Recognize When to Add Rather Than Increase

Critical decision point: When basal insulin exceeds 0.5 units/kg/day and glucose remains uncontrolled, adding prandial insulin is more appropriate than continuing to escalate basal insulin alone 3. This prevents "overbasalization," which increases hypoglycemia risk without improving control 3.

Signs of overbasalization include:

• Basal dose >0.5 units/kg/day 3
• High bedtime-to-morning glucose differential (≥50 mg/dL) 3
• Hypoglycemia episodes 3
• High glucose variability 3

Step 3: Specific Percentage Increases by Clinical Context

For hospitalized patients (insulin-naive or low-dose):

• Start with total daily dose of 0.3-0.5 units/kg, split 50% basal and 50% bolus 1
• For patients on high-dose home insulin (≥0.6 units/kg/day), reduce total daily dose by 20% upon admission to prevent hypoglycemia 1

For outpatients with persistent hyperglycemia:

• If >50% of glucose values are above target, increase the relevant insulin component by 10-15% 2
• Alternative approach: increase by 2-4 units once or twice weekly until targets are met 2, 3

Step 4: Safety Adjustments for Hypoglycemia

If hypoglycemia occurs:

• Reduce the dose by 10-20% if no clear precipitating cause is identified 1, 2
• If more than 2 glucose values per week are <80 mg/dL, decrease basal insulin by 2 units 3

Common Pitfalls to Avoid

Continuing to escalate basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia leads to suboptimal control and increased hypoglycemia risk 3. Blood glucose in the 200s mg/dL likely reflects both inadequate basal coverage AND postprandial excursions requiring mealtime insulin 3.

Delaying dose adjustments: Most patients can be taught to uptitrate their own insulin dose, adding 1-2 units (or 5-10% for higher doses) once or twice weekly if glucose levels remain above target 3. The traditional 50-50 basal-to-bolus ratio does not apply to all patients with type 2 diabetes; individual ratios vary significantly and change over time 5.

Using sliding scale insulin alone in patients with established diabetes is discouraged, as it treats hyperglycemia after it occurs rather than preventing it 1. Scheduled basal-bolus regimens provide superior glycemic control 1, 6.

Special Population Considerations

Older adults (>65 years), those with renal failure, or poor oral intake:

• Use lower starting doses (0.1-0.25 units/kg/day for basal-plus approach) 1
• These patients have higher hypoglycemia risk and require more conservative titration 1

Patients on glucocorticoids:

• May require additional NPH insulin (0.1-0.3 units/kg/day) or increased glargine doses 3