Inpatient reference · DM Management

Inpatient diabetes management

Basal-bolus insulin is the standard for the non-critical inpatient with hyperglycemia. Sliding-scale alone is discouraged. This page walks total-daily-dose (TDD) sizing, correction scales, insulin products, and how to handle non-insulin diabetes medications on admission — including which SGLT-2 and GLP-1 agents to hold and why.

Educational reference only. Doses assume an adult, non-pregnant patient without DKA/HHS. Verify every order against your institution's hyperglycemia protocol and adjust for renal function, weight, diet, and glucocorticoids.

Interactive · TDD + basal / prandial split

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Weight (kg)ScenarioInsulin sensitivityEating status

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AI Insulin Reviewer · Claude Sonnet 4.5

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Paste the exact insulin order set you would enter into the EMR. The AI is tuned for insulin-specific errors: "u" vs "units", missing correction scale, sliding-scale-only, wrong basal timing, missing hypoglycemia protocol, product-strength ambiguity, wrong TDD split.

The AI will flag missing "units", correction scale, monitoring, and hypoglycemia protocol. Verdict + rewritten order appear here.

Step 01

Basal-bolus initiation (the standard)

For persistent hyperglycemia (BG > 180 mg/dL) or a known diabetic admitted with active orders, initiate a scheduled basal + prandial + correction regimen. Estimate TDD from weight (or home dose), split it 50/50, then re-titrate every 24–48 h based on trends.

Step	How	Example (82 kg adult, insulin-naïve)
Estimate TDD	0.3–0.5 u/kg/day (0.3 if sensitive, 0.5 if resistant)	82 × 0.4 = 33 u/day
Split 50/50	Half as basal, half as prandial	Basal 16 u · Prandial 17 u
Divide prandial across 3 meals	Prandial ÷ 3, round to whole unit	5–6 u with each meal
Add correction scale	Pre-meal + bedtime (or Q6H if NPO)	Mild scale (see below)
Re-titrate at 24–48 h	If pre-meal BG > 180 x 2, increase basal 10–20 %	16 u → 18–19 u

Step 02

Correction (supplemental) scales

Correction is additional rapid-acting insulin layered on top of scheduled prandial. Pick a scale based on the patient's insulin sensitivity. Do not use correction alone — that's sliding-scale monotherapy and is discouraged in modern inpatient care.

Mild / sensitive

TDD < 40 u/day · elderly · CKD

BG mg/dL	Extra units
< 70	Hypoglycemia protocol
70–149	0 units (baseline)
150–199	+1 u
200–249	+2 u
250–299	+3 u
300–349	+4 u
≥ 350	+5 u + notify

Moderate / typical

TDD 40–80 u/day

BG mg/dL	Extra units
< 70	Hypoglycemia protocol
70–149	0 units
150–199	+2 u
200–249	+4 u
250–299	+6 u
300–349	+8 u
≥ 350	+10 u + notify

Resistant

TDD > 80 u/day · obese · steroids

BG mg/dL	Extra units
< 70	Hypoglycemia protocol
70–149	0 units
150–199	+3 u
200–249	+6 u
250–299	+9 u
300–349	+12 u
≥ 350	+15 u + notify

Rule of 1800 (correction factor) — a quick check: 1800 ÷ TDD ≈ mg/dL dropped per 1 u rapid insulin. For TDD 40 u, 1 u ≈ 45 mg/dL. Use it to sanity-check the scale.

Step 03

Sliding-scale insulin — why alone is discouraged

Reactive only

Sliding-scale-only responds after the BG is already high. It doesn't cover carbohydrate intake proactively, causes glucose roller-coasters, and is associated with longer LOS in retrospective inpatient data.

Where it's still OK

Very short admission < 24 h with mild hyperglycemia
Diet-controlled T2DM with occasional BG > 180
As the correction layer added to a scheduled basal + prandial regimen

Step 04

NPO and tube-feed patients

Scenario	Basal	Prandial	Correction	Monitoring
NPO (short-term, < 24 h)	Continue full dose	HOLD	Q6H rapid-acting	Q6H BG
NPO (prolonged) — T2DM	Reduce basal 20 %	HOLD	Q6H rapid-acting	Q6H BG
NPO — T1DM	NEVER hold basal — reduce 10–20 % only	HOLD	Q6H rapid-acting	Q4–6H BG
Continuous tube feed	Full basal + consider NPH q12h to match feed	HOLD (no discrete meals)	Q6H rapid-acting	Q6H BG
Bolus tube feed	Full basal	Give with each bolus feed	Pre-feed + HS	Q6H BG
Cyclic tube feed (nocturnal)	Basal small · add NPH at feed start	HOLD	Q6H rapid-acting	During + 4 h post-feed

Tube-feed interruption = highest hypoglycemia risk. If the feed is stopped unexpectedly, start D10W at the feed rate and check BG within 30 minutes.

Step 05

Steroid-induced hyperglycemia

Systemic glucocorticoids cause a post-prandial, afternoon-predominanthyperglycemia that classic once-daily basal misses. Match the insulin to the steroid's pharmacokinetics.

Steroid pattern	Insulin strategy	Why
Prednisone AM daily	Add NPH 0.1 u/kg SC in the morning WITH the steroid	NPH peaks 4–8 h → matches prednisone glucose peak
Dexamethasone BID / continuous	Weight-based basal + higher prandial (60/40 split favouring prandial)	Long half-life ≈ 24-hour effect
Methylprednisolone IV pulse	Consider IV insulin infusion during pulse days	High-dose steroids cause severe insulin resistance
Steroid taper	Reduce insulin ≈ 20 % per dose reduction step	Prevents hypoglycemia as resistance falls

Step 06

IV insulin drip → subcutaneous transition

After DKA/HHS resolution (anion gap closed, HCO₃⁻ ≥ 18, patient tolerating PO), transition before the drip is stopped — never stop the drip without overlap or the patient re-enters ketosis.

Estimate 24-h TDD from drip: last 6 h average rate × 4 × 0.8 (the 0.8 accounts for the more efficient SC absorption).
Split 50/50 basal / prandial as above. Choose glargine or detemir for basal.
Give the first SC basal dose 1–2 hours before stopping the drip.
Stop the drip only after the first meal + prandial dose is given.
Monitor BG Q1H × 4, then Q2H × 8, then Q4H. Continue home meds appropriately.

Step 07

Home regimen reconciliation on admission

Home therapy	On admission (eating)	On admission (NPO or acutely ill)
T1DM basal-bolus	Continue basal 100 % · prandial as ordered	Continue basal 80–100 % · HOLD prandial · correction Q6H
T2DM basal-bolus	Continue basal 80 % · prandial 50–80 %	Basal 50–80 % · HOLD prandial · correction Q6H
Basal-only (glargine)	Continue 80 % of home dose	Continue 50–80 % of home dose
Pre-mixed 70/30 or 75/25	Convert to basal-bolus (safer inpatient)	Convert to basal only + correction
Oral agents / GLP-1 only	Hold metformin if AKI, contrast, sepsis · hold SGLT2 in AKI/DKA risk · hold GLP-1 if NPO	Same — start insulin as needed for BG > 180

Step 08

Insulin pump on admission

Continue home pump only if all are true — otherwise transition to a standard basal-bolus regimen and store the pump with valuables.

Patient is alert, cognitively intact, and physically able to operate the pump
No DKA / HHS, ICU-level illness, or major surgery in the next 24 h
Team has documented the basal profile + carb ratio + correction factor in the chart
Institution has a pump-consent form on file and the primary team is comfortable co-managing

If the patient goes to the OR or radiology for a > 1 h procedure, disconnect the pump and cover with basal insulin instead — pump site occlusion under drapes is a common cause of intra-op DKA.

Step 09

Red flags and hold parameters

Hold / hypoglycemia

BG < 70 mg/dL → hypoglycemia protocol, hold next prandial + correction
BG < 100 pre-meal → consider ↓ prandial 25–50 %
NPO status → hold prandial (basal continues per T1/T2 rules above)
Renal function drop (CrCl < 45) → reduce TDD 20–25 %
Any hepatic decompensation → tighten monitoring, expect variable requirement

Order must contain

Specific insulin product (glargine 100 vs. 300 u/mL, U-500 flagged separately)
Dose in units — spell out, never "u"
Route (SC), timing anchored to meal or fixed time (e.g., 22:00)
Correction scale with hypoglycemia protocol reference
BG monitoring frequency
Indication and target BG range

Step 10

Sample complete orders

T2DM, eating, 82 kg, no CKD

Insulin glargine 16 units SC daily at 22:00
Insulin lispro 6 units SC with each meal (breakfast, lunch, dinner)
Insulin lispro correction — mild scale — pre-meal + HS
BG check: pre-meal + HS + PRN symptoms
Target BG: 140–180 mg/dL
Hypoglycemia protocol: institutional

T1DM, NPO for AM procedure

Insulin glargine 20 units SC daily (80 % of 25 u home dose)
Insulin lispro — HOLD prandial while NPO
Insulin lispro correction — moderate scale — Q6H
BG check: Q6H + pre-procedure
Target BG: 140–180 mg/dL
D5 ½NS at 75 mL/h while NPO

Step 11

Insulin products cheatsheet

Choose the right family based on the job — basal covers fasting glucose, prandial covers meals, correction fixes real-time hyperglycemia. Always specify the exact product AND concentration in the order.

Class	Products (generic · brand)	Onset · Peak · Duration	Inpatient use
Long-acting basal	glargine U-100 (Lantus, Basaglar) · glargine U-300 (Toujeo) · detemir (Levemir) · degludec (Tresiba)	1–2 h · minimal peak · 20–42 h	Once daily basal. Toujeo & Tresiba more forgiving. NEVER hold in T1DM.
Intermediate basal	NPH (Humulin N, Novolin N)	1–2 h · 4–8 h · 12–18 h	Twice daily, or matched to AM prednisone (peaks at steroid glucose spike).
Rapid-acting bolus	lispro (Humalog, Admelog) · aspart (Novolog, Fiasp) · glulisine (Apidra)	10–15 min · 1–2 h · 3–5 h	Prandial + correction. Give within 15 min of meal.
Short-acting	regular insulin (Humulin R, Novolin R U-100)	30 min · 2–4 h · 5–8 h	IV drip (DKA/HHS), K+ shift, TPN coverage. SC use largely replaced by rapid-acting.
Concentrated regular	regular U-500 (Humulin R U-500)	30 min · 4–8 h · up to 24 h	Severe insulin resistance (TDD > 200 u/day). Flag SEPARATELY — dispense on dedicated protocol only.
Pre-mixed	70/30 NPH-regular · 75/25 protamine-lispro · 70/30 protamine-aspart	Bi-modal	Home use — convert to basal-bolus on admission for tighter control.
Inhaled	insulin human (Afrezza)	1–2 min · 12–15 min · 2–3 h	Uncommon inpatient. Contraindicated in asthma, COPD, active smoker.

U-100 vs U-500 vs U-300 — an ambiguous "insulin regular" order is a 10-fold or 5-fold overdose waiting to happen. Every insulin order must name the exact product AND state units in words (never "u").

Step 12

Non-insulin diabetes medications — inpatient rules

On admission, most oral / injectable agents are HELD in favor of insulin for glycemic control. The exceptions matter — SGLT-2s in particular can trigger euglycemic DKA if continued during acute illness.

12 of 12 classes shown

Class	Examples	Inpatient hold / continue	Why
Biguanide	metformin (Glucophage)	HOLD on admission	Lactic acidosis risk if AKI, sepsis, IV contrast, decompensated HF. Restart when eGFR stable & no contrast for 48 h.
Sulfonylurea	glipizide, glimepiride, glyburide	HOLD	Prolonged hypoglycemia risk in NPO / reduced PO / CKD. Glyburide worst offender — avoid.
Meglitinide	repaglinide, nateglinide	HOLD	Prandial — meaningless if NPO. Hypoglycemia risk.
DPP-4 inhibitor	sitagliptin (Januvia), linagliptin (Tradjenta), saxagliptin (Onglyza)	OK to continue if eating	Low hypoglycemia risk. Saxagliptin: HOLD in HF. Renal-adjust sitagliptin.
SGLT-2 inhibitor	empagliflozin (Jardiance), dapagliflozin (Farxiga), canagliflozin (Invokana), ertugliflozin	HOLD ≥ 3 days pre-op & during acute illness	EUGLYCEMIC DKA risk — patients present with normal glucose + gap acidosis. Also volume depletion, GU infections.
GLP-1 agonist	liraglutide (Victoza), semaglutide (Ozempic / Wegovy / Rybelsus PO), dulaglutide (Trulicity), exenatide	HOLD if NPO, ileus, gastroparesis, upcoming anesthesia	Delayed gastric emptying → aspiration risk during induction. ASA guidance: hold weekly agents ≥ 1 week pre-op.
Dual GIP/GLP-1	tirzepatide (Mounjaro / Zepbound)	Same as GLP-1 — HOLD peri-op & if NPO	Same aspiration + gastroparesis concern; even stronger GI slowing.
Amylin analog	pramlintide (Symlin)	HOLD	Prandial adjunct — meaningless inpatient; nausea, hypoglycemia.
Thiazolidinedione	pioglitazone (Actos), rosiglitazone	HOLD in CHF / volume overload	Fluid retention, bone fracture risk. Slow onset — not useful for acute control.
α-glucosidase inhibitor	acarbose (Precose), miglitol	HOLD if NPO	Prandial only. GI side effects. Rarely inpatient.
Bile-acid sequestrant	colesevelam (Welchol)	OK to continue if eating	Minimal glycemic benefit. Watch drug absorption interactions.
Dopamine agonist	bromocriptine QR (Cycloset)	HOLD	Uncommon. Orthostasis, drug interactions.

Restart planning matters. Document a plan to resume home agents at discharge in the after-visit summary. SGLT-2s should not be resumed until the patient is eating normally and off IV fluids for ≥ 24 h.

Step 13

AI DM medication reconciliation

Paste the patient's home diabetes regimen and get a structured hold / continue / modify plan with a one-line rationale per drug. Brand names (Ozempic, Jardiance, Glucophage) are matched to their generics automatically.

Each home med will be classified as HOLD, CONTINUE, or MODIFY with a one-line clinical reason and a suggested inpatient alternative.

Not sure about a case?

Ask RxFlow to draft the order with you.

Open the chat widget (bottom-right) and describe the patient — weight, home regimen, eating status, comorbidities — and the AI will walk through TDD, split, and correction scale with you.