How should treatment be started for non-critically ill patients in the hospital with hyperglycemia on a basal-bolus insulin regimen?

Starting Basal-Bolus Insulin in Non-Critically Ill Hospitalized Patients with Hyperglycemia

For non-critically ill hospitalized patients with hyperglycemia requiring a basal-bolus insulin regimen, calculate the total daily dose (TDD) based on patient weight and insulin history: use 0.3-0.5 U/kg/day for insulin-naïve patients or those on low-dose insulin, with 50% allocated to basal insulin (given once or twice daily) and 50% to rapid-acting prandial insulin (divided before three meals), plus correctional doses as needed. 1

Initial Dose Calculation Algorithm

For Insulin-Naïve Patients or Low-Dose Insulin Users

• Start with TDD of 0.3-0.5 U/kg/day, dividing this equally between basal and prandial components 1
• Use the lower end (0.3 U/kg/day) for high-risk patients: those >65 years old, patients with renal failure, and those with poor or uncertain oral intake 1
• Example: For an 80 kg patient, TDD = 24-40 units/day (using 0.3-0.5 U/kg range)
  • Basal insulin: 12-20 units once or twice daily
  • Prandial insulin: 4-7 units before each meal (dividing remaining 50% by 3)
  • Plus correctional insulin as needed 1, 2

For Patients Already on Higher-Dose Insulin at Home

• If home insulin dose ≥0.6 U/kg/day, reduce the TDD by 20% upon hospital admission to prevent hypoglycemia in the setting of potentially reduced oral intake 1
• Maintain the 50/50 split between basal and prandial components 1

Basal Insulin Selection and Timing

• Use long-acting basal insulin analogs (glargine or detemir) rather than NPH insulin, as they more closely match physiological basal requirements and have lower hypoglycemia risk 3, 4
• Administer once daily at bedtime or twice daily if needed for 24-hour coverage 1, 5
• Basal insulin provides background insulin to prevent gluconeogenesis and ketogenesis between meals 4

Prandial Insulin Selection and Timing

• Use rapid-acting insulin analogs (aspart, lispro, or glulisine) before each meal 1, 3, 4
• Administer shortly before or immediately after meals to match nutritional intake 4
• Divide the prandial component equally across three meals unless meal sizes vary significantly 1

Correctional (Supplemental) Insulin Component

• Add correctional doses of rapid-acting insulin on top of scheduled basal-bolus therapy to address pre-meal or between-meal hyperglycemia 1
• This is distinct from—and superior to—sliding-scale insulin (SSI) alone, which is strongly discouraged as monotherapy 1

Glycemic Targets During Treatment

• Target pre-meal glucose <140 mg/dL and random glucose <180 mg/dL for most non-critically ill patients 1
• These targets balance efficacy with hypoglycemia risk 1
• Reassess the regimen if glucose falls below 100 mg/dL; modification is required if glucose <70 mg/dL unless easily explained (e.g., missed meal) 1

Critical Pitfalls to Avoid

Never Use Sliding-Scale Insulin Alone

• SSI as monotherapy is strongly discouraged and associated with poor glycemic control and increased complications 1, 2
• SSI only treats hyperglycemia after it occurs rather than preventing it 1
• The exception: SSI alone may be appropriate for patients without diabetes who have mild stress hyperglycemia 1

Never Use Premixed Insulin (70/30)

• Premixed insulin has an unacceptably high rate of hypoglycemia in the hospital setting and is not recommended 1, 2

Adjust for Nutritional Status

• For patients with poor oral intake or NPO status, switch to a basal-plus-correction regimen rather than full basal-bolus 1
• This consists of basal insulin (0.1-0.25 U/kg/day) plus correctional doses every 6 hours or before meals 1
• This approach reduces hypoglycemia risk in patients not eating regularly 1

Daily Monitoring and Adjustment

• Monitor point-of-care glucose every 4-6 hours initially, increasing frequency to every 1-2 hours if glucose >250 mg/dL or <70 mg/dL 2
• Adjust insulin doses daily based on glucose patterns: increase basal by 10-20% if fasting glucose elevated; increase prandial doses by 10-20% if pre-meal or post-meal glucose elevated 2
• If hypoglycemia occurs, reduce the responsible insulin component by 20-50% 6, 2

Important Nuances

Hypoglycemia Risk with Basal-Bolus Therapy

• The basal-bolus approach carries 4-6 times higher hypoglycemia risk than SSI alone (for glucose ≤70 mg/dL, risk ratio 5.75; for glucose ≤60 mg/dL, risk ratio 4.21) 1
• However, basal-bolus provides superior glycemic control and is associated with reduced complications including postoperative wound infection, pneumonia, bacteremia, and acute renal/respiratory failure 1
• The incidence of mild hypoglycemia with basal-bolus is 12-30% in controlled settings 1

Consider Basal-Plus for Mild Hyperglycemia

• For patients with mild hyperglycemia (glucose <200 mg/dL), decreased oral intake, or undergoing surgery, a basal-plus approach may be preferred over full basal-bolus to reduce hypoglycemia risk 1

Clinical Judgment Factors

• Incorporate ongoing assessment of illness severity, nutritional status, and medications affecting glucose (e.g., glucocorticoids, octreotide) into daily insulin dosing decisions 1
• Higher glucose targets may be acceptable in terminally ill patients or those with severe comorbidities 1