How should insulin doses be adjusted when sending a patient with diabetes home?

Insulin Adjustment Guidelines for Patients Discharged from Hospital

When sending a patient with diabetes home from the hospital, insulin doses should be adjusted to match their home routine, with patients generally returning to their pre-hospitalization insulin regimen unless significant improvements in glycemic control were achieved during hospitalization with a modified regimen. 1

General Principles for Insulin Adjustment at Discharge

• For patients with well-controlled diabetes before hospitalization, return to their pre-hospitalization insulin regimen upon discharge 1
• For patients with poor pre-admission glycemic control (high A1C levels), consider maintaining the improved hospital regimen if it demonstrated better control 1
• Provide detailed written instructions about the insulin regimen, including timing, dosage, and adjustment algorithms 2
• Ensure the patient has adequate supplies of insulin and monitoring equipment before discharge 2

Specific Insulin Adjustment Recommendations

For Patients on Basal-Bolus Regimens:

• Maintain the same distribution of approximately 50% basal insulin and 50% prandial insulin in the total daily dose 2
• For patients who will have increased physical activity at home compared to the hospital, consider reducing the total insulin dose by 10-20% to prevent hypoglycemia 1
• Adjust basal insulin doses based on fasting glucose values and prandial insulin based on both pre- and post-meal glucose values 1
• Continue basal insulin at the same time each day to maintain consistent blood glucose control 3

For Patients on Insulin Pumps:

• Ensure patients have adequate pump supplies including extra batteries 1
• Review any adjustments made to basal rates, insulin-to-carbohydrate ratios, or correction factors during hospitalization 1
• Document these changes clearly in discharge instructions 1

Documentation and Communication

• Provide a clear record of the insulin regimen used during hospitalization and any adjustments made for discharge 1
• Send a copy of this record to the patient's primary care provider or endocrinologist 1
• Document the rationale for any major changes to the insulin regimen 1

Patient Education Before Discharge

• Teach patients how to monitor blood glucose and adjust insulin doses based on results 1
• Instruct on carbohydrate counting and food choices to balance with insulin dosing 1
• Provide education on recognizing and treating hypoglycemia 4
• Ensure patients understand when to contact their healthcare provider for assistance with insulin adjustments 2

Common Pitfalls to Avoid

• Avoid using sliding scale insulin alone without basal insulin after discharge, as this leads to poor glycemic control 4
• Avoid abrupt discontinuation of insulin when transitioning from hospital to home, as this can lead to rebound hyperglycemia 5
• Avoid withholding basal insulin when blood glucose is in normal range (>100 mg/dL), as this disrupts glycemic stability 3
• Avoid making major changes to insulin type or regimen without discussing with the patient and their regular diabetes provider 1

Special Considerations

• For patients who experienced frequent hypoglycemia in the hospital, consider reducing insulin doses by 10-20% at discharge 1
• For patients with varying daily routines or physical activity levels, provide specific instructions on how to adjust insulin doses accordingly 2
• For elderly patients or those with cognitive impairment, simplify the regimen when possible and ensure adequate support for insulin administration 3
• For patients with renal or hepatic dysfunction, insulin doses may need to be reduced due to decreased clearance 6