Uncontrolled hyperglycaemia is associated with poor clinical outcomes among hospitalised patients with coronavirus disease 2019 (COVID-19). |
This review provides a practical guidance on the use of the basal-bolus insulin regimen for management of hyperglycaemia in hospitalised patients. |
Various case scenarios are provided to illustrate how to achieve optimal blood glucose control through adjustments in doses of prandial and basal insulin, the use of correctional insulin dosing and changes in timing and content of major and minor meals. |
This guidance can be used for patients admitted for indications other than COVID-19 and for those in ambulatory care. |
Introduction
Basic Principles of the Basal-Bolus Insulin Regimen
Insulin preparation | Onset of action | Peak of action (h) | Duration of action (h) | Time of administration |
---|---|---|---|---|
Prandial insulin | ||||
Regular | 30–60 min | 2–4 | 6–8 | 30 min before a meal |
Lispro | 10–15 min | 1–1.5 | 3–5 | 5–15 min before a meal |
Aspart | 10–15 min | 1–2 | 3–5 | 5–15 min before a meal |
Glulisine | 10–15 min | 1–2 | 3–5 | 5–15 min before a meal |
Fast-acting insulin aspart | 3–5 min | 1 | 3–4 | At the start of a meal or up to 20 min after starting a meal |
Basal insulin | ||||
NPH | 2.5–3 h | 5–7 | 12–16 | Bedtime. When given twice daily, morning dose is administered at around 9 a.m. |
Detemir | 2–3 h | 6–8 | 12–24 | Bedtime. May be required twice daily |
Glargine U-100 | 2–3 h | No peak | ≈ 24 | Given once a day at a fixed time, generally bedtime. May be required twice daily on rare occasions |
Glargine U-300 | 4–6 h | No peak | > 24 (≈ 36) | Given once a day at a fixed time |
Degludec | 1–4 h | No peak | > 24 (≈ 42) | Given once a day at a fixed time |
Indications for the Basal-Bolus Insulin Regimen
Prerequisites for Basal-Bolus Insulin Regimen
Blood Glucose Targets
Patient characteristics | Target blood glucose | |
---|---|---|
Fasting blood glucose | 2-h postprandial blood glucose | |
Young, no comorbidities or diabetes-related complications | ≤ 120 mg/dl (6.7 mmol/L) | ≤ 160 mg/dl (8.9 mmol/L) |
Patients with terminal illness and/or limited life expectancy or at high risk of hypoglycaemia | ≤ 140 mg/dl (7.8 mmol/L) | ≤ 180 mg/dl (10.0 mmol/L)a |
How to Decide Upon the Insulin Dose When Starting the Basal-Bolus Insulin Regimen?
Blood Glucose Monitoring
Important Factors to Consider in Patients with COVID-19 Admitted to Hospital
Pattern of Blood Glucose Monitoring
Day | BBF | ABF | BL | AL | BDN | ADN | 3 a.m.a | Remarks |
---|---|---|---|---|---|---|---|---|
Day 1 | x | x | ||||||
Day 2 | x | x | ||||||
Day 3 | x | x | ||||||
Day 4 | x | x |
Daya | BBF | ABF | BL | AL | BDN | ADN | 3 a.m.b | Remarks |
---|---|---|---|---|---|---|---|---|
Day 1 | x | x | x | x | ||||
Day 2 | x | x | x | x | ||||
Day 3 | x | x | x | x | ||||
Day 4 | x | x | x | x |
Day | BBF | ABF | BL | AL | BDN | ADN | 3 a.m.a | Remarks |
---|---|---|---|---|---|---|---|---|
Day 1 | x | x | x | x | x | x | ||
Day 2 | x | x | x | x | x | x | ||
Day 3 | x | x | x | x | x | x | ||
Day 4 | x | x | x | x | x | x |
Role of Continuous Glucose Monitoring System
Insulin Dose Titration
Understanding the Segment of the Day When Insulin Works
Understanding the Type of Adjustment Needed
Prandial Insulin Adjustments
Case scenario | BG (mg/dl) | Interpretation | Problem areas | Suggested actions |
---|---|---|---|---|
Scenario 1 | 105 (BBF) 195 (ABF) 155 (BL) | 1. ABF not in target range 2. ABF–BBF > 40 mg/dl | 1. Quantity and quality of carbohydrate in breakfast 2. Insulin injection technique 3. BBF insulin dose 4. Insulin–meal gap | 1. Review quantity and quality of carbohydrate in breakfast 2. Educate patient on proper insulin injection technique 3. Increase BBF dose of regular insulin 4. Ensure 30-min gap between regular insulin and breakfast |
Scenario 2 | 108 (BDN) 220 (ADN) 160 (BBF) | 1. ADN and BBF both not in target range 2. ADN–BBF > 40 mg/dl (indicates that dose of basal insulin is adequate) | 1. Quantity and quality of carbohydrate in dinner 2. Insulin injection technique 3. BDN insulin dose 4. Insulin–meal gap | 1. Review quantity and quality of carbohydrate in dinner 2. Educate patient on proper insulin injection technique 3. Increase BDN dose of regular insulin 4. Ensure 30-min gap between regular insulin and dinner |
Scenario 3 | 105 (BDN) 95 (ADN)a – | 1. ADN < BDN and ADN < 100 mg/dl | 1. Quantity and quality of carbohydrate in dinner 2. Insulin injection site/other factors 3. BDN insulin dose 4. Insulin-meal gap | 1. Review quantity and quality of carbohydrate in dinner 2. Enquire whether BDN insulin was administered on thigh or if patient did some brisk walking or vomited or had diarrhea after dinner 3. Decrease BDN dose of regular insulin 4. Ensure that the gap between insulin and meal was not too long (> 30 min) |
Correctional Insulin Adjustment
Total daily dose (units/kg/day) | Correction factor (mg/dl)a |
---|---|
< 0.5 | 50 |
0.5 to < 1 | 40 |
1 to < 1.5 | 30 |
1.5–2 | 20 |
> 2 | Consider intravenous insulin infusion instead of correctional insulin for uncontrolled hyperglycaemia |
Basal Insulin Adjustments
Case scenario | BG (mg/dl) | Interpretation | Problem areas | Suggested actions |
---|---|---|---|---|
Scenario 1 | 154 (ADN) 60 (3 A.M.) 155 (BBF) | 1. BBF not in target range 2. 3 a.m. hypoglycaemia | 1. Missed or inadequate bedtime snack 2. Dose of basal insulin | 1. Ensure adequate bedtime snack 2. Decrease dose of basal insulin |
Scenario 2 | 158 (ADN) 140 (3 a.m.) 164 (BBF) | 1. BBF not in target range 2. 3 a.m. > 100 mg/dl 3. ADN–BBF < 40 mg/dl | 1.Quantity and quality of carbohydrate in bedtime snack 2. Insulin technique 3. Dose of basal insulin | 1. Check quantity and quality of carbohydrate in bedtime snack 2. Educate patient on proper insulin injection technique 3. Increase dose of basal insulin |
Scenario 3 | 142 (ADN) 94 (3 a.m.) 80 (BBF) | 1. BBF 70–90 mg/dl 2. 3 a.m. < 100 mg/dl | 1. Inadequate bedtime snack 2. Dose of basal insulin | 1. Ensure adequate bedtime snack 2. Decrease dose of basal insulin |
Scenario 4 | 114 (BBF)a 142 (AL) 212 (BDN) | 1. BDN not in target range 2. AL in target range | 1. Quantity and quality of carbohydrate in evening snack 2. Dose of morning basal insulin | 1. Review quantity and quality of carbohydrate in evening snack 2. Increase dose of morning basal insulinb |
Adjustment of Meals and Snacks
Case scenario | BG (mg/dl) | Interpretation | Problem area(s) | Suggested action(s) |
---|---|---|---|---|
Scenario 1 | 105 (BBF) 135 (ABF) 175 (BL) | 1. BL not in target range 2. ABF-BBF < 40 mg/dl 3. ABF in target range | 1. Mid-morning snack | Review quantity and quality of carbohydrate in mid-morning snack |
Scenario 2 | 105 (BBF) 168 (ABF) 205 (BL) | 1. ABF and BL both not in target range 1. ABF-BBF > 40 mg/dl 3. BL > ABF | 1.Quantity and quality of carbohydrate in breakfast 2.Insulin injection technique 3.Insulin dose before breakfast 4.Insulin–meal gap 5. Quantity and quality of carbohydrate in mid-morning snack(s) | 1. Review quantity and quality of carbohydrate in breakfast 2 .Educate patient on proper insulin injection technique 3. Increase BBF dose of regular insulin 4. Ensure 30-min gap between regular insulin and meal 5. Review quantity and quality of carbohydrate in mid-morning snack |
Scenario 3 | 105 (BBF) 120 (ABF) 78(BL)a | 1. BBF and ABF in target range 2. BL < BBF | 1.Delayed lunch timings 2. Missed or inadequate mid-morning snack(s) 3. Other factors | 1.Ensure lunch is not delayed 2. Ensure adequate mid-morning snack 3. Enquire whether if patient did some brisk walking or vomited or had diarrhea around lunch time |