Insulin Therapy in Hospitalized Patients

Introduction to Basal-Bolus Regimen

The basal-bolus regimen consists of administering basal insulin one or two times a day along with rapid-acting insulin before meals, plus corrective doses of rapid-acting insulin to control hyperglycemia, as recommended by the American Diabetes Association 1
This regimen provides 24-hour insulin coverage, with options including insulin glargine, insulin NPH, and other long-acting insulins, according to the American Association of Clinical Endocrinologists 1

For patients without prior insulin treatment or with low doses, the initial total daily dose is 0.3-0.5 U/kg/day, with 50% administered as basal insulin and 50% as prandial insulin, as suggested by the Endocrine Society 1
The distribution of insulin can be adjusted based on the patient's needs, with a focus on providing adequate basal and prandial coverage, according to the American College of Endocrinology 1

For patients at higher risk of hypoglycemia, such as older adults, those with renal insufficiency, or inadequate oral intake, lower doses should be used, as recommended by the American Geriatrics Society 1, 2
For patients already treated with high doses of insulin (≥0.6 U/kg/day), the total daily dose should be reduced by 20% during hospitalization, according to the Society of Hospital Medicine 1

When transitioning from intravenous insulin to subcutaneous insulin, basal insulin should be administered 2-4 hours before discontinuing the IV infusion, as recommended by the American Diabetes Association 3
The total daily dose should be calculated based on the average amount of insulin infused during the 12 hours prior to the transition, according to the Endocrine Society 1
The dose of basal insulin can be converted to 60-80% of the daily infusion dose, as suggested by the American Association of Clinical Endocrinologists 3

The basal-bolus regimen is indicated for patients with hyperglycemia, reduced oral intake, or those undergoing surgery, as recommended by the American College of Surgeons 1, 2
This regimen has been shown to provide better glycemic control and reduce hospital complications compared to simpler regimens, such as sliding scale insulin alone, according to the Society of Hospital Medicine 1

The incidence of mild hypoglycemia (≤70 mg/dL) with the basal-bolus regimen is 12-30%, as reported by the American Diabetes Association 1
Premixed insulin (70/30) is not recommended in the hospital setting due to its high risk of hypoglycemia, as stated by the Endocrine Society 1, 2
Blood glucose monitoring should be performed before meals and at bedtime, with daily adjustments to insulin doses based on glucose patterns, according to the American Association of Clinical Endocrinologists 1