What does the basal-bolus regimen mean?
The basal-bolus regimen tries to mimic the normal functioning of the pancreas using two types of insulin. Basal (long-acting) insulin maintains stable blood glucose between meals and overnight, while rapid-acting insulin boluses are given for each meal and corrections. Basal insulin generally represents half of the daily requirement. This regimen offers you the greatest flexibility in choosing when and what to eat.
With the basal-bolus regimen you take a minimum of four injections per day, but you achieve the best possible glycemic control. You can make fine adjustments whenever you want. For example, you can skip a meal, eat more or less, make corrections when needed. It is the gold standard regimen for administering insulin injections in type 1 diabetes because it comes closest to normal pancreatic function.
How many injections are needed per day?
Most people with type 1 diabetes take between four and eight injections per day. The minimum for the basal-bolus regimen is four. You take one long-acting insulin injection and one rapid-acting insulin injection for each of the three main meals. In reality, most patients take more than six injections by adding corrections for hyperglycemia or boluses for snacks.
There is no "too many" injections if they improve your control. Some highly motivated people take ten injections daily for the best possible glycemic control. Insulin pumps eliminate multiple injections, and technically speaking they deliver hundreds of micro-doses per day. The important thing is to take enough injections to keep your blood glucose on target, not to minimize their number.
What is intensive insulin therapy?
Intensive therapy means active and frequent adjustment of insulin doses based on blood glucose, carbohydrates, physical activity, and other factors. It includes a minimum of four injections per day (or pump), measuring blood glucose at least four times per day, and precise dose calculation. You don't follow fixed doses, but adapt each dose to the current situation using insulin-to-carbohydrate ratios and correction factors that differ across various time intervals.
Intensive therapy requires solid diabetes education, but offers the best control and the greatest freedom. The DCCT study demonstrated that it dramatically reduces long-term complications. It requires dedication and continuous learning. It is the only regimen currently recommended for type 1 diabetes.
Can I use only two injections per day?
The two-injection regimen (mixed insulin in the morning and evening) is outdated and inadequate for most people with type 1 diabetes. It provides poor glycemic control, requires meals and snacks at fixed times, and does not allow flexibility. It may be temporarily acceptable only in special situations, such as elderly people or those with severe cognitive problems.
With only two injections you cannot correct hyperglycemia, cannot adapt doses to meal content, and risk frequent hypoglycemia due to NPH insulin action peaks. HbA1c will probably be above 8% (64 mmol/mol) and the risk of complications increases significantly. If your doctor proposes this regimen for type 1 diabetes, seek a second opinion from another diabetologist.
What do I do if I forget an insulin dose?
If you forget your mealtime rapid-acting insulin and remember within 30-60 minutes, take the full dose immediately. After two hours, take only half the dose because part of the food has already been absorbed. You are actually taking a correction dose now. After three hours, only take a correction based on your current blood glucose. Check your blood glucose two hours after taking the missed dose and correct additionally if necessary.
For missed basal insulin, take the full dose. In the following days, gradually modify the administration time to return to your usual time. For insulin degludec, if you forgot the evening dose, you can take it in the morning and then take the next dose directly in the evening, as if nothing had happened. Monitor blood glucose carefully and make corrections with rapid-acting insulin if needed.
How do I adjust insulin doses?
Dose adjustment is done gradually, changing the dose very little and waiting three days to see the effect. For basal insulin, if blood glucose rises or falls too much overnight, adjust by 1-2 units. For meal boluses, if blood glucose two hours after a meal is consistently too high or too low, modify the insulin-to-carbohydrate ratio.
Keep a detailed log with blood glucose readings, doses, carbohydrates, and activities to identify patterns. The general rule is that if you see the same pattern for several days in a row, make a small adjustment. Don't make big changes. Small and repeated adjustments are better. Learn to distinguish between an atypical day and a real trend that truly requires an adjustment.
What regimens do children with diabetes use?
Children use the same basal-bolus regimens as adults, but with age-specific particularities. Doses are much smaller and require frequent adjustments. Sometimes insulin dilutions are used for very small doses. The insulin pump is ideal for children due to the small doses needed, as well as the precision and flexibility offered.
Parents must be taught to manage the tendency for high glycemic variability. Children have sometimes unpredictable physical activity, irregular meals, frequent (common) illnesses. Adolescents need higher doses due to insulin resistance associated with puberty, sometimes reaching 1.5-2 units/kg/day. The regimen must allow progressive autonomy for the child, who must gradually learn to manage their diabetes on their own.
Is the pump better than multiple injections?
The insulin pump offers clear advantages through more precise dosing, programmable basal rates for different times of day, extended boluses for complex meals, and elimination of multiple injections. Studies show similar or slightly better HbA1c achievement with the standard pump, but fewer severe hypoglycemia episodes and less glycemic variability. Quality of life is usually better with the pump.
However, the standard pump does not guarantee better control. Some people achieve excellent control with insulin pens and prefer not to be "connected" permanently to a device. The pump is more expensive and requires technical training. The best option is the one you use correctly and consistently. The exception might be pumps capable of closed-loop operation (clearly superior).