Insulin Dosing for Non-Acidotic Hyperglycemia
For patients with non-acidotic hyperglycemia, the recommended initial insulin dose is 0.1-0.2 units/kg per day for basal insulin, with dosing strategy determined by severity of hyperglycemia. 1, 2
Insulin Dosing Based on Hyperglycemia Severity
Mild Hyperglycemia (BG <200 mg/dL)
- Consider low-dose basal insulin (0.1 units/kg/day) or oral antidiabetic agent if no contraindications 1
- Provide correction doses with rapid-acting insulin before meals or every 6 hours 1
- DPP-4 inhibitors with or without low-dose basal insulin can achieve similar control to more complex insulin regimens 1
Moderate Hyperglycemia (BG 201-300 mg/dL)
- Start basal insulin at 0.2-0.3 units/kg per day 1
- Add correction doses with rapid-acting insulin before meals or every 6 hours 1
- For insulin-naïve patients, start with 10 units per day or 0.1-0.2 units/kg per day 1, 2
- Choose an evidence-based titration algorithm: increase by 2 units every 3 days to reach fasting plasma glucose goal without hypoglycemia 1
Severe Hyperglycemia (BG >300 mg/dL)
- Implement basal-bolus regimen with total daily dose of 0.3 units/kg per day (half as basal, half as bolus) 1
- For patients already on insulin, reduce home insulin total daily dose by 20% 1
- Adjust doses as needed based on glucose monitoring 1
Titration and Monitoring
- Set fasting plasma glucose goals according to clinical context 1
- For hypoglycemia: determine cause; if no clear reason, lower corresponding dose by 10-20% 1, 3
- Assess adequacy of insulin dose at every visit 1
- If adding prandial insulin, start with 4 units per day or 10% of basal insulin dose 1
- Increase prandial insulin dose by 1-2 units or 10-15% twice weekly as needed 2
Special Considerations
Patients at Higher Risk for Hypoglycemia
- For frail, elderly patients or those with acute kidney injury, reduce starting dose to 0.15 units/kg per day (basal alone) 1
- Total daily dose should be reduced to 0.3 units/kg per day (basal-bolus) in high-risk patients 1
- Monitor closely for signs of hypoglycemia 3
Patients on NPH Insulin
- If converting from bedtime NPH to twice-daily NPH, use 80% of current bedtime NPH dose 1
- Add 4 units of short/rapid-acting insulin or 10% of reduced NPH dose 1, 2
Common Pitfalls to Avoid
- Avoid sliding scale insulin alone as the sole regimen, especially for patients with type 1 diabetes or significant hyperglycemia 4, 5
- Don't maintain the same insulin dose despite low pre-meal glucose readings 3
- Avoid premixed insulin in the hospital setting due to higher rates of hypoglycemia 1, 3
- Don't overlook the need to adjust both prandial and basal insulin if hypoglycemia is recurrent 3
Continuous Insulin Infusion
- For severe hyperglycemia with significant metabolic derangement, consider continuous insulin infusion 1, 4
- For mild DKA, a "priming" dose of regular insulin (0.4-0.6 units/kg body weight) may be given, half as IV bolus and half as subcutaneous/intramuscular injection 1
Remember that insulin dosing must be adjusted based on regular glucose monitoring, with the goal of maintaining blood glucose between 140-180 mg/dL for most hospitalized patients 6, 4.