Insulin Regimens for Inpatient Diabetes Management

Recommended Insulin Regimens

For non-critically ill hospitalized patients with diabetes, the American Diabetes Association recommends using a basal-bolus insulin regimen starting at 0.3 units/kg/day total daily dose (TDD), with half given as basal insulin once daily and half as rapid-acting insulin before meals, rather than sliding scale insulin alone 1
The Endocrine Society recommends tailoring the starting insulin regimen based on admission blood glucose levels, with different regimens for mild, moderate, and severe hyperglycemia 2

For patients with mild hyperglycemia (blood glucose <200 mg/dL), the European Association for the Study of Diabetes recommends starting with low-dose basal insulin (0.1 units/kg/day) or considering a DPP-4 inhibitor, and adding correction doses with rapid-acting insulin before meals or every 6 hours 2
For patients with moderate hyperglycemia (blood glucose 201-300 mg/dL), the American College of Endocrinology recommends starting basal insulin at 0.2-0.3 units/kg/day and adding correction doses with rapid-acting insulin before meals, and may combine with oral agents if no contraindications exist 2
For patients with severe hyperglycemia (blood glucose >300 mg/dL), the American Diabetes Association recommends initiating a full basal-bolus regimen at 0.3 units/kg/day TDD, with 50% as basal insulin once daily and 50% as prandial insulin divided before meals 1, 2

For patients with poor or no oral intake (NPO), the Society of Hospital Medicine recommends using basal insulin plus correction insulin only, and reducing the starting dose to 0.1-0.15 units/kg/day given mainly as basal insulin, and adding rapid-acting insulin as correctional coverage for glucose >180 mg/dL 1, 3, 4

The American College of Endocrinology strongly discourages using sliding scale insulin (SSI) alone as the sole regimen, as it results in poorer glycemic control and increased hospital complications compared to basal-bolus regimens 1, 3, 4
The Endocrine Society recommends avoiding premixed insulin formulations in the hospital setting, as they cause a threefold higher rate of hypoglycemia compared to basal-bolus regimens with insulin analogs, and have fixed ratios that cannot be adjusted for variable oral intake 1, 2

The American Diabetes Association recommends using long-acting basal insulin analogs (glargine, detemir) rather than NPH insulin when possible, as they provide more physiologic action with lower hypoglycemia risk, and using rapid-acting analogs (lispro, aspart, glulisine) for prandial coverage 1

The European Association for the Study of Diabetes recommends reducing the starting dose to 0.15 units/kg/day in frail, elderly patients or those with acute kidney injury, to minimize hypoglycemia risk, and starting conservatively and titrating upward based on glucose monitoring 1, 2

The American College of Endocrinology recommends targeting premeal blood glucose <140 mg/dL and random blood glucose <180 mg/dL for most non-critically ill patients, with more stringent targets for stable patients with previous tight control, and less stringent targets for patients with severe comorbidities 3, 4