What is the recommended inpatient insulin regimen for a 76kg, 91-year-old male with hyperglycemia (elevated blood glucose levels) on a sliding scale insulin regimen?

Basal-Bolus Insulin Regimen for Elderly Patient with Hyperglycemia

For a 91-year-old male weighing 76kg with blood glucose levels in the 250-300 mg/dL range, a basal-plus regimen is recommended with a starting total daily insulin dose of 0.1-0.15 units/kg/day (approximately 8-11 units), given primarily as basal insulin, with supplemental rapid-acting insulin for correction. 1

Recommended Insulin Regimen

Initial Dosing

• For elderly patients (>65 years) with hyperglycemia, a lower starting dose of 0.1-0.15 units/kg/day is recommended to minimize hypoglycemia risk 1
• For this 91-year-old patient weighing 76kg, this translates to approximately 8-11 units total daily dose 1
• Basal insulin (glargine or detemir) should be the primary component of this regimen 1

Insulin Distribution

• Administer basal insulin once daily (glargine) at the same time each day 2
• Add correction doses of rapid-acting insulin before meals or every 6 hours if NPO for blood glucose >180 mg/dL 1
• Sliding scale insulin alone is strongly discouraged as it has been consistently shown to be less effective than basal-bolus or basal-plus regimens 1, 3

Rationale for Basal-Plus Approach

• Randomized trials have consistently demonstrated better glycemic control with basal-bolus approaches compared to sliding scale insulin alone 1, 3
• For elderly patients with hyperglycemia, the basal-plus approach provides better glycemic control while minimizing hypoglycemia risk 1
• This approach has been associated with reduced complications including postoperative wound infections, pneumonia, bacteremia, and acute renal and respiratory failure 1

Special Considerations for Elderly Patients

• Lower insulin doses are recommended for older patients (>65 years) due to increased hypoglycemia risk 1
• The basal-plus approach is particularly appropriate for elderly patients who may have decreased oral intake 1
• Avoid premixed insulin formulations as they have been associated with unacceptably high rates of hypoglycemia in elderly patients 1

Monitoring and Adjustment

• Perform point-of-care glucose testing before meals and at bedtime 1
• Target blood glucose range of 140-180 mg/dL for most hospitalized patients 1
• If glucose remains persistently >180 mg/dL, consider increasing basal insulin dose by 1-2 units every 1-2 days 1
• If hypoglycemia occurs (blood glucose <70 mg/dL), reduce basal insulin dose by 20% 1

Common Pitfalls to Avoid

• Relying solely on sliding scale insulin therapy, which treats hyperglycemia reactively rather than preventively 1, 3
• Using premixed insulin formulations, which have shown higher hypoglycemia rates in elderly patients 1
• Starting with excessive insulin doses in elderly patients, which significantly increases hypoglycemia risk 1
• Failing to adjust insulin doses based on nutritional intake, which can lead to dangerous glucose fluctuations 1

Evidence of Superiority

• The RABBIT 2 trial demonstrated that basal-bolus insulin therapy achieved target glucose levels in 66% of patients compared to only 38% with sliding scale insulin alone 3
• Implementation of basal-bolus insulin therapy has been shown to reduce hypoglycemic events by 21% compared to traditional approaches 4
• Patients treated with basal-bolus regimens have demonstrated shorter hospital lengths of stay by an average of 3.18 days 4, 5