Insulin Initiation and Management in Hospitalized Patients

Glycemic Targets

The American Diabetes Association recommends a target blood glucose range of 140-180 mg/dL for most hospitalized patients, as more intensive targets have been associated with increased mortality and hypoglycemia risk 3
For critically ill patients, the American Diabetes Association recommends continuous intravenous insulin infusion to maintain blood glucose in the 140-180 mg/dL range 4
For non-critically ill patients, the American Diabetes Association recommends pre-meal glucose targets of <140 mg/dL and random blood glucose <180 mg/dL, as long as these can be safely achieved 5

The American Diabetes Association recommends continuous intravenous insulin infusion as the most effective method for achieving glycemic targets in critically ill patients 1, 4
The American Diabetes Association recommends that infusions be administered using validated written or computerized protocols that allow for predefined adjustments based on glycemic fluctuations and insulin dose 2
The American Diabetes Association recommends more frequent bedside blood glucose testing (every 30 min to 2 hours) for safe use of intravenous insulin 2
For patients with good nutritional intake, the American Diabetes Association recommends implementing a basal-bolus-correction insulin regimen, including basal insulin, prandial insulin, and correction insulin 1, 3, 6
For insulin-naive patients, the American Diabetes Association recommends starting with a total daily insulin dose of 0.3-0.5 units/kg/day, allocating 50% to basal insulin and 50% to prandial insulin divided across three meals 6
For patients with poor or no oral intake, the American Diabetes Association recommends using basal insulin with correction insulin, starting with a lower basal insulin dose of 0.1-0.25 units/kg/day 1, 2, 6

The American Diabetes Association recommends that insulin pens be safely used in the hospital setting, but must be strictly labeled "For single patient use only" 7
The American Diabetes Association recommends that human and analog insulins provide similar glycemic control in the hospital setting 7

The American Diabetes Association recommends monitoring blood glucose before meals for patients who are eating, and every 4-6 hours for patients not eating 2
The American Diabetes Association recommends monitoring every 30 minutes to 2 hours as required for patients on IV insulin 2
The American Diabetes Association recommends that safety standards prohibiting sharing of lancets and testing materials must be strictly followed 2

The Lancet Diabetes and Endocrinology recommends calculating the 24-hour insulin requirement based on the average hourly infusion rate over the previous 12 hours when transitioning from IV insulin infusion to subcutaneous insulin 6
The American Diabetes Association recommends administering the first dose of subcutaneous basal insulin 2-4 hours before discontinuing the insulin infusion to prevent rebound hyperglycemia 8

The American Diabetes Association recommends that a hypoglycemia management protocol be adopted by each hospital, and that treatment regimens be reviewed and adjusted when blood glucose falls below 100 mg/dL 5, 7
The American Diabetes Association recommends modifying the insulin regimen when blood glucose values are <70 mg/dL 7
The American Diabetes Association recommends documenting all hypoglycemic episodes in the medical record for quality improvement tracking 7

The American Diabetes Association recommends always maintaining basal insulin for patients with type 1 diabetes, as dosing based solely on premeal glucose levels does not account for basal requirements and increases risk of both hypoglycemia and hyperglycemia 4, 7
The American Diabetes Association recommends treating patients with renal insufficiency with lower insulin doses 4
The American Diabetes Association recommends establishing a protocol for resuming home medications 1-2 days before discharge 7
The American Diabetes Association recommends that diabetes self-management may be appropriate for competent patients who successfully self-manage at home, have stable consciousness, stable insulin requirements, and adequate skills 5