dromlakhani Initial correctional or scheduled insulin for diet‑ or noninsulin‑treated diabetes; add scheduled if persistent hyperglycemia
STEP 1 — Gather Information
Collect admission point‑of‑care blood glucose (POC‑BG), diabetes treatment prior to admission (diet‑only or noninsulin oral agents), and relevant comorbidities (renal function, hypoglycemia risk).
STEP 2 — Rule In / Rule Out
If the patient is treated with diet or noninsulin medications prior to admission, proceed; otherwise, this pathway does not apply (consider insulin‑treated patients).
STEP 3 — Classify or Stratify
If admission POC‑BG ≥180 mg/dL, initiate scheduled basal‑bolus insulin (or basal insulin) to maintain glucose 100–180 mg/dL. If admission POC‑BG <180 mg/dL, start correctional insulin (rapid‑acting) before meals and at bedtime or every 4–6 h if NPO.
STEP 4 — Decide
After starting correctional insulin, review POC‑BG over the next 24 h; if ≥2 readings are ≥180 mg/dL, add scheduled basal insulin (or basal‑bolus) to the regimen; otherwise continue correctional insulin alone and reassess daily.
Clinical Guardrails / Mimics / Pitfalls
Do not rely on sliding scale insulin alone for persistent hyperglycemia; avoid delaying scheduled insulin when criteria are met; monitor for hypoglycemia, especially in renal impairment; do not use this pathway for type 1 diabetes or patients with significant insulin deficiency.
Concrete Clinical Example
A 68‑year‑old woman with type 2 diabetes on metformin admitted for cholecystectomy. Admission POC‑BG 162 mg/dL. She is diet‑ and metformin‑treated prior to admission. Start correctional insulin (lispro 4 units AC and HS). Over the next 24 h, three POC‑BG values are 192, 205, and 178 mg/dL (≥2 ≥180). Add basal insulin glargine 10 units nightly and continue correctional insulin.
Source: Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2022, https://doi.org/10.1210/clinem/dgac278
TODO: consider adding scripts/calc.py for the endo-initial-correctional-or-scheduled-insulin-diet-noninsulin-prior calculator