Should I hold basal (basal insulin) when experiencing hypoglycemia and resume when glucose levels return to normal?

Management of Basal Insulin During Hypoglycemia

Do not hold basal insulin when hypoglycemia occurs; instead, immediately reduce the basal insulin dose by 10-20% and continue administration while treating the acute hypoglycemic episode. 1, 2

Critical Context: Why Basal Insulin Should Not Be Held

Basal insulin must be continued in hospitalized patients, particularly those with type 1 diabetes, even during hypoglycemia. 1 The 2025 American Diabetes Association guidelines explicitly state that policies should be in place to ensure basal insulin is not held for people with type 1 diabetes, especially during care transitions. 1

The evidence is clear on the dangers of holding basal insulin:

• 75% of hospitalized patients who experienced hypoglycemia did not have their basal insulin dose adjusted before the next administration, leading to recurrent episodes. 1, 2
• 84% of patients who develop severe hypoglycemia (<40 mg/dL) had a preceding episode of milder hypoglycemia (<70 mg/dL) during the same admission. 1, 2

Immediate Management Algorithm

Step 1: Treat the Acute Hypoglycemia

• Implement your hospital's standardized hypoglycemia treatment protocol for blood glucose <70 mg/dL (<3.9 mmol/L). 1
• Administer 15-20 grams of fast-acting carbohydrates and recheck glucose in 15 minutes. 2

Step 2: Reduce Basal Insulin Dose (Do Not Hold)

The treatment plan must be reviewed and changed when blood glucose falls below 70 mg/dL (<3.9 mmol/L), as this level predicts subsequent severe hypoglycemia. 1, 2

Dose reduction protocol:

• For first hypoglycemic episode with no other risk factors: Reduce basal insulin by 10%. 2
• For recurrent hypoglycemia, near-hypoglycemic values (<80 mg/dL), or patients with renal insufficiency: Reduce basal insulin by 20%. 2

Step 3: Continue Basal Insulin at Reduced Dose

• Administer the reduced dose at the scheduled time. 1
• Never hold basal insulin entirely, as this creates a gap in coverage that leads to rebound hyperglycemia and metabolic instability. 1

Monitoring After Dose Adjustment

Intensify glucose monitoring immediately after any hypoglycemic episode: 2

• Check fasting blood glucose daily for at least one week. 2
• Target fasting glucose range: 80-130 mg/dL (4.4-7.2 mmol/L). 2
• Consider checking glucose at bedtime, 3:00 AM, and upon waking if nocturnal hypoglycemia occurred. 3

Subsequent titration based on monitoring: 2

• If >50% of fasting glucose values remain above 130 mg/dL (7.2 mmol/L): Increase insulin by 1 unit.
• If ≥2 glucose values per week fall below 80 mg/dL (4.4 mmol/L): Decrease insulin by an additional 1 unit.

Special Populations Requiring Extra Caution

Type 1 diabetes patients: 1

• Basal insulin is absolutely essential and must never be held, even if the patient is NPO (nothing by mouth).
• Holding basal insulin in type 1 diabetes can precipitate diabetic ketoacidosis.
• Electronic health record alerts should be in place to prevent inadvertent holding of basal insulin. 1

High-risk patients requiring lower initial doses (0.3 U/kg/day or less): 1, 4

• Age >65 years
• Renal failure (decreased insulin clearance increases hypoglycemia risk) 1
• Poor oral intake
• Previous severe hypoglycemia

Common Pitfalls to Avoid

Do not continue the same basal insulin dose without adjustment. 1, 2 This is the most common error—in one study, 75% of patients with hypoglycemia had no dose change before their next insulin administration, leading to recurrent episodes. 1

Do not assume the hypoglycemia was caused by a reversible factor without clear documentation. 2 While nutrition-insulin mismatch should be evaluated, isolated hypoglycemia typically indicates excessive insulin dosing requiring permanent dose reduction. 2

Do not use sliding scale (correctional) insulin alone as the sole treatment. 1 This outdated practice is strongly discouraged and provides inadequate glycemic control while increasing hypoglycemia risk. 1

Risk Factor Assessment

Evaluate for modifiable causes: 2

• Nutrition-insulin mismatch: Ensure insulin timing is coordinated with meal delivery. 1, 2
• Acute kidney injury or declining renal function (major risk factor due to decreased insulin clearance). 1, 2
• Changes in physical activity or medication regimen. 5

Documentation and Quality Improvement

All hypoglycemic episodes must be documented in the electronic health record and tracked as part of quality improvement efforts. 1, 2 This allows for system-level interventions to reduce preventable hypoglycemia. 1

When to Consider Alternative Insulin Regimens

If hypoglycemia recurs despite appropriate dose reduction: 2, 3

• Consider switching to ultra-long-acting basal insulin analogs (e.g., insulin degludec), which have lower rates of nocturnal hypoglycemia. 6, 7, 8
• Evaluate for "overbasalization" and consider switching to separate basal and bolus components if using premixed insulin. 3
• Reassess timing of insulin administration (e.g., moving evening dose to earlier in the day for nocturnal hypoglycemia). 3