Inpatient Insulin Management

Learning Objective: Develop a plan for insulin initiation and adjustment for inpatients with
hyperglycemia.

Why insulin?

 Current recommendation is to hold noninsulin agents in hospitalized patients. Most not studied.
o Sulfonylureas risk of hypoglycemia
o Metformin  risk of AKI with contrast dye
o DPP4i  may increase risk of heart failure in setting of heart or kidney disease
o GLP1-RA  GI side effects, long onset for weekly agents
o Thiazolidinediones risk for fluid overload or CHF
o SGLT2i Discontinue prior to surgery, risk for ketosis, hypovolemia, AKI

Goals in Hospitalized Patients

 Goal BG _____________mg/dL for most patients

 More stringent goal of 110-140 mg/dL may be appropriate in select patients
o _________________, ______________________________, ____________________
 Hyperglycemia needing treatment: persistent BG > ________ mg/dL
 Monitoring every 4-6 hours
 Get A1c on all patients with known diabetes mellitus (DM) upon admission unless available in
past 3 months

Approaches

Approach to
treating
Hyperglycemia

Non-insulin
Insulin (preferred) therapies (not
preferred)

Subcutaneous
IV infusion (critical
Insulin (noncritical
care)
care)

Basal infusion with

Sliding scale or
or without boluses, Basal-Bolus
correctional
titrated to control
Critical Care
 ______________________ insulin preferred
 Example titration schedule (managed by nursing):
Initiation of Insulin Drip Table Maintenance of Insulin Drip Table

If baseline BG is greater than 110 mg/dL: Initiate at 2 units per
hour
If baseline BG is greater than 220 mg/dL: Initiate at 4 units per
hour
First Insulin Titration Table
If next BG is between 110-140 mg/dL: Increase by 1 unit per hour
If next BG is greater than 140 mg/dL: Increase by 2 units per
hour
If BG is less than or equal to 70 mg/dL: Stop infusion and
administer D50% per protocol, check 15 min
If BG is 71-99 mg/dL: Decrease infusion by 50% and recheck
glucose in 60 minutes.
If current BG is below 120 mg/dL and the change from previous
BG is more than 50mg/dL per hour: Decrease infusion by 2 units
per hour and recheck BG in 60 minutes.
If BG is 100-150 mg/dL: No change
If BG is 151-180 mg/dL: Increase infusion by 1 units/hour
If BG is 181-200 mg/dL: Increase by 2 units/hour, bolus 2 units
If BG is 201-250 mg/dL: Increase by 2 units/hour bolus 4 units
If BG is 251-300 mg/dL: Increase by 3 units/hour, bolus 6 units
If BG is Greater than 300 mg/dL: Notify Physician

 Transitioning from IV to subcutaneous insulin:

o Total daily dose for subcutaneous regimen: __________% daily infusion dose
o Subcutaneous long-acting insulin should be given _________hours __________ stopping
infusion

Noncritical Care
 _________________ insulin preferred
 Basal-bolus treatment improves glycemic control and reduces complications compared to sliding
scale regimens

Basal Bolus Correctional

As needed based on
Scheduled Scheduled
BG (retroactive)

-Not recommended
Covers meals, other alone in T2DM
Covers overnight and
nutrition, or other
between meals -NEVER appropriate
sources of calories
alone in T1DM
 Inpatient
subcutaneous insulin
requirements

Assess home
regimen

Previously on
Previously on
Insulin Naïve basal/bolus
basal insulin
regimen

Initiate 10 units Decrease Total Decrease total daily

or 0.1-0.2 daily dose by dose by 20-40% and
units/kg daily of _____% unless add correctional
basal insulin uncontrolled at insulin
home

Order correctional Omit prandial If basal insulin is

insulin. If requires >2 dose if patient is titrated to FBG <180
doses in 24 hours then NPO mg/dL, patient
add weight-based
consistently eating,
basal/nutrition PRN
and BG elevated, add
prandial

Adjustment

 Reassess glucose and insulin regimen every 1-2 days; requires clinical judgement
 T1DM: Even if NPO always need ______________________
 Converting between insulins:
o NPH to insulin glargine: decrease total daily dose ________
o Toujeo to Lantus or Basaglar: decrease total daily dose 20%
o Detemir to glargine or glargine to determine: unit-per-unit
o Glargine or determine to degludec: unit-per-unit or consider 20% dose reduction
 Pre-mixed insulins: ___________________________
o Divide total daily dose (consider reduction) approx. ______% prandial, _______% basal

Subcutaneous Options

 Pens vs. Vials vs. Pumps

 Concentrated insulins: U-500 (Average Pre-meal BG <80: decrease 10%, BG 131-180: increase
5%; BG 181-220: increase 10%; BG >220 increase 15%)
Hypoglycemia (BG <70mg/dL)

 Common causes
o _________________________________________________
_________________________________________________
_________________________________________________
 Address Cause
 Consider time of day when hypoglycemia occurs; adjust 10-20% or more if severe (<54 mg/dL)
o Fasting: reduce ____________ insulin
o Post-prandial: reduce ________________ insulin
o Overnight: reduce ___________________ insulin
 Institutions should have hypoglycemic protocols in place; can use same oral agents as outpatient
or IV dextrose (ex. 25-50 mL of D50W)

Glucocorticoid Use

 Once-daily or short-acting steroids: prandial insulin such as daily NPH with glucocorticoid
 Long-acting (dexamethasone), multi-dose, or continuous steroids: ________-acting insulin
 Often have more prandial requirements than patients without steroids

Total Parenteral Nutrition (TPN)

 If patient is known to have diabetes, ______________________ is preferred

 ASPEN goal: ____________ mg/dL
 Remember: if you put something in a TPN, you can’t take it out. If insulin causes the patient to
have hypoglycemia, then have to stop the whole TPN.
 Consider adding to TPN if >20 units of correctional in the past 24 hours
 Variable strategies if adding to TPN for dosing:
o Ex. 0.1 unit: 1 gm of dextrose; 80% of total daily dose in TPN (or divided 50/50 between
TPN and basal subcut injection)

Perioperative Care

 Risks of hyperglycemia: ___________________

 Target range: ______________ mg/dL
 Morning of surgery give _________ of NPH dose or __________ of long-acting or pump basal
insulin
 Hold metformin on morning of surgery

Transitions of Care:

 Do not necessarily have to use insulin after discharge. May resume home medications.
 Follow-up with PCP or endocrinologist within 1 month of discharge
 Financial barriers to obtaining therapy
 Counselling and education: dosing, injection technique, monitoring sick day management
 Admission and discharge reconciliation
Prepared by Maggie Kline, PharmD
mkline4@iuhealth.org
September 21, 2020

References:

American Diabetes Association. 15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-
2020. Diabetes Care. 2020;43(Suppl 1):S193-S202. doi:10.2337/dc20-S015.

Donihi AC. Moorman, JM. Abla A, Hanania R, Carneal D, Windham MacMaster H. Pharmacists’ role in
glycemic management in the inpatient setting: An opinion of the endocrine and metabolism practice
and research network of the American College of Clinical Pharmacy. JACCP 2018;2:167-176.

Pharmacist’s Letter. How to Switch Insulin Products. Available at:

https://pharmacist.therapeuticresearch.com/Home/PL. Accessed August 3, 2020.

Indiana University Health. Diabetes Mellitus (Adult), Pharmacy Protocol (CDTM), Ambulatory. Updated
March 2019. Accessed September 19, 2020.

McMahon MM, Nystrom E, Braunschweig C, et al. A.S.P.E.N. clinical guidelines: nutrition support of
adult patients with hyperglycemia [published correction appears in JPEN J Parenter Enteral Nutr. 2014
May;38(4):524]. JPEN J Parenter Enteral Nutr. 2013;37(1):23-36. doi:10.1177/0148607112452001

Gosmanov AR, Umpierrez GE. Management of hyperglycemia during enteral and parenteral nutrition
therapy. Curr Diab Rep. 2013;13(1):155-162. doi:10.1007/s11892-012-0335-y