Inpatient Management

of Diabetes Mellitus

Ben Rafla
Internal Medicine PGY-2
Presentation adapted from Dana Awad
 Non critically-ill patients:
• Pre-prandial: < 140 mg/dl
Blood • All Random glucose readings :
Glucose <180 mg/dl
targets Critically ill patients:
• 140-180 mg/dl
After MI

• There is increasing evidence that suboptimal

glycemic control in diabetic patients and stress-
induced hyperglycemia in nondiabetic patients
are associated with worse outcomes after acute
myocardial infarction (MI) and that better
glycemic control may be beneficial in some
individuals.
Things to keep in mind

Their last A1c before admission

How much they will be eating while in the hospital. NPO?

Their kidney function. (remember insulin is cleared by the kidneys)

NEVER EVER hold basal insulin for patients with type 1 DM.

Patients will need more insulin when treated with steroids.

For any patient with diabetes being admitted.
REMEMBER TO..

1. Order a carbohydrate consistent diet

2. Blood glucose checks aka Accu checks 4 times
a day
 Always HOLD on admission.
Patients on oral Why?
hypoglycemics • Metformin
before • SGLT-2i
admission • Sulphonylureas
• GLP-1 analogues
• Thiazolidinediones
 Always HOLD on admission.

Why?
• Metformin: lactic acidosis, AKI and risk of
Patients on oral contrast induced nephropathy if we use
hypoglycemics contrast
• SGLT-2i: Euglycemic DKA
before admission • Sulfonylureas: unpredictable
hypoglycemia
• GLP-1 analogues: Nausea and vomiting
• Thiazolidinediones: water retention and
edema
The preferred regimen while
inpatient is always Basal +
pre-prandial insulin
Types of insulin
• Rapid acting (1-2 hrs)
• Humalog- Lispro
• Novolog- Aspart
• Apidra- Glulisine

• Short acting (2-3 hrs)

• Regular

• Intermediate acting (6 hrs)

• NPH insulin

• Long acting 
• Lantus - Glargine
The physiological insulin secretion in the body
 Basal insulin 
• Background coverage/ long
Preferred inpatient acting eg: Lantus
regimen Prandial
• Before meals / rapid or short
acting (fixed amount)

Correctional
• Before meals ( sliding scale
insulin)
What is a sliding scale?

A variable amount of insulin that you add in

addition to the fixed pre- meal insulin.
 Based on the patient's insulin
What level of sensitivity (How much their
blood glucose drops with each
correction unit of insulin)

scale should I
order? Always start with level 1 and
then you can adjust during their
hospital stay
Scenario one

• A 45-year-old M with type 2 DM admitted with

sepsis secondary to CAP.
• He is on metformin 1000 mg BID at home.

• What will you do with their diabetes regimen?

1. Hold metformin
2. Start an insulin regimen.

• Ideally you would want: Basal + prandial + correction.

• Is it ok to start a sliding scale only for this patient?

1. Hold metformin
2. Start an insulin regimen.

• Ideally you would want: Basal + prandial + correction.

• Is it ok to start sliding scale only for this patient?

• Answer: Yes and No

• If the patient is staying in the hospital for 24-48 hours only. It's ok to keep
them on a sliding scale.
•  However, after 2 days , you need a more physiological insulin regimen. That
is basal +prandial

• How to calculate the dose?

• (0.3-0.6) x body weight in Kg to get the total daily dose TDD

Eg: 70 Kg man
0.3x 70 = 21

Divide The TDD:

50% Basal and 50% prandial 
10 units Lantus QHS + 4 units Humalog TID before meals = 22 units total
Scenario 2

• Mr Moreno is a 65 yo gentleman with type 2 DM, CHF and HTN. 

• He is admitted to the hospital with CHF exacerbation.
• His home regimen is Metformin 1000 mg BID, Lantus 35 units
QHS and Humalog 15 units TID with meals.

What will you do?

1. Hold Metformin
2. Order Glucose checks QID ( AM and before each meal)
3. Order carbohydrate consistent diet
4. Resume insulin but at LOWER DOSES

• Basal: Decrease by 20-50% 

• Mealtime: based on how much the patient will be eating. You can start with a
sliding scale only and then increase based on his blood sugar readings
Scenario 3

• Mr Kent is a 35 yo male with type 1 DM is admitted with left

foot cellulitis.
• His home regimen is Lantus 20 units QHS and Humalog 7 units
TID.

• What will you do?

1. Order Glucose checks QID ( AM and before each meal)
2. Order carbohydrate consistent diet
3. Resume insulin and NEVER EVER HOLD basal insulin for type 1
DM!!!!!!!

• Basal: cont same dose or decrease by 20% 

• Mealtime: based on how much the patient will be eating. You can start with a
sliding scale only and then increase based on his blood sugar readings.
Scenario 4
The NPO patient (very common)

• Mr Simmon has been in the hospital for 2 days and he is

scheduled for a vascular surgery tomorrow morning and he will
be NPO at midnight.
• He has type 2 DM and currently takes 20 units Lantus QHS and 8
units Aspart TID with meals + level 1 correction
• The nurse calls you at 8 PM and asks if she should give the
Lantus since he will be NPO at midnight.
Answer:
• Yes
• Give but decrease dose by 20-50%
Scenario 5 
(very common- a page with high BG reading)

• You are the intern on NF and you are paged from the nurse on
Mr. smith whose blood sugar before dinner was 450 mg/dl. She
gave him his pre-dinner scheduled and correction insulin of 14
units and his blood glucose now is 380 mg/dl.

• What will you do next?

1. Ask if the patient is symptomatic?
2. Is the patient in DKA? Can get a BMP for BG readings > 300
mg/dl,especially in sick patients, to look for AG.
3. Give insulin (rapid or short acting).
• How Much??

• Theoritically speaking, each unit of insulin should drop BG by 30-50

units , and it varies depending on the individual’s sensitivity.
• Give 5 units of Humalog or regular insulin and ask the nurse to re-
check BG in 30 to 60 mins.
Adjusting insulin regimen in daily rounds

• Quick trick. 

How to check BG readings while chart checking in the

morning?
• Current regimen is Insulin Glargine 20 units QHS and Humalog 7 units
TID with meals.
• You have the following readings
  Morning/fasting Pre-Lunch Pre-dinner bedtime

155 mg/dl 175 mg/dl 160 mg/dl 165 mg/dl

• Is it at goal?  (Remember goal is <140 fasting and <180 random)

• If morning Glucose is not at goal, increased nighttime Lantus by 20%
every 2 days

• If pre-lunch BG is not at goal>>>Increase the pre-breakfast bolus

• If pre-dinner is not at goal>>>> Increase the pre-lunch bolus
• If bedtime is not at goal>>> increase the pre-dinner bolus
Discharge planning

• For patients known to have DM whose A1C and BG readings

were not controlled during their inpatient stay. They probably
need some adjustments to their discharge regimen.
• A good estimate of the discharge regimen would be how much
insulin they were requiring during hospitalization but also make
sure not to do MAJOR adjustments as the situation may be
different at home

• So the best thing is to do minor changes and make them follow

with their PCP /endo in a week with BG log.
Discharge Planning, cont.

• For newly diagnosed DM patients who are diagnosed in the hospital Eg:
Admitted with DKA or you diagnose it incidentally during admission:
• Patient need to be educated about their disease. Always make A diabetes
educator consult.
• If you will be discharging on insulin. Put in mind that for those who don't
have insurance, NPH insulin is cheaper than Lantus, but it’s a BID dose.
• You can always ask the SW to assist you when it comes to the cost of
medications
• Always make them establish a care with a PCP or endo if they don't have
one. Otherwise, they can follow up with their PCP in no more than 2
weeks after discharge to find the best longterm management plan for
their diabetes
A 55-year-old man with type 1 DM was admitted for management of a NSTEMI. He is
clinically stable and eating well. He will begin fasting at midnight in preparation for a
cardiac cath tomorrow. His current fasting BG values range from 70 to 80 mg/dL ,
and his premeal BG values range from 140 to 160 mg/dL  on his home doses of basal
insulin glargine and prandial insulin aspart. His  A1c  value was 7.2%.

In addition of holding his prandial insulin. Which of the

following is the best management for his Diabetes?

A. Continue basal insuloin dose

B. Continue basal insuloin dose and add correction
C. Decrease basal insulin dose and add correction insulin
D. Hold basal insulin and add sliding scale regimen
A 55-year-old man with type 1 DM was admitted for management of a NSTEMI. He is
clinically stable and eating well. He will begin fasting at midnight in preparation for a
cardiac cath tomorrow. His current fasting BG values range from 70 to 80 mg/dL ,
and his premeal BG values range from 140 to 160 mg/dL  on his home doses of basal
insulin glargine and prandial insulin aspart. His  A1c  value was 7.2%.

In addition of holding his prandial insulin. Which of the

following is the best management for his Diabetes?

A. Continue basal insulin dose

B. Continue basal insulin dose and add correction
C. Decrease basal insulin dose and add correction insulin
D. Hold basal insulin and add sliding scale regimen
 THANK YOU
For any questions please don't hesitate to email or text me

Ben Rafla
Internal medicine PGY-2

• Phone: 646-474-9751
• email: benrafla@creighton.edu