Multiple daily injection (basal–bolus) insulin regimen

In a multiple daily injection (basal–bolus) insulin regimen, basal and bolus insulins are given in approximately equal amounts. Insulin doses are age specific and should be adjusted for each child according to their response. Examples of total daily insulin doses at different phases and ages are:

• during remission phase for all ages—less than 0.5 units/kg daily
• beyond remission phase for pre-adolescent children—0.7 to 1 unit/kg daily
• beyond remission phase during puberty—1.2 to 1.5 units/kg daily.

Basal insulin makes up approximately 40 to 50% of the total daily insulin dose and is given as long- or intermediate-acting insulin once or twice daily, before bedtime and/or breakfast. Long-acting insulin is associated with lower rates of nocturnal hypoglycaemia than intermediate-acting insulin. Basal insulin is adjusted to achieve fasting blood glucose concentrations between 4 and 8 mmol/L.

Bolus insulin is given as rapid-acting insulin immediately before each main meal or large snack. Rapid-acting insulin provides more flexibility and safety compared with short-acting insulin, and is therefore preferred for bolus doses.

For insulin formulations, see Action profiles of insulin formulations.

When diabetes is first diagnosed, and during periods of dietary change, blood glucose concentrations should be monitored more frequently so that insulin doses can be adjusted in relation to the amount of food eaten. The patient and their family or carers should be referred to an experienced accredited practising dietitian for training and education. They need to be taught to be proactive in matching the dose and timing of insulin to meals and expected level of activity. Day-to-day insulin adjustment may be based on carbohydrate intake using a flexible insulin treatment approach. However, some patients are managed well with fixed insulin doses and a regular diet.