From the Guidelines
For patients presenting with hypoglycemia in the hospital, it is recommended to reduce their home insulin dose, with a specific reduction of 20% as suggested for severe hyperglycemia management in hospitalized patients 1. This approach helps prevent recurrent hypoglycemia while maintaining some level of glucose control.
- The reduction should be individualized based on several factors, including:
- Severity of the hypoglycemic episode
- Patient's nutritional status
- Any acute illness
- Renal function
- Whether they will be resuming normal oral intake
- Patients with severe hypoglycemia, poor oral intake, acute kidney injury, or critical illness may require more cautious management, potentially needing greater reductions in their insulin dose.
- The physiological rationale for dose reduction is that hospitalized patients often experience altered insulin sensitivity due to stress, decreased activity, and changes in nutritional intake.
- Monitoring blood glucose closely after restarting insulin, typically before meals and at bedtime, and adjusting the dose daily as needed is crucial.
- It's also important to note that basal insulin should generally be continued even when the patient is NPO, though at a reduced dose, while mealtime insulin should be held if the patient is not eating, as per hospital regulations and guidelines for managing diabetes and hyperglycemia in the hospital 1.
From the Research
Insulin Dosing for Hypoglycemia in Hospital
- When a patient presents with hypoglycemia in the hospital, the insulin dose is often held at the time of the hypoglycemic episode, as seen in a study where diabetes specialists agreed with this decision 100% of the time 2.
- However, there is no clear consensus on the exact percentage of home insulin to restart the patient on after an episode of hypoglycemia.
- A study found that reductions in the home insulin total daily dose (TDD) ranging from 10% to 50% were not associated with normoglycemia or hyperglycemia, whereas increases ranging from 10% to 50% were associated with 2-5-fold increased odds of hyperglycemia 3.
- Another study suggested that a weight-based dose of 0.4-0.6 units/kg/day may be associated with significantly higher odds of normoglycemia on hospital day 2 (OR 3.99; 95% CI 1.42-11.21) compared to lower doses 3.
- Current recommendations for insulin therapy in hospitalized patients emphasize the importance of establishing comprehensive protocols for dysglycemia management, but do not provide specific guidance on restarting home insulin after an episode of hypoglycemia 4.
Considerations for Insulin Dosing
- The decision to restart home insulin and the percentage of the dose to restart should be individualized based on the patient's specific needs and circumstances.
- Factors such as the patient's glucose levels, insulin sensitivity, and medical history should be taken into account when making decisions about insulin dosing.
- It is essential to monitor the patient's glucose levels closely after restarting insulin to adjust the dose as needed and prevent further episodes of hypoglycemia or hyperglycemia.