Do hospitalized patients remain on their home insulin dose or is a sliding scale insulin regimen used?

Insulin Management for Hospitalized Patients

Hospitalized patients with diabetes should NOT be placed on sliding scale insulin alone—instead, use a scheduled basal-bolus insulin regimen for those on insulin at home, or basal-plus-correction for those with poor oral intake. 1, 2

The Evidence Against Sliding Scale Insulin Monotherapy

Sliding scale insulin (SSI) as sole therapy is strongly discouraged and associated with clinically significant hyperglycemia and worse outcomes. 1 The American Diabetes Association explicitly states that "prolonged sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged." 1

Why SSI Fails:

• SSI is reactive rather than proactive—it treats hyperglycemia after it occurs instead of preventing it 1, 3
• Randomized controlled trials demonstrate that basal-bolus regimens improve glycemic control AND reduce hospital complications (including postoperative wound infection, pneumonia, bacteremia, acute renal and respiratory failure) compared to SSI alone 1
• SSI does not account for basal insulin requirements or caloric intake, particularly dangerous in Type 1 diabetes where it increases both hypoglycemia and hyperglycemia risks 1

Recommended Approach Based on Patient Status

For Patients Eating Well (Good Oral Intake):

Use a basal-bolus-correction regimen with three components: 1, 2, 4

• Basal insulin: 50% of total daily dose given once or twice daily (long-acting analogs like glargine or detemir preferred) 2, 4
• Prandial insulin: 50% of total daily dose divided before three meals (rapid-acting analogs like aspart, lispro, or glulisine) 2, 4
• Correction insulin: Rapid-acting insulin for hyperglycemia as needed 2, 4

Dosing for insulin-naive patients: Start with 0.3-0.5 units/kg/day total daily dose 1, 4

Dosing for patients on high-dose insulin at home (≥0.6 units/kg/day): Reduce total daily dose by 20% to prevent hypoglycemia 1

For Patients with Poor or No Oral Intake (NPO):

Use basal insulin with correction doses only (basal-plus approach): 1, 4

• Start with lower basal insulin dose of 0.1-0.25 units/kg/day 1, 2, 4
• Add rapid-acting correction insulin before meals or every 6 hours if NPO 1
• This approach reduces hypoglycemia risk compared to full basal-bolus regimens in patients with unpredictable intake 1

The ONLY Acceptable Use of SSI Alone:

SSI monotherapy may be appropriate ONLY for: 1, 2, 5

• Patients WITHOUT diabetes who have mild stress hyperglycemia 1, 2
• Diet-controlled Type 2 diabetes patients (not on medications at home)—start with SSI alone, adding basal insulin only if glucose consistently exceeds 180 mg/dL 2, 5

SSI alone should NEVER be used in Type 1 diabetes. 2

Critical Pitfalls to Avoid

• Do not continue home insulin doses unchanged—hospital stress, illness, and altered oral intake require dose adjustments 1, 4
• Do not use premixed insulin (70/30) in the hospital—it causes unacceptably high rates of hypoglycemia compared to basal-bolus regimens 1, 5
• Do not forget to reduce insulin doses by 20% for patients on high home doses to prevent hypoglycemia with reduced hospital oral intake 1
• Do not use SSI alone for established diabetes—this is the most common and dangerous error 1, 2, 3

Hypoglycemia Risk Considerations

The basal-bolus approach carries 4-6 times higher hypoglycemia risk than SSI (12-30% incidence in controlled settings), making careful monitoring essential: 1, 2

• Review insulin regimen whenever blood glucose falls below 70 mg/dL 1, 4
• Use lower doses (0.1-0.25 units/kg/day basal-plus approach) for high-risk patients: older adults (>65 years), renal failure, poor oral intake 1, 4
• Implement hospital-wide hypoglycemia management protocols 1, 4

Glycemic Targets

Target blood glucose 140-180 mg/dL for most hospitalized patients (premeal <140 mg/dL, random <180 mg/dL for non-critically ill): 2, 4, 6

• More stringent targets increase mortality and hypoglycemia risk 6
• For critically ill patients, use continuous IV insulin infusion targeting 140-180 mg/dL 4, 6

Transitioning from Home Regimens

For patients on oral medications at home: Hold oral agents during hospitalization, but resume them 1-2 days before discharge 1, 2

For patients transitioning from IV to subcutaneous insulin: Give subcutaneous basal insulin 2-4 hours before discontinuing IV infusion, using 60-80% of the 24-hour IV insulin dose 1, 4