Gcih Basal Insulin Titration

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name: gcih-basal-insulin-titration
description: Adjust basal insulin dose day-to-day in a hospitalised patient being managed for glucocorticoid-induced hyperglycemia (GCIH) using the Lakhani protocol. Trigger when a clinician asks "how to titrate basal insulin in steroid patient", "adjust glargine for GCIH", "fasting glucose high on steroid protocol what to do", "increase or decrease basal insulin GCIH", or any day-to-day basal insulin adjustment question in a patient on glucocorticoids.
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# GCIH Basal Insulin Titration Guide

## What this skill does
Provides the daily basal insulin adjustment rule for patients managed on the Lakhani GCIH protocol. This applies to **both** the experimental and standard (control) groups. Based on Lakhani et al. 2017 (IJEM, DOI: 10.4103/ijem.IJEM_226_17).

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## When to apply

- Patient is on background basal-bolus insulin as part of the GCIH protocol (Group 1 patients)
- Fasting (pre-breakfast) CBG is available
- It is Day 2 or later of the protocol (Day 1 readings are a titration phase — do not use for adjustments)

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## Step 1 — Check fasting CBG

Measure fasting capillary blood glucose (CBG) each morning before breakfast.

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## Step 2 — Apply titration rule

| Fasting CBG | Action |
|---|---|
| > 200 mg/dl | **Increase** basal insulin dose by **20%** |
| 140–199 mg/dl | **Increase** basal insulin dose by **10%** |
| 100–140 mg/dl | **No change** (target range — maintain current dose) |
| 70–100 mg/dl | **Decrease** basal insulin dose by **10%** |
| < 70 mg/dl | **Decrease** basal insulin dose by **20%** + treat hypoglycemia per protocol |

**Round to nearest whole unit.**

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## Step 3 — Apply the change

- Adjust the **bedtime glargine dose** based on the rule above.
- Bolus insulin (lispro) doses are NOT adjusted here — they are managed separately via the premeal supplemental scale.
- Re-check fasting CBG the following morning and repeat.

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## Step 4 — Watch for hypoglycemia

If CBG < 70 mg/dl at any point:
1. Treat hypoglycemia per hospital protocol.
2. Discard remaining CBG readings for the rest of that day from analysis.
3. Reduce basal insulin by 20% the following day.
4. If fasting CBG < 70 mg/dl despite reduction → consider stopping background basal entirely and reassess (especially in Group 1 patients whose glucocorticoid dose has been reduced).

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## Clinical Guardrails

- This titration applies to **basal insulin only** — do not use fasting CBG to adjust bolus doses.
- Target fasting CBG = **100–140 mg/dl**.
- If the glucocorticoid dose is changed (increased or decreased), reassess the correctional insulin dose first before adjusting basal. Correctional insulin adjustment takes priority.
- In elderly patients (≥70 years) or those with renal impairment: apply adjustments cautiously. Prefer 10% increments even when fasting BG > 200.
- Do not increase basal if the patient had a hypoglycemia event in the preceding 24 h.

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**Source:** Lakhani OJ, Kumar S, Tripathi S, Desai M, Seth C. Comparison of two protocols in the management of glucocorticoid-induced hyperglycemia among hospitalized patients. *Indian J Endocr Metab* 2017;21:836–44. DOI: 10.4103/ijem.IJEM_226_17