Initial Basal Insulin Dosing for Uncontrolled Type 2 Diabetics in the Hospital
For uncontrolled type 2 diabetics in the hospital, the recommended initial basal insulin dose is 0.2-0.3 units/kg/day for patients with moderate hyperglycemia (blood glucose 201-300 mg/dL) and 0.3 units/kg/day for those with severe hyperglycemia (>300 mg/dL). 1
Patient Stratification for Initial Insulin Dosing
The initial basal insulin dose should be determined based on the severity of hyperglycemia and the patient's clinical characteristics:
Mild Hyperglycemia (BG <200 mg/dL)
- Consider low-dose basal insulin at 0.1 units/kg/day or oral antidiabetic agents if appropriate 1
- Provide correction doses with rapid-acting insulin before meals or every 6 hours 1
Moderate Hyperglycemia (BG 201-300 mg/dL)
- Start basal insulin at 0.2-0.3 units/kg/day 1
- Add correction doses with rapid-acting insulin before meals or every 6 hours 1
- Appropriate for patients on multiple oral agents or with insulin total daily dose (TDD) <0.6 units/kg/day 1
Severe Hyperglycemia (BG >300 mg/dL)
- Implement basal-bolus regimen starting at 0.3 units/kg/day (half as basal, half as bolus) 1
- For patients already on insulin with TDD >0.6 units/kg/day, reduce home insulin dose by 20% 1
- For insulin-naive patients, start at 0.3-0.5 units/kg/day 1
Special Considerations
Patients at Higher Risk for Hypoglycemia
- Lower doses (0.1-0.2 units/kg/day) should be used for:
Type 1 Diabetes Patients
- Always maintain basal insulin even if feedings are discontinued 1
- In the absence of previous insulin dosing, start with 5 units of NPH/detemir every 12 hours or 10 units of insulin glargine every 24 hours 1
Transitioning from IV to Subcutaneous Insulin
- Convert to basal insulin at 60-80% of the daily IV infusion dose 1
- Administer subcutaneous basal insulin 2-4 hours before discontinuing IV insulin 1
Insulin Regimen Selection
Basal Insulin Options
- Long-acting analogs (glargine, detemir) are preferred over NPH due to lower risk of nocturnal hypoglycemia 2
- NPH insulin may be used twice daily (every 12 hours) or three times daily (every 8 hours) for patients on enteral nutrition 1
Basal-Bolus vs. Sliding Scale
- Basal-bolus approach has consistently shown better glycemic control than sliding scale insulin alone 1
- Sliding scale insulin alone should not be used in patients with type 1 diabetes 1
- Basal-plus approach (basal insulin with correction doses) may be preferred for patients with mild hyperglycemia or decreased oral intake 1
Monitoring and Titration
- Perform point-of-care glucose testing before meals or every 4-6 hours if NPO 1
- Adjust basal insulin dose based on fasting glucose levels 1
- Document and track all episodes of hypoglycemia (<70 mg/dL) 1
- Implement a hypoglycemia prevention and management protocol 1
Common Pitfalls to Avoid
Overreliance on sliding scale insulin: Sliding scale insulin alone is associated with clinically significant hyperglycemia and should not be the sole treatment strategy 1
Failure to adjust basal insulin after hypoglycemia: Studies show that 75% of patients did not have their basal insulin dose adjusted after a hypoglycemic episode 1
Premixed insulin use: Premixed insulin therapy has been associated with unacceptably high rates of hypoglycemia and is not recommended for inpatient use 1
Discontinuing basal insulin during NPO status: For patients with type 1 diabetes, it is crucial to continue basal insulin even when NPO to prevent diabetic ketoacidosis 1
Inappropriate dose reduction when transitioning from IV to subcutaneous insulin: Converting to 60-80% of the daily infusion dose is recommended to prevent rebound hyperglycemia 1
By following these evidence-based guidelines for initial basal insulin dosing in hospitalized patients with uncontrolled type 2 diabetes, clinicians can effectively manage hyperglycemia while minimizing the risk of hypoglycemia and other complications.