Table 3—

Practical guidelines for hospital use of insulin

Clinical settingProgrammed/scheduled insulin option(s)
Supplemental/correction-insulin option(s)Comments
BasalPrandial and/or nutritional
• Total daily insulin requirement may be calculated based on prior insulin doses or as 0.6 units · kg−1 · day−1
• Basal insulin generally accounts for 40–50% of daily insulin requirement
• Prandial and/or nutritional or supplemental/correction doses may be calculated as 10–20% of total daily insulin requirement for each dose
• Patients with type 1 diabetes always require continuous insulin coverage to avoid ketosis
Eating meals• Int-I bid or hs• Reg-I or rapid-I ac− B&D or B, L, and D• Reg-I or rapid-I ac +/− hs• Give Reg-I, 30–45 min ac; rapid-I, 0–15 min ac
• LA-I hs or am• Glargine given as once-daily dose, usually at hs
• Insulin drip• Avoid/minimize Reg-I and rapid-I doses at hs to decrease risk of nocturnal hypoglycemia
• 70/30 or 75/25 insulin may be used ac breakfast and dinner to meet both basal and prandial needs
• Insulin drip is Rx of choice in severely decompensated type 1, with or without DKA, and in type 2 with HHS
Not eating• Insulin dripN/A• Reg-I q 4–6 hours
• Int-I bid or hs• Rapid-I q 4 hours
• LA-I hs or am
Perioperative or periprocedural
 Will eat post-op or postprocedure (e.g., cataract extraction, cardiac catheterization, endoscopy)Base on prior insulin Rx:When resumes eatingUntil resumes eating:• Usual insulin and/or oral agent doses given the night prior to surgery to assure adequate glycemic control on the morning of the procedure
• Int-I give 1/2-2/3 usual am dose• Restart prior doses of Reg-I or rapid-I ac• Reg-I q 4–6 h
• Rapid-I q 4 h• Patients with diabetes should be on the OR list for the early morning to minimize amount of time that they will be kept NPO. This decreases risk of hypoglycemia and allows maintenance of optimum metabolic homeostasis
• LA-I glargine, continue usual dose pm prior
 Will not eat (e.g., major surgery)• Insulin dripN/AUntil resumes eating:• Where a prolonged postoperative npo period is anticipated, e.g., cardiothoracic, major abdominal, CNS cases, insulin drip Rx is recommended
• Reg-I q 4–6 hours• Reg-I q 4–6 h
• rapid-I q 4 hours• Rapid-I q 4 h• Starting dose for perioperative maintenance insulin drip is 0.2 units · kg−1 · h−1
• Int-I, give ½ usual am dose
• LA-I glargine, give usual daily dose
ICUIf npo and/or clinically unstable:If npo:• Reg-I q 4–6 h• Evidence-based outcomes studies support use of insulin drip as Rx of choice for decompensated diabetes in the ICU setting including coronary care (acute myocardial infarction) and surgical intensive care units (Malmberg, Van den Berghe, Furnary)
• N/A• Rapid-I q 4 h
• Insulin dripIf eating:
• Reg-I q 4–6 h• Reg-I or RA-I ac and hs
• Rapid-I q 4 h
If eating:
• Continue prior Int-I or LA-I
Enteral tube feeding
 Continuous24 h:• Reg-I q 4–6 h• Reg-I q 4–6 hours• Basal insulin dose generally no more than 40% of total daily insulin requirement to avoid hypoglycemia if enteral feeding interrupted
• Int-I bid;• Rapid-I q 4 h• Rapid-I q 4 hours• Nutritional insulin requirements met with programmed doses of reg-I or rapid-I
• LA-I hs or am• May use low-dose int-I at hs to control fasting hyperglycemia
Daytime only:During tube feeding delivery period only:• If tube feeding interrupted, e.g., for procedure or intolerance, increase frequency of fingerstick BG checks
• Int-I am
• Reg-I q 4–6 h
• Rapid-I q 4 h
Bolus24 h:• Reg-I q 4–6 h• Reg-I q 4–6 h• Give reg-I, 30–45 mins, or rapid-I, 0–15 mins prior to bolus to control post-bolus BG excursions
• Int-I bid;• Rapid-I q 4 h• Rapid-I q 4 h
• LA-I hs or am• Check finger stick BG 2 h after reg-I or 1 h after rapid-I to determine dose adjustments for post-bolus target BG < 180 mg/dl
• May use low-dose int-I at hs to control fasting hyperglycemia
Bolus (cont.)Daytime only:During bolus delivery period only:
• Int-I am
• Reg-I q 4–6 h
• Rapid-I q 4 h
TPN• Reg-I added to TPN bags• Reg-I q 4–6 h• Basal and nutritional insulin needs met with reg-I added to TPN bag directly
• To determine daily dose of insulin to add to TPN bag, consider use of separate IV insulin infusion for 24 h to determine daily insulin requirement, then add 2/3 of this amount to subsequent TPN bags; or add 2/3 of total units of insulin administered SQ the previous day to the next day’s TPN bag as reg-I, until daily dose determined
• Use SQ insulin with caution with TPN. Lack of correlation of insulin peaks and troughs with nutrient delivery may lead to erratic BG control
Transition to oral intake• Int-I bid• Reg-I or rapid-I ac• Reg-I or rapid-I ac ac +/− hs• Give reg-I, 30–45 min or rapid-I 0–15 min prior to meal to control postprandial BG excursions
• LA-I hs or am
• Postprandial target BG < 180 mg/dl
• Check fingerstick BG 2 h after reg-I or 1 h after rapid-I to determine prandial insulin dose adjustments
High-dose glucocorticoid Rx•Insulin drip; Int-I bid; LA-I hs or amReg-I or RA-I:Reg-I or rapid-I:• High-dose glucocorticoids raise insulin requirements
•ac (B and D) or ac (B, L, and D) if eating; or q 4–6 h if NPO•ac and hs if eating; or q 4–6 hours if NPO• Adjust/increase insulin doses to counter postprandial hyperglycemia and BG peak that may occur 8–12 h following once-daily GC dose
• Alternate-day steroid doses require alternate-day insulin doses
  • ac, before meals; am, morning; B, breakfast; BG, blood glucose; D, dinner; DKA, diabetic ketoacidosis; GC, glucocorticoid; HHS, hyperglycemic hyperosmolar state; hs, bedtime; I, insulin; Int-I, intermediate acting insulin (NPH or Lente); IV, intravenous; L, lunch; LA-I, long-acting insulin (glargine or ultralente); OR, operating room; q, every; qd, every day; rapid-I, rapid acting insulin (lispro or aspart); Reg-I, regular insulin; SQ, subcutaneous.