Basal-Bolus Insulin Preparation
Initial Dosing Strategy
- For insulin-naive patients with type 2 diabetes, the American Diabetes Association recommends starting with a total daily dose of 0.3-0.5 units/kg, split 50% as basal insulin and 50% as rapid-acting prandial insulin, with lower doses for high-risk patients 1, 2, 3
- The initial dosing strategy involves calculating the total daily dose and distributing it as 50% basal insulin and 50% rapid-acting prandial insulin, with adjustments based on patient risk factors 1, 2, 3
Risk-Based Dose Reduction
- For patients at higher hypoglycemia risk, such as those over 65 years, with renal failure, or poor oral intake, the American Diabetes Association recommends using lower starting doses of 0.1-0.25 units/kg/day 1, 2
Stepwise Intensification Approach
- When basal insulin is optimized but A1C remains above goal, the American Diabetes Association recommends adding a single prandial dose of 4 units or 10% of the basal dose before the largest meal, with titration based on glucose response 4, 5
- The stepwise intensification approach involves progressing from one to two to three meals with additional prandial injections until glycemic targets are achieved 4, 5, 6
Transitioning from IV to Subcutaneous Insulin
- For ICU patients transitioning to subcutaneous therapy, the American Diabetes Association recommends calculating the total daily dose based on the average hourly IV insulin rate and splitting the dose into basal and prandial components 3, 7
Hypoglycemia Risk Management
- Basal-bolus therapy carries a higher hypoglycemia risk, and the American Diabetes Association recommends determining the cause of hypoglycemia and reducing the corresponding insulin dose by 10-20% if no clear reason is identified 4, 5
Insulin Selection
- The American Diabetes Association recommends considering prandial insulin options, including rapid-acting analogs, ultra-rapid-acting analogs, short-acting human insulin, and inhaled human insulin, based on patient needs and preferences 4, 5