What should be my basal bolus regimen if the average infusion rate of insulin is 11 units/hour?

Basal-Bolus Insulin Regimen After 11 Units/Hour Infusion

For a patient receiving an average insulin infusion of 11 units/hour, calculate the total daily dose as 264 units (11 units/hour × 24 hours), then administer 50% as basal insulin (132 units daily) and 50% as prandial insulin (44 units divided before each of three meals). 1

Calculation Method

The transition from continuous insulin infusion to subcutaneous therapy should be based on the average insulin infusion rate over the preceding 12-24 hours before transition. 1

Total Daily Dose Calculation:

• Average infusion rate: 11 units/hour
• Total daily requirement: 11 × 24 = 264 units/day 1

Standard Basal-Bolus Distribution

Basal Insulin Component:

• 50% of total daily dose = 132 units 1, 2
• Administer as long-acting insulin (glargine or detemir) once or twice daily 1
• If using glargine once daily: 132 units at the same time each day 1
• If using NPH or detemir: Consider splitting into 66 units twice daily 1

Prandial Insulin Component:

• 50% of total daily dose = 132 units 1, 2
• Divide equally before three meals: 44 units before each meal 1
• Use rapid-acting insulin analogs (lispro, aspart, or glulisine) 1, 3

Critical Timing Considerations

When to Transition:

• Ensure stable glucose measurements for at least 4-6 hours consecutively 1
• Confirm hemodynamic stability (not requiring vasopressors) 1
• Verify normal anion gap and resolution of acidosis if transitioning from DKA 1
• Establish stable nutrition plan 1

Overlap Strategy:

• Administer the first subcutaneous basal insulin dose 2-4 hours before discontinuing the insulin infusion to prevent rebound hyperglycemia 1

Alternative Approach: Basal-Plus Regimen

For patients with poor or unpredictable oral intake, consider a basal-plus regimen as an effective alternative: 3

• Basal insulin: 132 units once daily (same as above) 3
• Correctional rapid-acting insulin only before meals (no scheduled prandial doses) 3
• This approach resulted in similar glycemic control to full basal-bolus with lower hypoglycemia risk in medical/surgical patients 3

High-Risk Patient Modifications

This patient requires dose reduction due to the high total daily dose (264 units represents approximately 2.6 units/kg for a 100 kg patient). 1

For patients at higher risk of hypoglycemia, reduce the calculated dose by 20%: 1

• Elderly patients (>65 years) 1
• Renal failure 1
• Poor or unpredictable oral intake 1

Adjusted doses for high-risk patients:

• Total daily dose: 264 × 0.8 = 211 units
• Basal: 106 units daily
• Prandial: 35 units before each meal

Monitoring and Titration

Initial Monitoring:

• Check fasting glucose daily to assess basal insulin adequacy 1, 4
• Check pre-meal and 2-hour post-meal glucose to assess prandial insulin 1
• Monitor for hypoglycemia, especially in the first 24-48 hours 1

Dose Adjustments:

• Adjust basal insulin by 10-15% or 2-4 units every 3 days based on fasting glucose 1, 4
• Adjust prandial insulin by 1-2 units or 10-15% every 3 days based on post-meal glucose 4, 2
• If hypoglycemia occurs, reduce the corresponding insulin component by 10-20% 1, 2

Critical Pitfalls to Avoid

Do not use sliding scale insulin alone as the primary regimen—this approach is associated with poor glycemic control and increased complications. 1 Scheduled basal-bolus therapy with correctional insulin is superior. 1

Monitor potassium closely during the transition, as hypokalaemia occurs in approximately 50% of patients during treatment of hyperglycemic crises, and severe hypokalaemia (<2.5 mEq/L) is associated with increased mortality. 1

Watch for signs of overbasalization if you need to increase doses beyond 0.5 units/kg/day, including bedtime-to-morning glucose differential ≥50 mg/dL and increased hypoglycemia. 4, 2