Initial Insulin Dosing for Non-Insulin Dependent (Type 2) Diabetes Patients in the Inpatient Setting

Choosing the Initial Insulin Regimen

The American Diabetes Association recommends starting with a total daily dose of 0.3-0.5 U/kg/day for insulin-naive Type 2 diabetes patients, with half given as basal insulin and half as rapid-acting insulin, using lower doses for patients at higher risk of hypoglycemia, including those over 65 years, with renal failure, or poor oral intake 1
A basal-bolus regimen is the preferred approach for non-critically ill hospitalized Type 2 diabetes patients with good nutritional intake, as it demonstrates superior glycemic control compared to sliding scale insulin alone 1
The basal-bolus regimen has been shown to reduce postoperative complications, including wound infection, pneumonia, bacteremia, and acute renal and respiratory failure 1
The American College of Clinical Endocrinologists recommends a basal-bolus regimen for better outcomes than reactive insulin regimens in general surgery patients 2, 3

For insulin-naive patients, the starting dose is 0.3-0.5 U/kg/day total daily insulin, with 50% as basal insulin and 50% as rapid-acting insulin 1
The American Association of Clinical Endocrinologists recommends starting at 0.3 U/kg/day for high-risk patients, including those over 65 years of age, with renal failure, or poor oral intake 1, 3, 4

The Endocrine Society recommends administering rapid-acting insulin immediately before meals for eating patients, and performing point-of-care glucose testing immediately before meals 2, 3
For patients with uncertain or poor oral intake, the American Diabetes Association recommends administering prandial insulin immediately after the patient eats, with dose adjusted for the amount actually ingested 2, 3

Sliding scale insulin alone as the sole treatment is strongly discouraged for prolonged use in hospitalized patients, as it provides inadequate glycemic control 1, 2, 3, 4
Premixed insulin is not recommended in the hospital setting due to unacceptably high rates of iatrogenic hypoglycemia 1, 2, 3

The basal-bolus approach carries a 4-6 times higher risk of hypoglycemia compared to sliding scale insulin alone, with a risk ratio of 5.75 for blood glucose ≤3.9 mmol/L (70 mg/dL) 1
In controlled settings, mild hypoglycemia occurs in 12-30% of patients on basal-bolus regimens, which must be balanced against the improved glycemic control and reduced complications 1

The American Association of Clinical Endocrinologists recommends increasing the frequency of blood glucose monitoring during insulin regimen changes, with target glucose ranges in the hospital typically 7.8-10.0 mmol/L (140-180 mg/dL) for most non-critically ill patients 1
The Endocrine Society recommends implementing a hypoglycemia prevention and management protocol, as many episodes are preventable 2, 3