Basal Bolus Dosing: A Clinical Experience

Abstract

Basal bolus insulin dosing (BBD) may be defined as the physiological replacement of basal and bolus insulin to achieve near normal glycemia without hypoglycemia and loss of life quality. Normally, continuous and variable basal insulin release provides partial suppression of hepatic glucose production to maintain euglycemia during the fasting period. With meals, additional insulin is released in a biphasic pattern to further suppress hepatic glucose production and to increase glucose transport into muscle, fat and liver. Newer subcutaneous insulins for bolus and basal mimic near normal secretion. In addition, improvements in continuous subcutaneous insulin infusion pump features such as dual wave insulin delivery allow improved postprandial glycemia. Insulin dosing is done in a three step process. Firstly, the dosage is estimated based on formulas derived from body weight or previous insulin requirements. Secondly, pre-dosing adjustments modify these formulas by considering estimations of insulin sensitivity based on clinical judgment and laboratory evaluations. Lastly, post-dosage adjustments are based on timed, self-monitored, blood glucose determinations assisted by overall average glucose determinations such as hemoglobin A1c. Continuous glucose monitoring systems have provided a more insightful tool for dosage adjustments. Daily consecutive intensive glucose evaluations using a continuous glucose monitoring system and corresponding dosage adjustments may offer an even better tool for insulin dosing selection.

Attributes Influencing Insulin Pen Preference Among Caregivers and Patients With Diabetes Who Require Greater Than 20 Units of Mealtime Insulin

“…4 In addition, some patients with T2DM may have higher insulin requirements particularly if they are overweight or obese. [5][6][7] Excess body weight is known to be a major contributor to insulin resistance, 8 and as insulin resistance worsens, exogenous insulin requirements increase. 9 Published real-life data from retrospective, [10][11][12] prospective observational, 13,14 and noninterventional studies 15 have identified patients with T2DM who report using more than 20 units of mealtime insulin per day.…”

Weight-Based, Insulin Dose–Related Hypoglycemia in Hospitalized Patients With Diabetes

“…Current guidelines on inpatient diabetes management call for basal-bolus insulin therapy for hospital-ward patients (4–6), in which one approach to determining insulin dose is based on weight (i.e., total daily units per kilogram of body weight). The initial daily insulin doses of basal-bolus protocols vary widely, from 0.3 to 1.5 units/kg (5,7–10).…”

Insulin Therapy for the Management of Hyperglycemia in Hospitalized Patients

“…Scheduled subcutaneous insulin therapy with basal or intermediate acting insulin given once or twice a day in combination with short-acting or rapid-acting insulin administered before meals is preferred as an effective and safe strategy for glycemic management in non–critically ill patients. 18,149 Subcutaneous insulin programs should address the 3 components of insulin requirement: basal (what is required in the fasting state), nutritional (what is required for glucose elevations or to dispose of glucose in hyperglycemia) (Fig. 3).…”