What are the typical prescriptions for type 2 diabetes mellitus (T2DM) management in Indian clinical practice for In-Patient Department (IPD), Out-Patient Department (OPD), emergency, and Intensive Care Unit (ICU) settings?

Type 2 Diabetes Mellitus Prescriptions for Indian Clinical Practice

OPD (Outpatient Department) Prescription

Start with metformin 500-850 mg once or twice daily with meals as the foundation, then immediately add an SGLT2 inhibitor (empagliflozin 10 mg once daily) or GLP-1 receptor agonist if the patient has cardiovascular risk factors, which is common in the Asian-Indian phenotype. 1, 2

Initial Prescription Template:

• Metformin 500 mg or 850 mg PO twice daily (with breakfast and dinner) 1

  • Titrate up to 2000 mg/day over 2-4 weeks based on tolerance
  • Hold if eGFR <30 mL/min/1.73 m² 3

• Add SGLT2 inhibitor immediately if:

  • Any cardiovascular disease history (including diastolic dysfunction) 4
  • Age >40 years with cardiovascular risk factors 1
  • Empagliflozin 10 mg PO once daily (preferred) 4
  • Alternative: Dapagliflozin 10 mg or Canagliflozin 100 mg once daily 4

• If HbA1c ≥7.5% despite above, add:

  • DPP-4 inhibitor (e.g., Sitagliptin 100 mg once daily or Vildagliptin 50 mg twice daily) 2
  • This SGLT2i + DPP4i combination is particularly suited for Asian-Indian phenotype 2

• If HbA1c ≥8.5-9%, consider adding sulfonylurea:

  • Glimepiride 1-2 mg PO once daily with breakfast 5
  • Start at 1 mg in elderly or those with renal impairment 5
  • Titrate by 1-2 mg every 1-2 weeks, maximum 8 mg/day 5
  • Must be given at least 4 hours before colesevelam if used 5

When to Start Insulin in OPD:

• HbA1c ≥10% despite optimal oral agents 6
• Symptomatic hyperglycemia with glucose toxicity 6
• Start with basal insulin (Insulin Glargine or Detemir) 10 units or 0.1-0.2 units/kg subcutaneously at bedtime 6
• Reduce sulfonylurea dose by 50% when starting insulin 7

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IPD (Inpatient Department) Prescription

Use basal-bolus insulin regimen for most hospitalized patients with T2DM, avoiding sliding scale insulin monotherapy and oral sulfonylureas due to hypoglycemia risk. 3

Standard IPD Insulin Regimen:

• Total Daily Dose (TDD): 0.3-0.4 units/kg/day 3, 8
  • 50% as basal insulin (once daily)
  • 50% divided as rapid-acting insulin before meals (if eating) 3, 8

Specific Prescription:

For a 70 kg patient:

• Insulin Glargine 10-14 units SC at bedtime (basal component)
• Insulin Aspart/Lispro 3-5 units SC before each meal (bolus component) 3
• Correction insulin: Add 1-2 units for every 50 mg/dL above 150 mg/dL 3

For NPO/Fasting Patients:

• Basal-plus approach: Basal insulin only (0.1-0.25 units/kg/day) with correction doses every 6 hours 3
• Example: Insulin Glargine 10 units SC once daily + correction scale 3

Oral Agents in Hospital:

• Continue metformin ONLY if: 3
  • eGFR >45 mL/min/1.73 m²
  • No sepsis, hypoxia, or acute kidney injury
  • No planned contrast imaging
  • Lactate levels normal
• STOP metformin if: eGFR <30, sepsis, shock, or acute illness 3
• AVOID sulfonylureas completely in hospital due to unpredictable hypoglycemia risk 3

Monitoring:

• Blood glucose every 4-6 hours on subcutaneous insulin 8
• Target glucose: 140-180 mg/dL (7.8-10 mmol/L) 3

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Emergency Department Prescription

Immediately assess for diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), then initiate IV insulin infusion for severe hyperglycemia (glucose >250-300 mg/dL with symptoms) or subcutaneous insulin for moderate hyperglycemia. 8

For DKA/Euglycemic DKA (especially if on SGLT2i):

• IV Normal Saline 1-2 liters bolus for volume resuscitation 8
• IV Insulin infusion: 0.1 units/kg/hour (e.g., 7 units/hour for 70 kg patient) 8
• Check ketones every 2-4 hours until <0.6 mmol/L 8
• Monitor potassium every 2-4 hours, replace aggressively 8
• Continue insulin until ketones clear, add dextrose if glucose <200 mg/dL 8
• Permanently discontinue SGLT2 inhibitor if euDKA occurred 8

For Severe Hyperglycemia Without DKA:

• If glucose >400 mg/dL or symptomatic:
  • Insulin Aspart/Lispro 10-15 units SC immediately 6
  • Repeat every 2-3 hours until glucose <250 mg/dL
  • Then transition to basal-bolus regimen 6

For Moderate Hyperglycemia (250-400 mg/dL):

• Insulin Aspart 5-10 units SC 6
• Recheck in 2 hours, repeat if needed
• Admit if not improving or unable to tolerate oral intake

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ICU Prescription

Use continuous IV insulin infusion for all ICU patients with persistent hyperglycemia (glucose >180 mg/dL), targeting 140-180 mg/dL to avoid hypoglycemia while maintaining adequate control. 3

IV Insulin Protocol:

• Start IV insulin infusion at 0.1 units/kg/hour (e.g., 7 units/hour for 70 kg) 8
• Target glucose: 140-180 mg/dL (7.8-10 mmol/L) 3
• AVOID tight control (<110 mg/dL) due to severe hypoglycemia risk 3

Titration Algorithm:

• Check glucose every 1-2 hours initially 8
• If glucose >180 mg/dL: Increase infusion by 1-2 units/hour
• If glucose 140-180 mg/dL: Continue current rate
• If glucose <140 mg/dL: Decrease by 0.5-1 unit/hour
• If glucose <100 mg/dL: Stop infusion, give D50W 25 mL IV, recheck in 15 minutes 3

Transition from IV to Subcutaneous:

When patient stable and tolerating oral intake: 8

• Calculate TDD from last 6 hours of IV insulin × 4
• Give 80% of this as subcutaneous basal-bolus regimen
• Give first SC dose 2-4 hours BEFORE stopping IV insulin to prevent rebound hyperglycemia 6

Example Transition:

• If patient received 6 units/hour IV insulin × 6 hours = 36 units
• TDD = 36 × 4 = 144 units, use 80% = ~115 units/day
• Insulin Glargine 60 units SC once daily (50% of TDD)
• Insulin Aspart 18 units SC before each meal (remaining 50% divided by 3) 3

Critical Monitoring:

• Glucose every 1-2 hours on IV insulin 8
• Potassium every 4-6 hours, maintain >3.3 mEq/L before starting insulin 8
• If on vasopressors or septic: Continue IV insulin, do not use subcutaneous 3

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Common Pitfalls to Avoid

• Never use sliding scale insulin alone in hospitalized patients—it leads to poor control and reactive hyperglycemia 3
• Never continue SGLT2 inhibitors in hospital—risk of euglycemic DKA, especially with acute illness 8
• Never assume normal glucose excludes DKA in patients on SGLT2 inhibitors—check ketones 8
• Never stop insulin prematurely in DKA—continue until ketones <0.6 mmol/L even if glucose normalizes 8
• Never use metformin in sepsis, hypoxia, or eGFR <30—risk of fatal lactic acidosis 3
• Never use sulfonylureas in hospital—unpredictable absorption and high hypoglycemia risk 3
• Never target glucose <140 mg/dL in ICU—increases mortality from severe hypoglycemia 3
• In Asian-Indian patients, prioritize cardiovascular protection early—most have high cardiovascular risk by age 40 9, 2