Current Insulin Management Protocol

Initial Insulin Dosing and Regimen Selection

For patients with type 2 diabetes requiring insulin therapy, start with basal insulin at 10 units once daily or 0.1-0.2 units/kg body weight, administered at the same time each day, while continuing metformin unless contraindicated. 1, 2

Type 1 Diabetes

Total daily insulin requirement: 0.4-1.0 units/kg/day, with 0.5 units/kg/day typical for metabolically stable patients 1, 2
Split as approximately 50% basal insulin and 50% prandial insulin divided among three meals 1, 2
Basal-bolus regimen is mandatory from the outset—basal insulin alone is insufficient 1, 2

Type 2 Diabetes

Insulin-naive patients: Start with 10 units once daily or 0.1-0.2 units/kg/day of basal insulin 1, 2
Severe hyperglycemia (A1C ≥9%, glucose ≥300-350 mg/dL, or symptomatic): Consider higher starting doses of 0.3-0.5 units/kg/day as total daily dose, using basal-bolus regimen immediately 1, 2
Continue metformin (up to 2000-2550 mg daily) and possibly one additional non-insulin agent 1, 2

Basal Insulin Titration Protocol

Increase basal insulin by 2-4 units every 3 days until fasting plasma glucose reaches 80-130 mg/dL. 1, 2

Specific Titration Algorithm

If fasting glucose 140-179 mg/dL: Increase by 2 units every 3 days 2
If fasting glucose ≥180 mg/dL: Increase by 4 units every 3 days 2
If hypoglycemia occurs: Reduce dose by 10-20% immediately 1, 2
If fasting glucose <80 mg/dL on ≥2 occasions per week: Decrease by 2 units 2

Daily Monitoring Requirements

Check fasting blood glucose every morning during titration 2
Assess adequacy of insulin dose at every clinical visit 1, 2

Critical Threshold: When to Add Prandial Insulin

When basal insulin exceeds 0.5 units/kg/day and approaches 1.0 units/kg/day, add prandial insulin rather than continuing to escalate basal insulin alone. 1, 2

Clinical Signals of "Overbasalization"

Basal insulin dose >0.5 units/kg/day 2
Bedtime-to-morning glucose differential ≥50 mg/dL 2
Hypoglycemia episodes 2
High glucose variability throughout the day 2
A1C remains above target after 3-6 months despite achieving fasting glucose goals 1, 2

Initiating Prandial Insulin

Start with 4 units of rapid-acting insulin before the largest meal, or use 10% of current basal dose 1, 2
Administer rapid-acting insulin 0-15 minutes before meals 1, 3
Titrate by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings 2
Target postprandial glucose <180 mg/dL 1

Special Considerations for Renal Impairment

Patients with impaired renal function require lower insulin doses with closer monitoring for hypoglycemia. 1, 2

Dose Adjustments by CKD Stage

CKD Stage 5 with type 2 diabetes: Reduce total daily insulin dose by 50% 2
CKD Stage 5 with type 1 diabetes: Reduce total daily insulin dose by 35-40% 2
High-risk patients (elderly >65 years, renal failure, poor oral intake): Use lower starting doses of 0.1-0.25 units/kg/day 1, 2

Monitoring in Renal Impairment

Insulin clearance decreases with declining kidney function 2
Titrate conservatively in patients with eGFR <45 mL/min/1.73 m² 2
Increase frequency of glucose monitoring to detect hypoglycemia early 1

Insulin Administration and Meal Timing

Multiple Daily Injection Plans

Take mealtime insulin before eating 1
Meals can be consumed at different times 1
If physical activity occurs within 1-2 hours of mealtime insulin, lower the dose to reduce hypoglycemia risk 1

Premixed Insulin Plans (Not Recommended in Hospital Settings)

Insulin doses must be taken at consistent times daily 1
Meals must be consumed at similar times daily 1
Do not skip meals to reduce hypoglycemia risk 1
Physical activity may cause hypoglycemia depending on timing—always carry quick-acting carbohydrates 1

Fixed Insulin Plans

Eat similar amounts of carbohydrates each day to match set insulin doses 1

Hypoglycemia Management Protocol

Treat hypoglycemia immediately when blood glucose is <70 mg/dL with 15-20 grams of fast-acting carbohydrate. 1

Treatment Protocol

Use glucose tablets or carbohydrate-containing foods (fruit juice, sports drinks, regular soda, hard candy) 1
Recheck blood glucose 15-20 minutes after treatment 1
Repeat treatment if hypoglycemia persists 1
For patients on α-glucosidase inhibitors: Use monosaccharides (glucose tablets) as the drug prevents digestion of polysaccharides 1

Prevention Strategies

Review and modify treatment regimen when blood glucose <70 mg/dL occurs 1
Reduce insulin dose by 10-20% if hypoglycemia occurs without clear cause 1, 2
Carry at least 15 grams of carbohydrate at all times 1
Family members should be instructed in glucagon administration 4

Hospital Insulin Management

Non-Critically Ill Hospitalized Patients

Scheduled basal-bolus insulin regimen is preferred over sliding scale insulin alone 1
Basal insulin or basal-bolus regimen for patients with poor oral intake or NPO status 1
Basal-bolus-correction regimen for patients with good nutritional intake 1

Initial Dosing for Hospitalized Patients

Insulin-naive or low-dose insulin at home: 0.3-0.5 units/kg/day total daily dose, with half as basal insulin 1, 2
High-dose home insulin (≥0.6 units/kg/day): Reduce total daily dose by 20% to prevent hypoglycemia 1, 2
High-risk patients: Use lower doses of 0.1-0.25 units/kg/day 1, 2

Glucose Targets

Non-critically ill patients: Premeal glucose <140 mg/dL, random glucose <180 mg/dL 1
Critically ill patients: Maintain glucose 140-180 mg/dL 1

Common Pitfalls to Avoid

Critical Errors in Insulin Management

Never delay insulin initiation in patients not achieving glycemic goals with oral medications—this prolongs hyperglycemia exposure and increases complication risk 2
Never continue escalating basal insulin beyond 0.5-1.0 units/kg/day without addressing postprandial hyperglycemia—this leads to overbasalization with increased hypoglycemia risk 1, 2
Never use sliding scale insulin as monotherapy—it treats hyperglycemia reactively rather than preventing it, leading to dangerous glucose fluctuations 1, 2
Never discontinue metformin when starting insulin unless contraindicated—the combination provides superior control with less weight gain 2
Never give rapid-acting insulin at bedtime—this significantly increases nocturnal hypoglycemia risk 2

Medication Management Errors

Never mix or dilute insulin glargine with other insulins—its low pH makes this unsafe 2
Discontinue sulfonylureas when advancing to basal-bolus regimens—the combination significantly increases hypoglycemia risk 2
Avoid premixed insulin in hospital settings—it has unacceptably high rates of iatrogenic hypoglycemia 2

Physical Activity Considerations

Regular physical activity (≥150 minutes weekly of moderate-intensity exercise) significantly decreases insulin resistance and may reduce insulin requirements. 2

Exercise sessions should be no more than 2 days apart to maintain insulin sensitivity 2
If physical activity occurs within 1-2 hours of mealtime insulin injection, lower the dose to reduce hypoglycemia risk 1
Always carry quick-acting carbohydrates during physical activity 1
Insulin absorbed and peaks faster during exercise, especially when injected into the leg 1

What is the recommended insulin management protocol for a patient with diabetes, considering their blood glucose levels, diet, physical activity level, and impaired renal function?

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