What is the recommended correction‑insulin sliding‑scale protocol for a non‑critically ill inpatient on a basal‑bolus regimen, including dosing with rapid‑acting analogues, adjustments for insulin‑resistance or insulin‑sensitivity, administration frequency, and criteria for discontinuation?

Correction Insulin Sliding Scale Protocol for Non-Critically Ill Inpatients

Correction insulin should NEVER be used as monotherapy—it must be combined with scheduled basal and prandial insulin in a basal-bolus regimen.

The sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged and has been definitively shown to be ineffective and dangerous 1. Sliding scale insulin treats hyperglycemia reactively after it occurs rather than preventing it, leading to dangerous glucose fluctuations 2, 3.

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Recommended Correction Insulin Protocol

Dosing with Rapid-Acting Analogues

For patients already on basal-bolus therapy, use this simplified correction scale before meals and at bedtime:

• Blood glucose >250 mg/dL (13.9 mmol/L): Add 2 units of rapid-acting insulin 1, 4
• Blood glucose >350 mg/dL (19.4 mmol/L): Add 4 units of rapid-acting insulin 1, 4

For individualized correction dosing, calculate the insulin sensitivity factor (ISF):

• ISF = 1500 ÷ Total Daily Dose (TDD) for regular insulin 4
• ISF = 1700 ÷ TDD for rapid-acting analogs 4
• Correction dose = (Current glucose - Target glucose) ÷ ISF 4

The target preprandial glucose should be 90-150 mg/dL (5.0-8.3 mmol/L) 4.

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Adjustments for Insulin Resistance or Sensitivity

Standard-Risk Patients (Insulin-Sensitive)

For insulin-naive or low-dose insulin patients, start with a total daily dose of 0.3-0.5 units/kg/day, divided as 50% basal and 50% prandial insulin 1, 4, 5.

High-Risk Patients (Insulin-Sensitive)

For elderly patients (>65 years), those with renal failure, or poor oral intake, use lower starting doses of 0.1-0.25 units/kg/day to prevent hypoglycemia 1, 4, 6.

Insulin-Resistant Patients

For patients on high-dose home insulin (≥0.6 units/kg/day), reduce the total daily dose by 20% upon hospitalization to prevent hypoglycemia 4. For patients on glucocorticoids, increase prandial and correction insulin by 40-60% or more in addition to basal insulin 4.

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Administration Frequency

Point-of-care glucose testing should be performed:

• Immediately before each meal (for patients eating regular meals) 1
• At bedtime 1
• Every 4-6 hours if the patient has poor oral intake or is NPO 1

Rapid-acting insulin analogs (lispro, aspart, glulisine) should be administered:

• 0-15 minutes before meals for optimal postprandial glucose control 1, 4
• Never at bedtime as correction alone, as this significantly increases nocturnal hypoglycemia risk 1, 4

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Required Foundation: Basal-Bolus Regimen Structure

All patients requiring insulin must receive scheduled therapy with three components:

1. Basal insulin: 50% of total daily dose given as glargine, detemir, or degludec once daily 1
2. Prandial insulin: 50% of total daily dose divided among three meals as rapid-acting insulin 1
3. Correction insulin: Supplemental doses using the protocol above, administered in addition to scheduled doses 1

A basal-plus-correction regimen (basal insulin with correction doses only, no scheduled prandial insulin) is acceptable for patients with poor oral intake or NPO status 1, 7.

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Titration and Adjustment Protocol

Basal Insulin Titration

• Increase by 2 units every 3 days if fasting glucose is 140-179 mg/dL 1, 4
• Increase by 4 units every 3 days if fasting glucose is ≥180 mg/dL 1, 4
• Target fasting glucose: 80-130 mg/dL 1, 4

Prandial Insulin Titration

• Increase by 1-2 units or 10-15% every 3 days based on 2-hour postprandial glucose readings 1, 4
• Target postprandial glucose: <180 mg/dL 1, 8

Correction Insulin Adjustment

If correction doses consistently fail to bring glucose into target range or cause hypoglycemia, adjust the ISF rather than the basal or prandial doses 4. Recalculate the ISF periodically (every few weeks to months), not daily 4.

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Criteria for Discontinuation or Modification

When to Stop Escalating Basal 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, 4. Clinical signals of "overbasalization" include:

• Basal dose >0.5 units/kg/day 4
• Bedtime-to-morning glucose differential ≥50 mg/dL 4
• Hypoglycemia episodes 4
• High glucose variability 4

Hypoglycemia Management

If hypoglycemia (glucose <70 mg/dL) occurs:

• Treat immediately with 15 grams of fast-acting carbohydrate 4
• Determine the cause 1, 4
• Reduce the corresponding insulin dose by 10-20% if no clear reason is identified 1, 4, 6

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Critical Pitfalls to Avoid

1. Never use sliding scale insulin as monotherapy—this approach has been definitively shown to be inferior, with only 38% of patients achieving mean blood glucose <140 mg/dL versus 68% with basal-bolus therapy 1, 2, 7

2. Never give rapid-acting insulin at bedtime for correction alone—this significantly increases nocturnal hypoglycemia risk 1, 4

3. 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 and suboptimal control 1, 4

4. Never delay adjustment of scheduled insulin doses when hypoglycemia or hyperglycemia patterns emerge—75% of hospitalized patients who experienced hypoglycemia had no basal insulin dose adjustment before the next administration 4

5. Avoid "stacking" correction doses—insulin from the previous dose may still be active 4