• Common in hospital; outpatient
•  *70/30 = 70% NPH, 30% regular insulin
• Not really used in the hospital - requires regular feeding to avoid hypoglycemia

Estimating average blood glucose

• (A1c - 6) * 30 + 100 (e.g. A1c of 7 = BG of 130)

Glycemic goals in the hospital

• Initiate insulin therapy for persistent hyperglycemia > 180 mg/dl
• Target glucose range 140-180 in most patients (NICE-SUGAR)
• 110-140 in select critically ill patients (e.g. cardiac surgical pts)
• Avoid hypoglycemia (< 70 mg/dl); clinically significant hypoglycemia = < 54 mg/dl

• Ask about patient's home insulin/oral medication regimen
• Timing of last dose of home meds, so that you don't double dose
• How often they miss doses
• How often they check BG/what are they
• Do they get hypoglycemic, when/how often, and do they have hypoglycemia unawareness

1. On admission
1. Perform A1c if not checked in last 3 months
2. Hold home oral medications in the hospital - use insulin for more accurate management of hyperglycemia
3. If pre-existing diabetes, order basal/bolus + correctional insulin
4. Pre-operative patients
1. T1DM can continue using inuslin pump; need endocrine consult if poorly controlled
2. Estimate total daily insulin requirement/dose (TDD) (e.g. sum of patient’s home daily insulin)
1. TDD = 0.3-0.6 U/kg, depending on insulin sensitivity
1. 0.15 U/kg - bolus/basal only for patients with good control on oral meds
2. 0.2-0.3 U/kg - insulin-naïve/sensitive (e.g. TIDM); lean/elderly; AKI/CKD IV-V (↑ insulin half-life); pancreatectomy (no glucagon/hypersensitive to insulin)
3. 0.4 U/kg - overweight/seems insulin sensitive
4. 0.5-0.6 U/kg - obese/insulin resistant; on steroids
2. Or, use 80% of home insulin dose for the hospital (decrease home dose for safety)
3. Basal – 50% TDD (less if risk factors for hypoglycemia)
1. Ideally provide 24-hour peakless insulin to suppress liver’s release of glucose during fasting state (should not cause hypoglycemia in NPO patients)
1. Lantus, Levemir (long-acting insulin) are relatively peakless
2. Lantus is qd dosing; NPH can be dosed q12 or q8 for more dynamic dosing adjustments
2. Best indicator of dose adequacy is fasting glucose
3. Never hold basal insulin in TIDM (liver still makes glucose even when NPO)
4. Bolus – 50% TDD (adjust based on % of meal eaten)
1. Prevent postprandial rise in glucose (rapid-acting)
1. No bolus insulin if NPO or pre-meal glucose < 70 mg/dl
2. Give 0-15 minutes after meal
2. Patients on corticosteroids will require higher percentage of TDD as bolus – inhibits glucose uptake into muscle
1. Or can give NPH with each dose of steroids (NPH has similar duration of action as prednisone)
2. NPH dosing = 0.1 U/kg x (pred dose - 20)/20
1. prednisone 20 mg = methylprednisone 16 mg = dexamethasone 3 mg
3. Give Lispro/Humalog, aspart, glulisine (rapid onset, peak in 1 hour)
1. Regular insulin must be given 30 minutes before meal – not realistic in hospital setting
2. However, use regular insulin (IV) when on tube feeds
5. Correctional sliding scale (based on insulin sensitivity)
1. Low dose - TDD < 40 U
2. Mid dose - TDD 40-80 U
3. High dose - TDD > 80 U
4. 1 U of insulin will correct glucose by 1500/TDD
5. **hide**Carb counting - 500/TDD = how much carbs (in g) that 1 U of insulin will cover. 
6. Give less slide at bedtime - more prone to hypoglycemia due to no PO intake
7. Adjusting basal/bolus insulin regimen
1. Take 1/2 of total correctional insulin, and divide between adding to basal/bolus (takes more insulin to correct hyperglycemia than to prevent)
6. Dosing considerations
1. NPO - hold bolus insulin, but continue basal insulin (liver still makes glucose even when NPO) - maybe decrease by 10-20%. Keep sliding scale ordered.
2. Perioperative - follow same NPO guidelines. When resuming diet, ease back into mealtime regimen if pt is not eating well.
3. Bridging off an insulin drip - turn off 2 hrs after starting basal insulin regimen (e.g. NPH)
4. Beware of insulin stacking (giving insulin more frequently than its duration) - if need to give more insulin earlier, give 1/2 dose
5. Hyperglycemia with TPN - can add 0.1 U/g of dextrose to the bag, e.g. 300g dextrose = 30 U regular insulin