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Insulin Initiation in Hyperglycemic Adult Patients in the Hospital Algorithm

Insulin Initiation in Hyperglycemic Adult Patients in the Hospital Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Diabetes and Endocrinology, Related


Last Updated 2/23/2017 I Last Reviewed 3/23/2017
Questions? Contact Inpatient Diabetes Quality Committee
Initiation of Insulin in Non-Critically Ill Insulin-Naive
Hyperglycemic Patients – Adult – Inpatient
Target Inpatient Blood Glucose for Non-critically Ill
140-180mg/dL; <140mg/dL may be appropriate for select patient if hypoglycemia can be avoided
Criteria for Algorithm Use
Inclusion criteria:
ξ Patients who have >3 blood glucose (BG)
readings >180mg/dL in a 24 hour time
period
ξ Patients not previously on scheduled insulin
or an insulin drip
Exclusion criteria:
ξ Type 1 diabetes
ξ Steroid induced hyperglycemia
ξ Parenteral nutrition
ξ Severe hyperglycemia (insulin drip required)
ξ Postoperative patients using Normoglycemia
Delegation Protocol
Step 1: Use the chart below to determine the patient’s initial Total Daily Dose (TDD) of insulin by taking the
baseline estimate and subtracting/adding for each risk factor. Actual body weight should be used for
TDD calculation. Stop all oral and non-insulin injectable diabetes medications if previously taking.
Baseline TDD estimate 0.4 units/kg/day
Age > 70 -0.1 unit/kg/day
Renal insufficiency (CrCl<60ml/min) -0.1-0.2 units/kg/day
End stage liver disease -0.1 unit/kg/day
Using non-insulin diabetes medication prior
to admission AND all BG>200mg/dL in past
24 hours
+0.1 unit/kg/day
Final TDD estimate =_____________
Step 2: Split TDD of insulin into basal-nutritional regimen depending on diet.
If eating meals: If receiving continuous tube feeds (TF): If NPO:
Basal: glargine = TDD x 0.5 daily
Nutritional: rapid-acting insulin
(i.e. lispro) =
TDD x 0.5 divided by 3 for 'set
meal' dosing or based on
insulin:carb ratio orders.
Correction: rapid-acting insulin
(i.e. lispro) TID prn & bedtime
prn
Diabetes meal plan
recommended
Not on DM meds prior to admission:
Basal: none
Nutritional*: regular insulin =
TDD divided by 4, dosed q6hrs (hold if TF off
for >1 hour)
Correction: regular insulin every 6hrs prn
Basal: glargine = TDD x 0.5 daily
Nutritional: none
Correction: rapid-acting insulin
(i.e. lispro) every 6hrs prn
Consider low-dose dextrose
infusion (D5-1/2NS at 75ml/hr)
to prevent hypoglycemia.
On DM meds prior to admission:
Basal: glargine = TDD x 0.4 daily
Nutritional*: regular insulin =
TDD x 0.6 divided by 4, dosed every 6hrs
(hold if TF off for >1 hour)
Correction: regular insulin every 6hrs prn
*If patient is not at goal tube feed rate, consider reducing initial nutritional dose by up to 50% and titrating dose up as
necessary.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

Last Updated 2/23/2017 I Last Reviewed 3/23/2017
Questions? Contact Inpatient Diabetes Quality Committee
Step 3: Choose correction scale insulin for blood glucose excursions TID PRN or every 6 hours prn. *May add
HS scale for glucose >200mg/dl for patients eating meals.
Lower intensity Higher intensity
Blood Glucose (mg/dL) Insulin (units) Blood Glucose (mg/dL) Insulin (units)
151-200 1 151-200 2
201-250 2 201-250 4
251-300 3 251-300 6
301-350 4 301-350 8
>350 5 >350 10
Generally used for:
ξ Insulin sensitive (TDD<40units)
ξ Renal failure
Generally used for:
ξ Insulin resistant (TDD>40units)
ξ Obese patients
References
1. Association AD. Professional Practice Committee for the Standards of Medical Care in Diabetes-2017.
Diabetes Care. Jan 2017;40 Suppl 1:S1-135.
2. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients
in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab.
2012;97(1):16-38.
3. Maynard G, Lee J, Phillips G, Fink E, Renvall M. Improved inpatient use of basal insulin, reduced
hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an
insulin management algorithm. J Hosp Med. 2009;4(1):3-15.
4. Baldwin D, Apel J. Management of hyperglycemia in hospitalized patients with renal insufficiency or
steroid-induced diabetes. Curr Diab Rep. 2013;13:114-120.
5. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and
American Diabetes Association Consensus Statement on inpatient glycemic control. Diabetes Care.
2009;32(6):1119-1131.
6. Wesorick D, O’Malley C, Rushakoff R, et al. Management of diabetes and hyperglycemia in the hospital: a
practical guide to subcutaneous insulin use in the non-critically ill, adult patient. J Hosp Med.
2008;3:17-28.
7. Umpierrez GE, Smiley D, Ariel Z, et al. Randomized study of basal-bolus insulin therapy in the inpatient
management of patients with type 2 diabetes (RABBIT 2 Trial). Diabetes Care. 2007:30(9):2181-2186.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org