Is basal-bolus insulin or insulin infusion preferred for non-critically ill hospitalized patients with hyperglycemia?

Basal-Bolus Insulin Regimen for Non-Critically Ill Hospitalized Patients

For non-critically ill hospitalized patients with blood glucose above 10 mmol/L (180 mg/dL), you should use a scheduled basal-bolus insulin regimen, NOT insulin infusion or sliding scale insulin alone. 1

Why Basal-Bolus is Preferred Over Insulin Infusion

Insulin infusion is reserved exclusively for critically ill patients requiring ICU-level care. 1, 2 For your non-critically ill patient on a general medical ward, continuous intravenous insulin infusion is inappropriate and unnecessarily intensive. 3

The key distinction is clinical setting:

• Critically ill (ICU) patients: Continuous IV insulin infusion is the most effective method 1, 3
• Non-critically ill patients: Scheduled subcutaneous basal-bolus insulin is the guideline-recommended approach 1, 2

Why Sliding Scale Insulin Alone is Strongly Discouraged

Using only sliding scale insulin (SSI) in the inpatient setting is strongly discouraged and condemned by all major guidelines. 1 The evidence is clear:

• SSI is associated with clinically significant hyperglycemia and poor glycemic control 1, 4
• SSI treats hyperglycemia only after it has already occurred, rather than preventing it 1
• Basal-bolus regimens achieve target glucose <140 mg/dL in 66% of patients versus only 38% with SSI 4
• Basal-bolus reduces complications including postoperative wound infection, pneumonia, bacteraemia, and acute renal failure compared to SSI 1

Recommended Basal-Bolus Regimen

For Patients with Good Oral Intake:

Use a complete basal-prandial-correction insulin regimen: 1, 3

• Starting total daily dose (TDD): 0.3-0.5 units/kg/day for insulin-naive patients 1, 2, 3
• Basal insulin: 50% of TDD given once daily (glargine or detemir) 2, 3
• Prandial insulin: 50% of TDD divided into three pre-meal doses of rapid-acting insulin (aspart, lispro, or glulisine) 2, 3
• Correction insulin: Additional rapid-acting insulin before meals based on pre-meal glucose 3

Example for an 80 kg patient: TDD = 24 units/day, with 12 units basal insulin once daily and 4 units rapid-acting insulin before each meal 2

For Patients with Poor or No Oral Intake:

Use basal insulin plus correction insulin only: 1, 3

• Starting dose: 0.1-0.25 units/kg/day of basal insulin 1, 3
• Correction insulin: Rapid-acting insulin every 4-6 hours as needed 1, 3

Target Glucose Range

Target blood glucose of 140-180 mg/dL (7.8-10.0 mmol/L) for the majority of non-critically ill patients. 1 This target:

• Balances efficacy with safety 1
• Avoids the increased mortality and hypoglycemia risk associated with tighter targets (<110 mg/dL) 1
• Is supported by the NICE-SUGAR trial showing harm from intensive glycemic control 1

Monitoring Requirements

Point-of-care glucose testing should be performed: 1, 3

• Before meals for patients who are eating 1, 3
• Every 4-6 hours for patients not eating 1, 3
• More frequently (every 1-2 hours) if glucose >250 mg/dL or <70 mg/dL 2

Note: IV insulin requires much more intensive monitoring (every 30 minutes to 2 hours), which is impractical and unnecessary for non-critically ill patients 1, 3

Critical Pitfall to Avoid

Never use sliding scale insulin alone as the sole regimen. 1 This outdated practice leads to reactive rather than proactive glucose management and is associated with worse outcomes. 1, 4 Always include scheduled basal insulin as the foundation of therapy. 1