Inpatient Insulin Management Guidelines

Introduction to Inpatient Insulin Therapy

The American Diabetes Association recommends increasing basal insulin by 2 units every 3 days if fasting glucose is 140-179 mg/dL, or by 4 units every 3 days if fasting glucose is ≥180 mg/dL 2, 3
Basal insulin titration must be based on fasting plasma glucose values, not on the total amount of insulin administered the previous day 1, 2
Basal insulin addresses fasting and between-meal glucose levels through restraining hepatic glucose production—it does not address postprandial hyperglycemia 2

Basal insulin can be adjusted every 3 days after a change is made, even when patients are concurrently receiving short-acting insulin (SSI) three times daily 2
Do not wait longer than 3 days between basal insulin adjustments in stable patients, as this unnecessarily prolongs the time to achieve glycemic targets 2
If hypoglycemia occurs without clear cause, reduce the dose by 10-20% immediately 2, 3

Prandial insulin should be titrated by 1-2 units or 10-15% every 3 days based on pre-meal and 2-hour postprandial glucose readings 2, 3
Start with 4 units of rapid-acting insulin before the largest meal or 10% of the current basal dose 2, 3

Correction insulin should be adjusted based on insulin sensitivity factor (ISF), calculated as 1500/TDD or 1700/TDD 2
If correction doses consistently fail to bring glucose into target range, adjust the ISF, not the basal dose 2

For hospitalized patients who are insulin-naive or on low-dose insulin, the American Diabetes Association recommends a total daily dose of 0.3-0.5 units/kg, with half as basal insulin 2, 3
For patients on high-dose home insulin (≥0.6 units/kg/day), reduce the total daily dose by 20% to prevent hypoglycemia 2, 3
Lower doses (0.1-0.25 units/kg/day) are recommended for high-risk patients, such as the elderly (>65 years), those with renal failure, or poor oral intake 2, 3

75% of hospitalized patients who experienced hypoglycemia had no basal insulin dose adjustment before the next administration 6, 2
A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system 1
For individual patients, treatment regimens should be reviewed and changed as necessary to prevent further hypoglycemia when a blood glucose value of <70 mg/dL (3.9 mmol/L) is documented 1

In hospitalized patients with diabetes who are eating, bedside glucose monitoring should be performed before meals; in those not eating, glucose monitoring is advised every 4-6 hours 1
Assess adequacy of insulin dose at every clinical visit, looking for signs of overbasalization, and adjust the basal dose by 10-20% immediately if hypoglycemia occurs 2