Considerations for Basal or Bolus Insulin in Diabetes

Serge Jabbour, MD: When I start patients on insulin, if they are in a metabolic state—meaning A1C above 9% and losing weight at the same time or looking sick—then I start basal insulin at mealtime right away. Now, if patients cannot handle 4 injections a day, one option for those patients is to use a premixed insulin as a twice-a-day injection. It’s not ideal, but it’s a good way to start. Until patients get more diabetes education, we can convert that to a basal mealtime regimen. If patients are not in a catabolic state, many times they find it much easier and more convenient to start 1 injection of a basal insulin and titrate it over time until we see, over some weeks to months, if we need to add a mealtime insulin. So, it depends on every patient. It depends on how they present to me with a high A1C level and their symptoms at the same time.

Davida F. Kruger, MSN, APN-BC, BC-ADM: When I’m looking at patients to decide to start insulin, there are a couple of things I might look at. First of all, what other therapies are on board? Are they working? What’s the A1C level, the age of the patient, or other comorbidities? But most of my patients are going to need to progress to insulin. I’m a specialist, so I’m going to put most of my patients on insulin. But if your A1C is high, and you’re not achieving goals on oral agents, you need to think about a basal insulin. You need to understand what the basal insulin does. It controls fasting blood sugars, and I like to think about it as the background for the rest of the day. So, it keeps the blood sugars at a steady state for the 24 hours we’re giving that type of insulin.

Now, as I get the A1C down, what we’ve learned is that if you get the A1C level to less than 8%, for many of our patients, we need to start thinking about what’s happening with the postprandial blood sugars 2 hours after meals. If I’m unable to control A1C and get them to treatment goal on a basal insulin only, I need to start thinking about mealtime insulin. It may not be all 3 meals at once. I may start at the largest meal, then give it for a second meal, and some patients do very well on basal and 2 meals a day. I may need 3 meals a day. But you have to understand that the basal insulin is for 24-hour coverage, waking up with a good blood glucose. The bolus insulin is designed for the blood glucose before the meal and the carbohydrates in the food that the patient is consuming.

Robert Hood, MD: From the standpoint of educating our patients, we should really try to put ourselves in the patient’s shoes and understand what it’s like to live with diabetes and what we’re asking them to do. First of all, a patient doesn’t want to be on insulin. They’ve often negotiated and tried to avoid insulin for as long as possible, and they sort of dread that first injection.

We should spend more time emphasizing with the patient the benefit of blood sugar control and the fact that because diabetes is progressive, going on to insulin isn’t necessarily their fault. Insulin is just 1 tool that we have to treat diabetes—and a very effective tool at that. The more time we spend with education, the better patients will do with taking their insulin. When we start patients on insulin or we make a significant change in insulin therapy, it’s not just the mechanics of how you administer the insulin—it’s also reviewing safety factors like recognition and treatment of hypoglycemia, knowing how often they should be checking their blood sugars, knowing how the insulin is going to be adjusted, having an ear to what the patients have going on in their lives, and understanding how it fits into their lifestyle. What is also very helpful is having a significant other in there, whether it’s a spouse, a sibling, a girlfriend or boyfriend—someone who can be their coach and support them through this. Finally, when it comes to an insulin therapy—or any injectable therapy, for that matter—it’s ideal if they get their first injection at that time. So, if you could do point-of-care education that includes the first injection, you’ve demystified a lot of the concerns that they have about the injection itself.

Davida F. Kruger, MSN, APN-BC, BC-ADM: When I start bolus insulin or mealtime insulin, it could be for just the meals, or it could be to cover snacks. There are a lot of reasons that you might use a rapid-acting insulin. You don’t want to necessarily give the patient a sliding scale. The problem with a sliding scale is that it is too late. The insulin is too late—meaning that you’re looking at a blood glucose and you’re giving an insulin for that blood glucose, but you’re not accounting for the food intake.

When you think about how to regulate a rapid-acting insulin, you need to look at the blood sugar and do a correction for the blood sugar. Then you need to give that patient coverage for the food intake. It’s 2 parts. The other thing is, you need to give it 10 to 15 minutes before the meal, because it’s to cover the food. If I give it during the meal or after the meal, I’m going to have a mismatch of the insulin. Look at the blood sugar. You have to have a component of that to cover the blood sugar, a component to cover the carbohydrates, and you must give it 10 to 15 minutes before the meal.

Transcript edited for clarity.