Insulin Management for Hospitalized Patients with Diabetes

Introduction to Insulin Regimens

The American Diabetes Association recommends scheduled basal-bolus insulin regimens instead of sliding scale insulin alone for hospitalized patients with diabetes, as sliding scale monotherapy is associated with inferior glycemic control and increased complications 1, 2, 3

Sliding scale insulin is a reactive approach that treats hyperglycemia after it occurs, leading to rapid blood glucose fluctuations, clinically significant hyperglycemia, and poor glycemic control, with only 38% of patients achieving mean blood glucose <140 mg/dL compared to 68% with basal-bolus regimens 3
Sliding scale insulin alone is associated with increased hospital complications, including postoperative wound infections and acute renal failure 2, 3

The American Diabetes Association recommends using basal-bolus insulin for all patients with type 1 diabetes, hospitalized patients with type 2 diabetes and good oral intake, and patients with poor or no oral intake 1, 2
For patients with type 2 diabetes and good oral intake, a basal-bolus regimen with basal, prandial, and correction components is recommended 2
For patients with poor or no oral intake, a basal-plus approach with basal insulin and correction doses of rapid-acting insulin is recommended 1, 2

For insulin-naive patients or low-dose users, start with a total daily dose of 0.3-0.5 units/kg/day, allocating 50% to basal insulin and 50% to rapid-acting prandial insulin 3
For patients on higher home insulin doses (≥0.6 units/kg/day), reduce the total daily dose by 20% during hospitalization to prevent hypoglycemia 1

The basal-bolus approach carries a 4-6 times higher hypoglycemia risk than SSI alone, with a risk ratio of 5.75 (95% CI 2.79-11.83) for blood glucose ≤70 mg/dL 1
To mitigate hypoglycemia, implement hospital-wide hypoglycemia protocols for glucose <70 mg/dL, review treatment regimen after any glucose <70 mg/dL, and use basal-plus rather than full basal-bolus for fasting patients or those undergoing procedures 1, 2

When discontinuing IV insulin infusion, administer subcutaneous basal insulin 2-4 hours before stopping IV infusion, and convert at 60-80% of daily IV infusion dose 2, 3

For older adults, consider simplified regimens, such as once-daily basal insulin, and use simplified sliding scale only as adjunct 4, 3
In the critical care setting, use continuous IV insulin infusion with validated protocols to achieve glycemic targets in ICU 2