Blood Glucose Management in Hospitalized Patients

Insulin Initiation and Glycemic Targets

The American Diabetes Association recommends initiating insulin therapy when blood glucose persistently exceeds 180 mg/dL on two separate measurements, and transitioning to continuous intravenous insulin infusion for critically ill patients requiring intensive glycemic management to maintain glucose between 140-180 mg/dL 1, 2
For hospitalized patients, the blood glucose threshold for initiating insulin therapy is >180 mg/dL (10.0 mmol/L) on two occasions 1, 2
The target glucose range for the majority of critically ill patients is 140-180 mg/dL (7.8-10.0 mmol/L) 3, 1, 5, 2
More stringent targets of 110-140 mg/dL may be considered for select patients, such as post-cardiac surgery, if achievable without significant hypoglycemia 1, 2

The basal-bolus regimen is preferred for noncritically ill patients with good nutritional intake, consisting of scheduled basal insulin plus prandial and correction doses 4, 1
Basal-plus correction insulin is recommended for patients with poor oral intake or those NPO (nothing by mouth) 3, 4
For patients with mild hyperglycemia (blood glucose <200 mg/dL), a basal-plus approach with corrective doses may be more appropriate than full basal-bolus to reduce hypoglycemia risk 7

Hyperglycemia is defined as blood glucose >140 mg/dL (7.8 mmol/L) in hospitalized patients, and persistent levels above this threshold should prompt dietary modifications or medication adjustments 4, 5, 2
Reassess insulin regimen when blood glucose falls below 100 mg/dL, as this predicts hypoglycemia within 24 hours 1, 2
Modify regimen when blood glucose <70 mg/dL, unless easily explained by missed meals 6

For insulin-naive patients or those on low doses, start with 0.3-0.5 U/kg total daily dose, with half as basal and half divided before meals 7
Lower doses (0.1-0.25 U/kg) are appropriate for patients at high hypoglycemia risk, such as the elderly (>65 years), renal failure, or poor oral intake 7