Insulin Management in Hospitalized Patients

Introduction to Insulin Therapy

The American Diabetes Association recommends against the sole use of sliding scale insulin (SSI) in hospitalized patients, as it should not be used as monotherapy for patients with established diabetes 1, 2
The American Diabetes Association discourages SSI alone for patients with Type 1 diabetes, as SSI alone should never be used in this population 3, 4
The American Diabetes Association suggests that patients with Type 2 diabetes on insulin at home require scheduled basal insulin, not reactive correction only, as SSI is associated with clinically significant hyperglycemia and poor outcomes 1, 2, 3, 4

SSI alone is inappropriate for patients with established insulin requirements, as it is associated with clinically significant hyperglycemia and poor outcomes 3, 4
The evidence is clear that SSI monotherapy results in inferior glycemic control compared to basal-bolus regimens, with one study showing a reduction in postoperative complications when using basal-bolus versus SSI alone 3, 4

SSI alone may be acceptable only in specific scenarios, such as patients without diabetes who have mild stress hyperglycemia, as these patients may respond adequately to correction insulin alone 3, 4
The American Diabetes Association suggests that diet-controlled Type 2 diabetes patients may start with SSI alone, adding basal insulin only if glucose consistently exceeds a certain level 5

For non-critically ill patients with good oral intake, the American Diabetes Association recommends using a basal-bolus-correction regimen 1, 2
Basal insulin should be 50% of total daily dose given once or twice daily, with long-acting analogs like glargine or detemir preferred 3, 4
Prandial insulin should be 50% of total daily dose divided before meals, with rapid-acting analogs like aspart, lispro, or glulisine 3, 4
Correction insulin should be rapid-acting insulin for hyperglycemia as needed 1, 2

The American Diabetes Association recommends blood glucose ranges of premeal <140 mg/dL, random <180 mg/dL for non-critically ill patients, and 140-180 mg/dL for critically ill patients 1, 2
More stringent targets (110-140 mg/dL) may be appropriate for stable patients with previous tight control, but only if achievable without significant hypoglycemia 1, 2

Every hospital must implement a standardized hypoglycemia management protocol, documentation and tracking of all hypoglycemic episodes, and individual prevention plans for each patient on insulin 1, 2
The risk of iatrogenic hypoglycemia with basal-bolus regimens is 12-30% in controlled settings, making careful monitoring essential 3, 4

Before discharge, patients should resume oral medications 1-2 days before discharge if suspended during hospitalization, obtain HbA1c if not available from previous 3 months, and be discharged on a basal-bolus regimen or previous oral agents plus 80% of hospital basal insulin dose for patients with HbA1c >10% 1, 2, 6