Table 1 Algorithm for titrating basal, prandial, and correctional insulin

Orders at admission

 Discontinue the patient’s oral and non-oral glucose-lowering medicaments.

Insulin orders during admission

 Basal insulin (mandatory order)

 Basal insulin is given at lunch to allow same-day insulin titration decisions during the morning to take effect. Starting basal insulin dose is 0.25 U/kg, rounded to the nearest unit. Exceptions are:

  • Basal insulin dose is 0.20 U/kg in patients aged >75 years and/or with an eGFR ≤60 ml/min/1.73 m² and/or body mass index (BMI) ≤ 22.5.

  • Basal insulin is continued on the usual out-hospital dose in patients treated with basal insulin at home.

  • In perioperative or fasting patients, basal insulin is paused on the day of surgery or during fasting and patients are managed by glucose-insulin-potassium (GIK) infusion. If the postoperative patient eats a full meal before 22:00 h, GIK infusion is stopped and half basal insulin dose is given. The full basal insulin dose is continued the following days.

 Prandial insulin (ordered at the discretion of the in-hospital diabetes teams when glucose levels >10.0 mmol/l [>180 mg/dl] are observed postprandially for 1-2 days)

 Starting total prandial insulin dose is 0.25 U/kg, rounded to the nearest unit, and given in three equally divided doses for breakfast, lunch, and dinner. Exceptions are:

  • Prandial insulin dose is 0.20 U/kg in patients aged >75 years and/or with an eGFR ≤60 mL/min/1.73 m² and/or body mass index (BMI) ≤22.5.

  • Prandial insulin is continued on the usual out-hospital dose in patients treated with prandial insulin at home.

  • In perioperative or fasting patients, prandial insulin is paused on the day of surgery or during fasting.

Correctional insulin (mandatory order)

Glucose Level

Recommended insulin (U)

Insulin change (U)

mmol/l

mg/dl

< 10.0

< 180

0

0

10.0 – 11.9

180 – 214

4

± 2

12.0 – 15.9

215 – 286

6

± 3

16.0 – 19.9

287 – 358

8

± 4

≥ 20.0

> 358

10

± 6

Titrating basal, prandial, and correctional insulin

 Titrating basal and prandial insulin in the POC-arm

  Titration of basal insulin (mmol/l) [mg/dl] is done daily by POC glucose levels during the night from 00:00 h till breakfast and is done prior to administration at lunch. Titration of prandial insulin for a specific meal is done by the pre-prandial POC glucose levels of the subsequent meal and for dinner, the POC glucose level before bedtime (22:00 h):

   • < 3.0 [< 54]: Decrease insulin dose by 30%.

   • 3.0 – 3.8 [54 – 69]: Decrease insulin dose by 20%.

   • 3.9 – 5.5 [70 – 99]: Decrease insulin dose by 10%.

   • 5.6 – 7.8 [100 – 140]: No changes.

   • 7.9 – 10.0 [141 – 180]: Increase insulin dose by 10% if no hypoglycaemic events are observed the previous day.

   • 10.1 – 15.0 [181 – 270]: Increase insulin dose by 20% if no hypoglycaemic events were observed the previous day.

   • >15.0 [>270]: Increase insulin dose by 30% if no hypoglycaemic events were observed the previous day.

Titrating prandial insulin in the CGM-arm

 Prandial insulin is titrated by the nadir of the between-meal CGM glucose levels. If there is no nadir on the CGM trace between meals, the pre-prandial glucose level guides the decision to titrate prandial insulin. Titration of prandial insulin is guided by the glucose level ranges similar to titration of prandial insulin in the POC-arm.

Titrating basal insulin in the CGM-arm

 Titration of basal insulin (mmol/l) [mg/dl] is done by glucose level ranges from 00:00 h till breakfast:

  • <3.0 [< 54]: If ≥5% of glucose levels are in this range and/or at least one level 2 hypoglycaemic event (three consecutive CGM glucose levels < 3.0 mmol/l [<54 mg/dl] [37]), decrease insulin dose by 30%.

  • 3.0 – 3.8 [54 – 69]: If ≥5% of glucose levels are in this range and/or at least one level 1 hypoglycaemic event (three consecutive glucose levels of 3.0–3.8 mmol/l [54–69 mg/dl] on CGM [37]), decrease insulin dose by 20%.

  • 3.9 – 5.5 [70 – 99]: If ≥10% of glucose levels are in this range, decrease insulin dose by 10%.

  • 5.6 – 7.8 [100 – 140]: No changes.

  • 7.9 – 10.0 [141 – 180): If ≥10% of glucose levels are in this range, increase insulin dose by 10%.

  • 10.1 – 15.0 [181 – 270]: If ≥10% of glucose levels are in this range, increase insulin dose by 20%.

  • >15.0 [>270]: If ≥10% of glucose levels are in this range, increase insulin dose by 30%.

Titrating correctional insulin in the POC-arm and CGM-arm

 Titration of sliding scale insulin is done based on the decision of whether the patient is insulin resistant (add insulin) or insulin sensitive (subtract insulin) by adjusting levels of Recommended insulin (U) by the column Insulin change (U). The trend in increasing or decreasing basal and/or prandial insulin might guide this decision.