Insulin Therapy for Hospitalized Patients

General Recommendations

The American Diabetes Association recommends using a basal-bolus-correction insulin regimen for non-critically ill hospitalized patients with good oral intake, and basal insulin plus correction insulin only for those with poor or no oral intake 1, 2, 3
For critically ill patients, continuous intravenous insulin infusion is the preferred method for managing hyperglycemia, with a target blood glucose range of 140-180 mg/dL 1, 3, 4

A basal-bolus-correction insulin regimen is the preferred treatment for non-critically ill hospitalized patients with good nutritional intake, consisting of basal insulin, prandial (bolus) insulin, and correction insulin 1, 2, 3, 8
Basal insulin should be given once daily, with prandial insulin given before each meal, and correction insulin given to correct elevated glucose levels 1, 2, 9
For patients with poor oral intake or those who are NPO, basal insulin plus correction insulin only is recommended, with a lower starting dose of 0.1-0.25 units/kg/day 1, 2, 3, 9

For patients with type 1 diabetes, an insulin regimen with basal and correction components is required, with addition of prandial insulin if eating 1, 2, 3
Basal insulin must never be discontinued in type 1 diabetes patients, and patients with renal insufficiency should be treated with lower doses 1, 2, 5

Subcutaneous basal insulin should be administered 2-4 hours before discontinuing IV insulin infusion to prevent rebound hyperglycemia 1, 2, 3, 8
The dose of subcutaneous basal insulin should be calculated at 60-80% of the daily IV infusion dose, based on the insulin infusion rate during the last 6-8 hours when stable glycemic goals were achieved 1, 2, 8

Prolonged sole use of sliding scale insulin (SSI) is strongly discouraged and should never be used as the only regimen, as it can lead to poorer glycemic control and increased risk of hypoglycemia and hyperglycemia 1, 2, 3, 8
Premixed insulin formulations are not routinely recommended for in-hospital use, as they can increase the risk of hypoglycemia and have fixed ratios that cannot be adjusted for variable oral intake 1, 2, 3, 8, 9
SGLT2 inhibitors should be discontinued 3-4 days before surgery and avoided during hospitalization, as they can increase the risk of ketonemia and ketonuria 3, 7

A standardized hospital-wide hypoglycemia management protocol must be implemented, with treatment regimens reviewed and adjusted when blood glucose falls below 70 mg/dL 1, 6, 7, 5
All hypoglycemic episodes should be documented in the medical record and tracked, with 84% of patients with severe hypoglycemia having a prior episode of hypoglycemia during the same admission 1, 2, 6, 5

Insulin pens may be safely used in the hospital setting, but must be strictly labeled "For single patient use only" per FDA warning, and human insulin and analog insulins provide similar glycemic control in the hospital setting 1, 2, 6, 5, 8