What insulin regimen adjustments should be made for a 77‑kg hospitalized patient on bedtime insulin glargine 30 U and a medical‑direction sliding‑scale insulin who remains hyperglycemic?

Increase Glargine Aggressively and Add Prandial Insulin Immediately

For a 77.5‑kg hospitalized patient on 30 units glargine at bedtime plus sliding‑scale insulin with persistent hyperglycemia, you must increase the basal dose by 4 units every 3 days until fasting glucose reaches 80–130 mg/dL and simultaneously initiate scheduled prandial insulin at 4–6 units before each meal, because sliding‑scale monotherapy is condemned by all major diabetes guidelines and only 38% of patients achieve adequate control versus 68% with basal‑bolus therapy. 1, 2

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Immediate Regimen Changes Required

Discontinue Sliding‑Scale Monotherapy

• Sliding‑scale insulin as the sole treatment is explicitly condemned by the American Diabetes Association because it reacts to hyperglycemia rather than preventing it, leading to dangerous glucose fluctuations. 1, 3
• Only ≈38% of hospitalized patients on sliding‑scale alone achieve mean glucose <140 mg/dL, compared with ≈68% using scheduled basal‑bolus regimens, with no increase in hypoglycemia when properly implemented. 1, 2, 3
• Correction insulin must supplement—not replace—scheduled basal and prandial doses. 2, 3

Increase Basal Insulin (Glargine) Aggressively

• For a 77.5‑kg patient, the current 30 units represents only ≈0.39 units/kg/day, which is insufficient for hospitalized hyperglycemia. 1, 2
• Increase glargine by 4 units every 3 days until fasting glucose consistently reaches 80–130 mg/dL, because persistent hyperglycemia warrants aggressive titration. 1, 2, 3
• Target basal dose is approximately 0.4–0.5 units/kg/day (≈31–39 units for this patient), but titrate based on glucose response rather than stopping at a predetermined dose. 1, 2, 3
• Critical threshold: When basal insulin approaches 0.5 units/kg/day (≈39 units) without achieving targets, focus on intensifying prandial insulin rather than further basal escalation to avoid "over‑basalization." 1, 2, 3

Initiate Scheduled Prandial Insulin

• Start rapid‑acting insulin (lispro, aspart, or glulisine) at 4–6 units before each of the three largest meals (or 10% of current basal dose ≈ 3 units per meal). 1, 2, 3
• Administer prandial insulin 0–15 minutes before meals for optimal postprandial control. 1, 2, 3
• Titrate each meal dose by 2 units every 3 days based on 2‑hour postprandial glucose, targeting <180 mg/dL. 1, 2, 3

Correction Insulin Protocol (Adjunct Only)

• Add 2 units rapid‑acting insulin for pre‑meal glucose >250 mg/dL. 1, 2, 3
• Add 4 units for pre‑meal glucose >350 mg/dL. 1, 2, 3
• These correction doses are in addition to scheduled prandial insulin, never as a replacement. 1, 2, 3

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Monitoring Requirements

• Fasting glucose daily to guide basal insulin adjustments. 1, 2, 3
• Pre‑meal glucose before each meal to calculate correction doses. 1, 2, 3
• 2‑hour postprandial glucose after each meal to assess prandial adequacy. 1, 2, 3
• Bedtime glucose to evaluate overall daily pattern. 1, 2, 3
• For hospitalized patients eating regular meals, check glucose before each meal and at bedtime (minimum four times daily). 1, 3

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Expected Clinical Outcomes

• With properly implemented basal‑bolus therapy, ≈68% of hospitalized patients achieve mean glucose <140 mg/dL versus ≈38% on sliding‑scale alone. 1, 2, 3
• Basal‑bolus regimens reduce hospital complications including postoperative wound infection and acute renal failure compared with sliding‑scale monotherapy. 3
• Correctly executed basal‑bolus therapy does not increase hypoglycemia incidence compared with inadequate sliding‑scale approaches. 1, 2, 3
• Target glucose range for non‑critically ill hospitalized patients is 140–180 mg/dL. 1, 4

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Hypoglycemia Management

• Treat any glucose <70 mg/dL immediately with 15 g fast‑acting carbohydrate, recheck in 15 minutes, and repeat if needed. 1, 2, 3
• If hypoglycemia occurs without an obvious cause, reduce the implicated insulin dose by 10–20% promptly. 1, 2, 3
• Never administer rapid‑acting insulin at bedtime as a sole correction dose, as this markedly raises nocturnal hypoglycemia risk. 1, 2, 3

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Critical Pitfalls to Avoid

• Do not continue sliding‑scale insulin as the sole regimen when glucose values repeatedly exceed 180 mg/dL; this strategy is inferior and unsafe. 1, 3
• Do not delay adding prandial insulin when basal insulin alone fails to control hyperglycemia; the patient clearly needs both basal and mealtime coverage. 1, 2, 3
• Do not increase basal insulin beyond 0.5–1.0 units/kg/day (≈39–78 units) without addressing postprandial hyperglycemia, to prevent over‑basalization and hypoglycemia. 1, 2, 3
• Do not rely solely on correction doses without adjusting scheduled basal and prandial insulin; this perpetuates inadequate control. 1, 2, 3

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Foundation Therapy Considerations

• Continue metformin at maximum tolerated dose (up to 2000–2550 mg daily) unless contraindicated by acute illness, renal impairment, or contrast administration, as this combination reduces total insulin requirements by 20–30%. 1, 2, 3
• Discontinue sulfonylureas when initiating basal‑bolus insulin to avoid additive hypoglycemia risk. 1, 2, 3

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Special Considerations for Hospitalized Patients

• For patients on high‑dose home insulin (≥0.6 units/kg/day), reduce total daily dose by 20% upon hospitalization to prevent hypoglycemia. 1, 3
• For high‑risk patients (age >65 years, renal impairment, poor oral intake), use lower starting doses of 0.1–0.25 units/kg/day. 1, 3
• 78% of hospitalized patients on basal insulin experience nocturnal hypoglycemia, yet 75% have no basal insulin dose adjustment before the next administration—highlighting the critical need for systematic monitoring and adjustment. 2