1. Basal-Bolus vs. Sliding Scale Insulin Regimens
The Basal/Bolus Insulin Concept
 Basal insulin


The dose of insulin used to create a constant background level of
insulin in the blood is called the basal dose
Suppresses glucose production between meals and overnight
40% to 50% of daily needs
 Bolus/Prandial insulin (mealtime)


The dose of insulin used to cover the need of each meal is the prandial
dose of insulin

Limits hyperglycemia after meals

10% to 20% of total daily insulin requirement at each meal which
then equals a total of approximately 40% to 50% of daily needs

2. Basal-Bolus vs. Sliding Scale Insulin Regimens
 What’s wrong with
Sliding Scale by itself?
 Reactive Approach- waiting until
BG elevates
 Causes rollercoaster effect for
patient
 Basal/bolus approach is proactive;
more like normal insulin delivery
 Basal bolus with correction should
be used, not correction by itself in
most cases.

3. Basal-Bolus vs. Sliding Scale Insulin Regimens
 During Hospitalization
 Patients are best served by conversion from oral diabetes
agents to basal-bolus insulin therapy.
 Insulin is more versatile and easily titrated.
 IV insulin infusions are preferable in the rapidly changing
environment of acute illness, DKA or surgery.
 IV insulin has a half life of 5 minutes.
 Moghissi E, Korytkowski M, DiNardo M, Einhorn,D et al. AACE consensus
statement on inpatient glycemic control. Endocrine Practice.
2009:15(4):1-17.

4. Launch into Hyperspace

7. Starting Basal Bolus Insulin Regimen
Dosing - TDD
• Calculating Total Daily Dose (TDD) of insulin for patients with
unknown insulin requirements:
• Type 1 diabetics, 0.5–0.7 units/kg insulin/24-h period
• Type 2 diabetics, 0.4–1.0 units/kg or more
• If NPO or low intake:
• Type 1 diabetics, reduce TDD by 50%
• Type 2 diabetics, only correctional insulin is usually sufficient

8. Starting Basal Bolus Insulin Regimen
Dosing – basal/bolus
•
•
•
Basal Insulin = ½ TDD TDD=total daily dose
• Give All of Calculated Glargine (Lantus) Dose Q 24h
• We usually give at 9:00 PM. It can be given in the am if the patient routinely takes it
at this time. It is most important to give it at the same time every day
• Goal: Fasting blood sugar And Pre-Meal blood sugar should = 110-140. Fasting is
used to determine dose adjustments of Lantus
Bolus Doses = ½ TDD divided into the 3 meals
• We give prandial doses before each meal
• Prandial doses are given when the patient is eating. They are the dose that is held if
the patient is NPO. Prandial = meal.
Correction scale
-We usually give correction doses before each meal added to the prandial dose however
they can and should be given independent of the prandial dose when warranted.
-Correction doses should always be given even when the patient is NPO and even if the
prandial portion is being held.

9. Basal Guidelines
 NEVER discontinue basal insulin on a patient with Type 1 Diabetes
unless on an IV insulin infusion or an insulin pump. Holding even a
single dose can result in DKA.
 Lantus should still be given when patient is NPO.
 Renal impairment dose for Lantus should be used for creatinine
clearance of less than 30
 Lantus is not currently approved for use in pregnancy.
 You may still see Lantus used in pregnancy or you see NPH dosed BID
or an insulin pump with HumaLOG or NovoLOG

10. Basal Insulin

12. Prandial Insulin

15. Correction Insulin algorithm
Glucose
Low
type 1, very insulin
sensitive, TDD less than 40
units/day
Medium
usual type 2 starting dose,
home TDD of 40-80
units/day)
High
type 2 insulin resistant,
TDD of over 80 units/day,
IV steroid pts
Individual
(pts that high correction is not
high enough consider adding
additional units
120-139
0 units
0 units
0 units
____
140-199
1 units
2 units
3 units
____
200-249
2 units
4 units
6 units
____
250-299
3 units
6 units
9 units
____
300-349
4 units
8 units
12 units
350-399
5 units
10 units
15 units
____
400 or greater
6 units
12 units
18 units
____
mg/dl

16. Correction Insulin

18. Correction Insulin Guidelines
 Correction insulin should still be given when patient is NPO
 Give with prandial insulin based on the pre-meal blood glucose value
when patient is eating.
 Bedtime Correction: Is a lesser dose than day time correction.
 IF patient is on continuous tube feedings/TPN bedtime correction dose
is based on blood glucose result with no reduction in dose of insulin

19. Hypoglycemia Protocol

20. What if the patient is NPO??
 Basal Dose (Give
It!)
Type 1 = (Give It!) 100% dose
 Type 2 = (Give It!) but can call MD
to get dose decreased if needed

 Prandial Dose: No prandial insulin (It’s the only insulin held when
NPO)
 Correction Dose: (Give
It!) Should give Correction insulin!

21. Nursing – Notification Guidelines
•Call physician if blood sugar less than 70mg/dL or greater than
400mg/dL.
•Verify results with STAT venipuncture if less than 40mg/dL or greater
than 600 mg/dL.
•Call physician for 3 blood glucoses over 180.
•Nursing to notify pharmacy of changes in diet orders to NPO or from
NPO to eating.
•Finger stick frequency will be adjusted to reflect patient nutrition
status.