Basal Insulin: The Unsung Hero

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I have to say I am a great lover of basal insulin, or background insulin as it is often known as. With the advent of carbohydrate counting, correction doses and insulin pump therapy, basal insulin has taken a bit of a back seat which is a shame, as basal insulin is the foundation in which insulin regimes are built on. It is the one insulin that most people ignore, or give up on it too quickly. I hasten to add that this blog is about basal insulin via injectables, as opposed to basal insulin rates in pump therapy.

Basal insulin is a background, once a day insulin that lasts 16-24 hours in the body. The two most commonly basal insulin’s are Levimir made by Novonordisk and Lantus by Sanofi Aventis. It is common for Levimir to be taken as a split dose i.e. that instead of 40units all together in the evening, you take 20units in the morning and 20 units in the evening. It is believed this may provide better coverage as Levimir is seen to have a shorter duration than Lantus [1].

Basal insulin has a very important function, to match the liver’s secretion of glucose into the bloodstream (and to prevent the liver from over secreting glucose). Everyone’s liver does it, and a healthy pancreas responds by secreting a small amount of insulin into the bloodstream every few minutes. Because the liver is secreting glucose into the bloodstream continuously, a complete lack of insulin, even for just an hour or two, would result in a sharp rise in blood glucose levels. Basal insulin also makes sure that the body’s cells are nourished with a steady supply of glucose to burn for energy. Without basal insulin, many of the body’s cells would starve for fuel. Some cells would resort to burning only fat for energy, and that leads to production of acidic waste [pull_quote align=”left”]Everyone’s basal requirements are unique and may vary considerably[/pull_quote]products called ketones.

Everyone’s basal requirements are unique and may vary considerably, especially in Type 2 Diabetes. In my opinion its really important for people to fine tune their doses of basal insulin before they start adjusting with bolus insulin, but unfortunately the habit of correcting with bolus insulin to get a quick response has become the norm.

Basal insulin’s real handy work is seen with fasting blood sugars. If you are consistently waking with raised blood sugar levels too high or too low, then your basal insulin maybe an issue. For those who inject many people adjust by 4 units which in my opinion is too much, basal insulin needs to be adjusted by 2 units every 2-3 days before the desired result is achieved. Many people don’t like doing this, because it could take over a week to see the desired results, but in the long term it is worth it. When you adjust by more than 2 units, you end up correcting daytime blood sugars with bolus insulin, either by reducing or taking more, therefore you will never know what doses actually work for you. Just be mindful if you are waking with very high blood sugars, one of the reasons could be a hypo while you are asleep which has caused a rebound. For further info go to Hidden Hypos

Many people ask me when is the best time to take basal insulin. I would stick to the old tried and tested which is at bedtime. This is due to the fact that most peoples basal requirements peak at night when they are asleep as growth hormones and other factors are at their most active.

So my advice to many people who attend my practice with ‘swings and roundabouts’ of blood sugars is: get your basal dose right first, give yourself the foundation to build good diabetes control off of. It takes time, it requires alot of patience, but it will be worth it in the long run.

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References:

[1] Tsujino, Daisuke, et al. “A crossover comparison of glycemic variations in Japanese patients with type 1 diabetes receiving insulin glargine versus insulin detemir twice daily using continuous glucose monitoring (CGM): J COLLECTION (Jikei COmparison of Lantus and LEvemir with Cgm for Thinking Insulin OptimizatioN).” Diabetes Technology & Therapeutics 14.7 (2012): 596-601.

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