dromlakhani GCIH Patient Classifier + Background Insulin Initiator
What this skill does
Classifies the patient into Group 1 (established DM) or Group 2 (new GCIH), then determines the starting background insulin regimen. The correctional insulin is handled separately — see [GCIH Correctional Insulin Selector].
Based on the Lakhani et al. 2017 GCIH protocol (IJEM, DOI: 10.4103/ijem.IJEM_226_17).
Step 1 — Confirm the patient qualifies for this protocol
Before classifying, confirm ALL of the following:
- Receiving systemic glucocorticoid (oral or parenteral) ≥ prednisolone 10 mg equivalent
- Duration of glucocorticoid ≥ 48 h and given daily
- 2 h post-lunch OR post-dinner plasma glucose ≥ 200 mg/dl
- Non-ICU, not on enteral/parenteral nutrition, not on IV insulin infusion, not on insulin pump
If any fail → protocol does not apply.
Step 2 — Classify the patient
Group 1 (Established Diabetes) — patient meets ANY of:
- Known history of DM in medical records
- Currently on oral antidiabetic drugs, injectable antidiabetics, or insulin
- HbA1c ≥ 6.5%
Group 2 (New GCIH, no prior DM) — patient meets NONE of the above.
Step 3 — Stop conflicting medications (both groups)
Stop ALL of the following before initiating the protocol:
- Oral antidiabetics
- Premixed insulin
- Non-insulin injectable antidiabetics (GLP-1 RA, etc.)
Patients already on basal-bolus insulin may continue (with adjustments per group below).
Step 4 — Determine background insulin
Group 2 (No prior DM)
No background insulin. Give correctional insulin only (matched to the glucocorticoid type and dose). Monitor closely. If glucose remains uncontrolled, reassess for reclassification.
Group 1 (Established DM) — starting dose by HbA1c
| Patient Situation | HbA1c < 6.5% | HbA1c 6.5–8.5% | HbA1c > 8.5% |
|---|---|---|---|
| No prior DM (new GCIH) | Correctional insulin only | N/A | N/A |
| Undiagnosed DM (found on workup) | N/A | Background 0.4 u/kg + correctional | Background 0.5 u/kg + correctional |
| Known DM, NOT on basal-bolus | Stop previous meds; Background 0.3 u/kg + correctional | Stop previous meds; Background 0.4 u/kg + correctional | Stop previous meds; Background 0.5 u/kg + correctional |
| Known DM, already on basal-bolus | Continue current basal-bolus + correctional | Continue current basal-bolus + correctional | Continue current basal-bolus + correctional |
Special rule: Patients ≥ 70 years in Group 1 → use starting dose of 0.3 units/kg regardless of HbA1c.
Step 5 — Divide background insulin
For patients starting new background insulin:
- 50% as Basal: Insulin Glargine, given at bedtime
- 50% as Bolus: Insulin Lispro, given 15 min before each meal (divide equally across 3 meals)
Add a supplemental premeal correction on top → see [GCIH Supplemental Premeal Insulin Scale].
Step 6 — Titrate daily
- Adjust basal insulin daily based on fasting CBG → see [GCIH Basal Insulin Titration Guide]
- Adjust correctional insulin if glucocorticoid dose changes
Clinical Guardrails
- If HbA1c is unavailable at the time of initiation, use clinical history + medications to classify.
- Do not start background insulin in Group 2 patients without re-assessing — correctional insulin alone is often sufficient.
- If patient develops DKA (BG >250 + ketones + pH <7.3 + HCO3 <18) → exclude from protocol; manage as DKA.
- CBG monitoring: 4× daily (fasting, pre-lunch, pre-dinner, bedtime). Do not use Day 1 readings for titration decisions.
Source: Lakhani OJ, Kumar S, Tripathi S, Desai M, Seth C. Comparison of two protocols in the management of glucocorticoid-induced hyperglycemia among hospitalized patients. Indian J Endocr Metab 2017;21:836–44. DOI: 10.4103/ijem.IJEM_226_17