What is the recommended inpatient management for severe hyperglycemia without Diabetic Ketoacidosis (DKA)/Hyperglycemic Hyperosmolar State (HHS), including choice of basal-bolus insulin versus insulin infusion, starting dose for insulin-naïve patients, and monitoring parameters?

Management of Severe Hyperglycemia Without DKA/HHS

For this insulin-naïve patient with severe hyperglycemia (621 mg/dL) and normal mental status, initiate a basal-bolus subcutaneous insulin regimen with a total daily dose of 0.3 U/kg (split 50% basal, 50% bolus), not an insulin infusion, since he is non-critically ill and does not meet criteria for hyperglycemic crisis. 1

Insulin Regimen Selection

Basal-bolus insulin is the guideline-recommended approach for severe hyperglycemia >300 mg/dL in non-critically ill patients. 1 Continuous insulin infusion is reserved for:

• Critically ill patients requiring ICU-level care 1
• Severe DKA or HHS 1
• Perioperative management during major surgery 2

Since this patient has normal mental status, no acidosis, and does not meet HHS criteria (osmolality 281, not >320), he does not require IV insulin infusion. 2

Starting Insulin Dose for Insulin-Naïve Patients

Calculate total daily dose (TDD) at 0.3 U/kg per day for this insulin-naïve patient with severe hyperglycemia. 1 The dosing algorithm is:

• Basal insulin: 50% of TDD given once daily (glargine or detemir) 1
• Prandial insulin: 50% of TDD divided into three pre-meal doses (rapid-acting analog: aspart, lispro, or glulisine) 1
• Correction insulin: Additional rapid-acting insulin before meals or every 6 hours using a correction scale 1

Important dose modification: If the patient has hypoglycemia risk factors (age >65 years, acute kidney injury, frail, poor oral intake), reduce the starting dose to 0.15 U/kg/day for basal alone or 0.3 U/kg/day total for basal-bolus. 1

Practical Example

For an 80 kg patient:

• TDD = 0.3 U/kg × 80 kg = 24 units/day
• Basal: 12 units glargine once daily at bedtime 1
• Prandial: 4 units rapid-acting insulin before each meal (breakfast, lunch, dinner) 1
• Plus correction doses per sliding scale 1

Why Not Insulin Infusion?

Insulin infusion is NOT indicated because:

• The patient is non-critically ill with normal mental status 1, 2
• No severe DKA or HHS present 1
• Subcutaneous basal-bolus achieves effective glycemic control in non-ICU patients 3, 4
• IV insulin increases nursing burden and hypoglycemia risk without added benefit in stable patients 4

The guideline explicitly states that continuous insulin infusion should be transitioned to subcutaneous regimens once patients are stable. 2 This patient is already stable.

Monitoring Parameters

Implement the following monitoring schedule:

Glucose Monitoring

• Point-of-care glucose testing every 4-6 hours initially (before meals and at bedtime if eating; every 6 hours if NPO) 1, 2
• Increase frequency to every 1-2 hours if glucose >250 mg/dL or <70 mg/dL 2
• Target glucose range: 140-180 mg/dL for non-critically ill patients 2, 3, 4

Electrolyte Monitoring

• Check basic metabolic panel (sodium, potassium, glucose, creatinine) every 2-4 hours initially given the hyponatremia 2
• Monitor for hypokalemia as insulin drives potassium intracellularly; replace potassium if <4.0 mEq/L before starting insulin 2
• Recheck serum osmolality to ensure it doesn't evolve into HHS 2

Additional Parameters

• Measure HbA1c at admission to assess chronic glycemic control and guide discharge planning 3
• Daily weight and fluid balance given the hyponatremia 2
• Assess for hypoglycemia symptoms at each glucose check 1

Daily Insulin Adjustment

Adjust insulin doses daily based on glucose patterns: 1

• If fasting glucose elevated: increase basal insulin by 10-20%
• If pre-meal or post-meal glucose elevated: increase corresponding prandial dose by 10-20%
• If hypoglycemia occurs: reduce the insulin component responsible by 20-50%

Withhold prandial insulin if the patient has poor oral intake or is NPO, but continue basal insulin with correction doses every 6 hours. 1

Critical Pitfalls to Avoid

Do NOT use sliding-scale insulin alone (correction insulin without basal component) as the sole regimen—this is explicitly condemned in guidelines and associated with poor glycemic control and increased complications. 1, 5, 6 Sliding scale is reactive rather than proactive. 2

Do NOT use premixed insulin (70/30) in the hospital setting—it has an unacceptably high rate of hypoglycemia. 1

Do NOT target glucose <140 mg/dL aggressively in the hospital—this increases hypoglycemia risk 4-6 times without improving outcomes. 1

Do NOT continue metformin if the patient is on it—given the hyponatremia and potential for evolving illness, there is increased lactic acidosis risk. 1

Transition Planning

Administer basal insulin 2-4 hours before discontinuing any insulin infusion if the patient later requires IV insulin. 2 This prevents rebound hyperglycemia.

Arrange endocrinology consultation for complex cases, recurrent hyperglycemic episodes, or unclear diabetes type. 2

Develop structured discharge planning including diabetes education, medication reconciliation, and outpatient follow-up within 1-2 weeks. 2, 3