What are examples of insulin regimens for non-critical patients who are eating and those who are nothing by mouth (NPO)?

Insulin Regimens for Non-Critical Hospitalized Patients

For Patients Who Are Eating

An insulin regimen with basal, prandial, and correction components is the preferred treatment for non-critically ill hospitalized patients with good nutritional intake. 1

Dosing Strategy Based on Severity

Mild Hyperglycemia (Blood Glucose <200 mg/dL):

• Consider low-dose basal insulin (0.1 U/kg/day) with correction doses of rapid-acting insulin before meals 1
• Alternative: DPP-4 inhibitor with or without low basal insulin dose 1
• Appropriate for insulin-naive patients or those with low HbA1c on admission 1

Moderate Hyperglycemia (Blood Glucose 201-300 mg/dL):

• Start basal insulin at 0.2-0.3 U/kg/day 1
• Add correction doses with rapid-acting insulin before meals 1
• May combine with oral antidiabetic agents if no contraindications 1

Severe Hyperglycemia (Blood Glucose >300 mg/dL):

• Implement basal-bolus regimen 1
• If on home insulin: reduce total daily dose by 20% 1
• If insulin-naive: start at 0.3 U/kg/day (give half as basal, half as bolus) 1
• Distribute prandial insulin across three meals 1

Practical Administration Details

Timing of Insulin Injections:

• Insulin injections should align with meals 1
• Perform point-of-care glucose testing immediately before meals 1
• If oral intake is poor, administer prandial insulin immediately after the patient eats, with the dose adjusted for actual carbohydrate consumption 1

Glucose Monitoring:

• Perform bedside glucose monitoring before meals for eating patients 1

What to Avoid

Sliding scale insulin as the sole treatment is strongly discouraged 1

• Basal-bolus treatment improved glycemic control and reduced hospital complications compared to sliding scale regimens 1

Premixed insulin regimens are not routinely recommended for in-hospital use 1

• Associated with significantly increased hypoglycemia compared to basal-bolus therapy 1

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For Patients Who Are NPO (Nothing By Mouth)

Basal insulin, or a basal plus bolus correction regimen, is the preferred treatment for non-critically ill hospitalized patients with poor oral intake or those who are NPO. 1

Dosing Strategy

Starting Dose:

• Basal insulin at 0.2 U/kg/day 1
• For patients at high risk of hypoglycemia (frail, elderly, acute kidney injury), reduce starting dose to 0.15 U/kg/day 1

Correction Insulin:

• Add correction doses with rapid-acting insulin every 4-6 hours as needed 1
• Do not use rapid- or short-acting insulin at bedtime 2

Glucose Monitoring

For NPO patients, glucose monitoring is advised every 4-6 hours 1

Special Considerations for NPO Patients

Withhold prandial insulin if poor oral intake 1

• Continue basal insulin to prevent metabolic decompensation 3
• Consider reducing basal dose to 60-80% of usual dose for patients with minimal intake 3

Continuous Enteral/Parenteral Nutrition:

• Basal insulin or basal plus correction regimen remains appropriate 1
• For continuous tube feedings: consider premixed 70/30 insulin every 8 hours at total daily dose of 0.6-1.0 U/kg divided into three doses 2

Common Pitfalls to Avoid

Do not rely solely on correction insulin without basal coverage 3

• This leads to inadequate glycemic control and metabolic instability 3

Monitor for hypoglycemia, especially overnight 3

• Have hypoglycemia treatment protocol in place (15g fast-acting carbohydrate for conscious patients, intravenous glucose for NPO patients) 3

Reassess insulin requirements daily 3

• As nutritional status changes, insulin needs will change 3
• Consider further basal dose reduction if blood glucose consistently <100 mg/dL 3