Starting Insulin Algorithms for Noncritical Illness: A Survey of 32 Academic Hospitals in the United States

Abstract

Glycemic control immediately upon hospitalization is difficult. Endocrine Society guidelines suggest starting scheduled insulin therapy at 0.2–0.5 units/kg/day, but there has been no rigorous study to support this recommendation. To understand the variability of current practice, we surveyed starting insulin algorithms for noncritically ill patients among the top-ranking academic hospitals in the United States. Among the 20 hospitals with reported algorithms, 12 specified which patients should start with basal/nutritional insulin, whereas 5 specified who should start with only correction insulin. Weight-based and/or home-dose-based calculations were used to estimate the initial insulin requirements with various modifiers. In addition, various factors were considered when choosing among the correction dose algorithms. In summary, among the U.S. academic hospitals, there is variability in methods for determining insulin dosing on admission for noncritically ill patients. This inconsistency suggests that future studies to estimate initial insulin requirements are required.

Introduction

Inpatient glycemic control is an important component of the management of hospitalized patients. Suboptimal inpatient glycemic control in noncritical illness has been associated with poor clinical outcomes and prolonged hospital length of stay.^1,2 In most instances, insulin is the preferred treatment for hyperglycemia in hospitalized patients.³

The current practice of inpatient glycemic management relies heavily on daily adjustments of insulin doses. In contrast, glycemic management immediately upon hospitalization is difficult, because multiple factors vary on admission, including severity of the illness, nutritional status, physical activity, medications, and transitioning from noninsulin agents to insulins. Based on clinical trials and observational data, it takes on average about 2 days to achieve the target glycemic range of 100–180 mg/dL in patients presenting with hyperglycemia.^4
–6

Guidelines from the Endocrine Society suggest starting basal or basal-bolus insulin therapy using a broad range of insulin dosing: 0.2–0.5 units/kg body weight per day.⁷ Of note, this recommendation is based on consensus rather than rigorous studies. Owing to fear of hypoglycemia, many clinicians start with conservative insulin dosing and often use sliding scale correction as the primary treatment strategy, which tends to result in hyperglycemia with much glucose variability.^3,7

The most recent real-world benchmarking of inpatient point-of-care (POC) blood glucose (BG) included 2,415,209 non-intensive care unit patients from 645 hospitals.⁸ The data showed that 32.3% of mean daily BG values were >180 mg/dL and 6.1% were <70 mg/dL for all patients with or without diabetes mellitus (DM). Approximately one-quarter of hospitalized patients in the United States have DM.⁹ Therefore, this real-world BG data suggest that current glycemic control in the United States is suboptimal.⁸

Given these observed glycemic measures with the current guidelines, we hypothesized that there were variable practices of insulin strategies in academic hospitals in the United States. To understand the variability of the current practice of initiating inpatient insulin therapy, we conducted a survey of starting insulin algorithms for noncritically ill patients among top-ranked academic hospitals in the United States.

Materials and Methods

We surveyed 32 academic hospitals, which represented the top 20 hospitals and top 30 endocrinology programs ranked by the U.S. News & World Report 2022. Emails were sent to the leaders of inpatient glycemic services to request their algorithms for initiating insulin for noncritically ill patients. If no reply was received, another email was sent to a different faculty member or division chair of the same hospital. If no reply was received from either faculty member, we reported this as no reply from this hospital.

From the provided algorithms, we attempted to answer the following questions. If there was no clear answer in the provided algorithms, we then sought clarification from the faculty member who provided the algorithms. 1.

Which patients should start with scheduled basal or nutritional insulin?

Which patients should start with only correction dose insulin?

If scheduled insulin is recommended, how should the initial dose be calculated?

How to choose the correction dose algorithms?

Are the algorithms incorporated into the electronic medical order system, or in a format of separate written protocols?

As the results are reported anonymously, no institutional review board approval was required.

Results

Because of the overlap between the top 20 hospitals and 30 endocrinology programs ranked by the U.S. News & World Report, a total of 32 hospitals were surveyed. As illustrated in Figure 1, replies were received from 25 hospitals. Of these 25, 20 provided their algorithms, 4 stated they did not have such, and 1 used a proprietary (commercial) algorithm. The 20 hospitals that provided algorithms are illustrated on the U.S. map (Fig. 1). The provided algorithms were formulated by internal committees of each hospital. A summary of their responses to the five questions is provided in Table 1 and aggregated below. The text in the table incorporates as much of the original wording of the responses as possible.

FIG. 1.

A total of 32 hospitals were surveyed and 20 hospitals provided their algorithms. The 20 academic hospitals that provided algorithms are marked with red dots on the U.S. map.

Table 1.

Summary of the Responses to the 5 Questions by the 20 Academic Hospitals

Academic hospitals	1. Which patients should start with basal/nutritional insulin?	2. Which patients should start with only correction insulin?	3. Inpatient TDD calculation	3. Basal insulin calculation	3. Nutritional insulin calculation	4. How to choose correction insulin algorithms?	5. Format
1	- Patient should receive basal insulin if T1D, on home basal insulin, A1c ≥7.5%, >2 OAD at home, or BG >180 mg/dL twice - Patient should receive nutritional insulin if DM with A1c ≥7.5%	Patient should start with only correction insulin if not meeting the basal or nutritional insulin criteria	- Home TDD × 75%–100%, or - Weight-based 0.25–1 U/kg (by insulin sensitivity)	- T2D on home insulin with A1c ≥7.5%: home basal × 75%–100% or weight-based 0.2–0.4 U/kg (on home basal-nutritional), 0.15–0.2 U/kg (on home basal only) - T2D on home insulin with A1c <7.5%: home basal × 75%–100% - T2D not on home insulin with A1c ≥7.5% or >2 OAD: 0.1–0.2 U/kg - T2D with A1c <7.5% and ≤2 OAD: no basal insulin - T1D: inpatient TDD × 50%	- T2D on home insulin with A1c ≥7.5%: 0.2–0.4 U/kg (on home basal-nutritional), 0.15–0.2 U/kg (on home basal only) - T2D on home insulin with A1c <7.5%: home nutritional × 75%–100% - T1D: inpatient TDD × 50%, divided by three meals	By TDD, DM type, insulin sensitivity (four scales)	Written protocol
2	- Patient should receive basal insulin if T1D, T2D, no DM history with A1c ≥6.5% - Patient should receive nutritional insulin if adequate oral intake with T1D, T2D, no DM history with A1c ≥6.5%	Patient should start with only correction insulin if no DM history with A1c <6.5%	- Home TDD × 70% if T2D on home insulin - Weight-based 0.2–0.5 U/kg if T2D not on home insulin or no DM history with A1c >6.5% (by insulin sensitivity)	- Home basal dose × 80% if T1D - Inpatient TDD × 50% if T2D on home insulin or no DM history with A1c >6.5%	Inpatient TDD × 50%, divided by three meals if T2D on home insulin or no DM history with A1c >6.5%	By TDD (three scales)	Order set
3	- Basal-nutritional insulin for most patient with DM or BG >180 mg/dL - Basal plus correction insulin if high risk for hypoglycemia (acute or chronic renal failure, failure to thrive, poor nutritional status, or oral intake, NPO status for anticipated procedures)	Patient with no DM history and not on high-dose glucocorticoid (prednisone ≥50 mg) start with only correction insulin	0.15, 0.2, 0.4, 0.5, 0.6 U/kg (by DM type, glucocorticoid use, high risk for hypoglycemia) - T1D: consult endocrine	- Inpatient TDD × 50% if not on high-dose glucocorticoid (prednisone ≥50 mg) - Inpatient TDD × 40% if on high-dose glucocorticoid - Weight-based 0.15–0.2 U/kg if high risk for hypoglycemia (AKI/CKD, failure to thrive, poor nutritional status or oral intake, NPO)	- Inpatient TDD × 50% if not on high-dose glucocorticoid - Inpatient TDD × 60% if on high-dose glucocorticoid - No nutritional insulin if high risk for hypoglycemia	By TDD, weight (three scales)	Written protocol
4	- Patient on home basal-nutritional insulin should receive basal-nutritional insulin - Patient only on home basal insulin should receive basal insulin	Patient not on home insulin start with only correction insulin		- Home basal dose × 80% for patient on home basal and nutritional insulin (unless home BG always high)- Home TDD × 50%–60% for patient on home premixed insulin- Home basal dose × 50%–80% for patient only on home basal insulin	- Home nutritional dose × 80% for patient on home basal and nutritional insulin (unless home BG always high)- Home TDD × 40%–50% for patient on home premixed insulin	By TDD, habitus, T1D, GFR <30 (three scales)	Written protocol
5	- T1D should always receive basal insulin and nutritional insulin if eating- T2D or stress hyperglycemia with BG >150 mg/dL should receive basal-nutritional insulin		- Home TDD × 80%, or- Weight-based 0.5 U/kg(adjusted by elderly, low eGFR, advanced cirrhosis, pancreatic insufficiency, high A1c, or glucocorticoid)	Inpatient TDD × 40%–50%	Inpatient TDD × 50%–60%, divided by three meals(60% if on tube feed or glucocorticoid)	By TDD (three scales)	Written protocol
6	T1D should receive basal insulin			- Home basal dose if adequate glycemic control- Home basal dose × 50% if NPO or eating poorly- Weight-based 0.1–0.25 U/kg if poor control, admission BG >200 mg/dL or not on home insulin	0.05, 0.07, 0.08 U/kg per meal(by intake, BMI, admission BG, home TDD, high home basal dose, renal insufficiency, elderly, total parenteral nutrition)	Most patients start with medium scale (three scales)	Written protocol
7	T1D should have basal insulin			0.1, 0.2, 0.3 U/kg(by lean or obese habitus, T1D, elderly, renal insufficiency, pancreatectomy, glucocorticoid)	2, 4, 6 U per meal(same algorithm as basal insulin)	Same algorithm as basal insulin (three scales)	Order set
8	- Patient on home insulin should receive basal insulin- Patient who eat or receive nutritional therapy should receive nutritional insulin- T1D or patient with fasting BG >140 should not receive only correction insulin			- Patient on home insulin: the lower of either home TDD divided by 2 and decrease 10%–20%, or home basal insulin- Patient not on home insulin: 0.2 U/kg if GFR >60 and age <70, otherwise 0.1 U/kg	Basal insulin dose, divided by three meals	By basal insulin dose (three scales)	Written protocol
9	Patient with ≥2 BG ≥180 mg/dL, T1D, on home insulin, or poorly controlled T2D (A1c >7.5%) should receive basal-nutritional insulin		- Home TDD, or(adjusted by outpatient control, current degree of hyperglycemia and patient status)- Weight-based 0.3, 0.4, 0.5, 0.6 U/kg(by DM type, BMI, glucocorticoid use, malnourished, cognitive impairment, elderly, renal or liver disease, pancreatectomy)	- Inpatient TDD × 50% if eating or bolus tube feed- Inpatient TDD × 40% if NPO	- Inpatient TDD × 50%, divided by number of meals- Carbohydrate counting if patient does this at home	By TDD (three scales)	Written protocol
10	Basal-nutritional insulin recommended for all who need insulin in the hospital		- Home TDD (preferred)- Weight-based 0.4 U/kg	Inpatient TDD × 40%–50%	Inpatient TDD × 15%–20% per meal	By habitus, glucocorticoid, or known insulin resistance (three scales)	Order set
11	- Patient on home basal insulin should receive basal insulin- T1D should receive basal insulin			- T2D: home basal dose × 50%–60%(by diet and renal function)- T1D: home basal dose × 80%–100%	- Home nutritional dose × 50% or start with no nutritional insulin	Start with low or medium dose (three scales)	Written protocol
12	T1D should receive basal insulin		- Home TDD × 80%, or- Weight-based 0.3, 0.4, 0.5, 0.6 U/kg(by BMI, insulin naïve, malnourished, elderly)	Inpatient TDD × 50%(basal decrease 20% if NPO)	- Inpatient TDD × 50%, divided by three meals, or- Carb counting using home insulin-to-carb ratio	By TDD, BMI, T1D, chronic renal insufficiency, elderly (three scales)	Written protocol
13		- Patient without DM or patient with DM well-controlled on noninsulin meds typically appropriate to receive only correction insulin- If BG >180 mg/dL twice, reevaluate the need of basal/nutritional insulin	The lower of the following- Home TDD × 80%- Weight-based 0.3, 0.5 U/kg(by insulin use, DM type, BMI, pancreatectomy, AKI/CKD/ESRD/ESLD, malnourished, elderly, glucocorticoid use)	Inpatient TDD × 50%Consider decrease 10%–20% if NPO	Inpatient TDD × 50%, divided by three meals	Same algorithm as weight-based TDD (two scales)	Order set
14			- Home TDD × 50%–75%, or- Weight-based 0.5 U/kg (0.2–0.4 U/kg if age >75, renal failure, liver failure, underweight, uncertain oral intake)	- Home basal dose x 50%–75%, or- 0.25 U/kg if inpatient TDD calculated by 0.5 U/kg	- Home nutritional dose x 50%–75%, or- 0.1 U/kg per meal if inpatient TDD calculated by 0.5 U/kg	By TDD, T1D, elderly, underweight, ESRD (two scales)	Order set
15				0.2 U/kg	0.066 U/kg per meal	By TDD (two scales)	Order set
16			Weight-based 0.3, 0.5, 0.7 U/kg(by insulin sensitivity)	0.15, 0.25, 0.35 U/kg(by insulin sensitivity)Basal × 50% if NPO	0.15, 0.25, 0.35 U/kg, divided by three meals(by insulin sensitivity)	By TDD (three scales)	Order set
17				0, 0.1, 0.2 U/kg(by NPO, insulin sensitivity, habitus, T1D, elderly, renal insufficiency, pancreatectomy, high risk for hypoglycemia, glucocorticoid use, uncontrolled at home)	2, 4, 6 U per meal(by insulin sensitivity, habitus, T1D, elderly, renal insufficiency, pancreatectomy, high risk for hypoglycemia, glucocorticoid use, uncontrolled at home)	Same algorithm as nutritional insulin, plus a lowest scale if NPO (four scales)	Written protocol
18			- Home TDD, or(consider adherence to insulin, renal function, liver function, appetite, inpatient diet order)- Weight-based 0.2, 0.3, 0.4, 0.6 U/kg(by GFR, DM type)	Inpatient TDD × 50(maximum 0.5 U/kg)(basal decrease 20% if NPO)	Inpatient TDD × 50%, divided by three meals	By TDD (three scales)	Written protocol
19			- Home TDD × 70%–80% (preferred unless outpatient poorly controlled)consider 50% if very high dose of home basal insulin- Weight-based 0.3–0.5 U/kg(0.5 U/kg if sick, obese, insulin resistant, receiving glucocorticoid)	Inpatient TDD × 50%(25% if receiving glucocorticoid)	Inpatient TDD × 50%(75% if receiving glucocorticoid), divided by three meals	By TDD, BMI (three scales)	Training material
20				- Home basal dose × 75%–100%, or(decrease 20% if renal failure, extreme malnutrition, NPO)- Weight-based 0.1, 0.2, 0.3 U/kg(by insulin sensitive, naïve, renal failure, DM type)	- Home nutritional dose × 80%, divided by three meals, or- 0.1 U/kg per meal(decrease 20% by both approaches if renal failure, extreme malnutrition, sepsis)	By TDD, GFR, hemodialysis, elderly, habitus, malnourished, insulin native, DM type, high-dose glucocorticoid (three scales)	Order set

A1c, glycated hemoglobin; AKI, acute kidney injury; BG, blood glucose; BMI, body mass index; CKD, chronic kidney disease; DM, diabetes mellitus; eGFR, estimated glomerular filtration rate; ESLD, end-stage liver disease; ESRD, end-stage renal disease; NPO, nothing by mouth; OAD, oral antidiabetic drug; T1D, type 1 diabetes; T2D, type 2 diabetes; TDD, total daily dose.

Which patients should start with scheduled basal or nutritional insulin?

Out of 20, 12 (60%) hospitals specified which patients should start with scheduled basal or nutritional insulin (Supplementary Fig. S1). Of these 12 hospitals, 9 specified that patients with type 1 diabetes mellitus (T1D) should always receive basal insulin. Two suggested basal-nutritional insulin for all or most patients who need insulin in the hospital (DM or BG >180 mg/dL). One hospital suggested that patients on home basal insulin should receive basal insulin in the hospital.

For patients with type 2 diabetes mellitus (T2D), there were inconsistent recommendations of basal or nutritional insulin. These differences were based on whether they were receiving insulin at home, their glycated hemoglobin (A1c), BG on presentation, or taking greater than two oral glucose-lowering medications before admission.

Which patients should start with only correction dose insulin?

Out of 20, 5 (25%) hospitals specified which patients should start with only correction dose insulin (Supplementary Fig. S1). Among them, three suggested that patients without a history of DM (one suggested no history of DM and not on high-dose glucocorticoid) could start with only correction insulin. Two hospitals suggested that patients with DM well-controlled on noninsulin medications could start with only correction insulin.

If scheduled insulin is recommended, how should the initial dose be calculated?

To calculate the initial basal or nutritional insulin doses, 13 hospitals (65%) suggested both weight- and home-dose-based calculations, 5 (25%) suggested only a weight-based calculation, and 2 (10%) suggested only a home-dose-based calculation. Among the 13 hospitals that suggested both weight- and home-dose-based calculations, 7 did not specify which approach to use, whereas 2 preferred a home-dose-based calculation, 2 preferred a home-dose-based calculation if diabetes was well-controlled in the outpatient setting, and 2 preferred the lower dose of the two approaches. Various factors were used to adjust the insulin dose based on either weight-or home-dose-based calculations (Table 1).

How to choose the correction dose algorithms?

Most hospitals had three dosage levels for their correction insulin scales—high, medium, and low dose, whereas three (15%) had two levels and two (10%) had four levels. Various factors were considered when choosing among the correction algorithms, with the most common factors being daily/basal insulin dose and body mass index (BMI)/body habitus. When choosing the correction algorithms, six (30%) hospitals considered both daily/basal insulin dose and BMI/body habitus, eight (40%) considered daily/basal insulin, and four (20%) considered BMI/body habitus.

Are the algorithms incorporated into the electronic medical order system or in a format of separate written protocols?

Among the 20 hospitals with reported algorithms, 8 were incorporated into the electronic medical order system, 11 were in the format of separate protocols, and 1 was in teaching materials (Table 1).

Use of oral glucose-lowering medications and glucagon-like peptide receptor agonists

Seven out of 10 hospitals that mentioned oral glucose-lowering medications recommended they be discontinued on admission. Of the six hospitals that discussed glucagon-like peptide receptor agonists (GLP-1RAs), three recommended discontinuing them on admission and the other three withholding them on the day of surgery. No hospital protocol suggested different insulin dosing for patients receiving any of these other medications while admitted.

Discussion

We surveyed 32 academic hospitals in the United States to understand the current practice of initiating inpatient insulin therapy for noncritically ill patients. Among the 20 hospitals that provided algorithms, we found a great deal of variability in starting insulin modalities, calculation strategies of the initial dose, and factors that were considered when choosing the correction dose algorithms.

In the survey, all hospitals suggested that basal insulin should be used in patients with T1D, aligning with major guidelines from specialty societies.^3,7,10 On the contrary, the survey revealed inconsistent recommendations for basal or nutritional insulin for patients with T2D. This is not surprising given the lack of evidence on how to best initiate insulin in this population, in addition to the heterogenicity of beta-cell function and insulin resistance in these hospitalized patients.

The current survey concludes that up to 60% of the hospitals specified which patients should start with scheduled basal or nutritional insulin, whereas 25% specified which patients should start with only correction insulin. In comparison, major guidelines and prior trials recommended basal-nutritional or basal insulin for most noncritically ill patients in the hospital.^{3
–5,7,10,11} Recently, two studies found most noncritically ill patients with T2D and with admission BG <180 mg/dL treated with correction dose insulin alone achieved target glycemic control during hospitalization.^12,13 This indicates that it may be appropriate to give only correction insulin to this population with mild hyperglycemia. Guidelines from specialty societies also suggest giving only correction dose insulin in certain scenarios. For example, the 2024 American Diabetes Association guidelines discourage prolonged use of correction or supplemental insulin without basal insulin as the sole treatment of hyperglycemia, except for people with T2D in noncritical care with mild hyperglycemia.³ The 2022 Endocrine Society guidelines suggest initial therapy with correctional insulin in adults with no DM history hospitalized for noncritical illness with BG >140 mg/dL.¹⁴ The same guidelines suggest initial therapy with correctional insulin or scheduled insulin therapy in adults with diabetes treated with diet or noninsulin diabetes medications before admission. Finally, the 2022 American Association of Clinical Endocrinology guidelines recommend that the use of “sliding-scale” insulin be reserved exclusively for those whose glucose values are in the target range most of the time, and only occasionally exceed the target range.¹⁰

Regarding the calculation of basal or nutritional insulin doses, 65% of hospitals in the survey suggested both weight- and home-dose-based calculations, and most did not specify which approach to use. This may be a strategy to provide flexibility to clinicians to tackle the need for highly variable insulin dosing. The home-dose-based calculation has the advantage of knowing patients’ insulin requirements before admission. However, if patients’ BG was not well-controlled before admission, their home doses would underestimate or overestimate their insulin requirements. What makes the dosing even more complicated is the variety of factors used by different hospitals to adjust the insulin doses. These factors included age, diabetes type, BMI/body habitus, nutritional status, risk of hypoglycemia, sepsis, renal and liver failure, pancreatic insufficiency, A1c, noninsulin medications, glucocorticoid dose, and cognitive impairment. Thus, we infer that an evidenced-based standardized algorithm using multiple factors might be able to better predict a patient’s insulin requirement more precisely.

Correction “sliding-scale” insulin has been widely used in clinical practice.¹⁵ When used with scheduled basal and/or nutritional insulin, correction dose insulin has the merit of restoring hyperglycemia according to POC BG values. In the current survey, daily/basal insulin dose and BMI/body habitus were commonly considered when choosing the correction algorithms. Various other factors were also considered by some hospitals. To our knowledge, no study has been done that compares which factor(s) guides correction algorithms better than the other in the inpatient setting. Besides, the correction doses for each BG threshold differed among hospitals (the exact scales are not provided in this article), which further demonstrates the inconsistency of how each hospital approaches the correction dose insulin.

A few hospitals provided information on oral glucose-lowering medications and GLP-1RAs. Although the majority suggested discontinuing oral glucose-lowering medications on admission, only half who commented on GLP-1RAs suggested the same. Interestingly, those who allowed the continuation of GLP-1RAs on admission suggested they be withheld on the day of surgery. The withholding of GLP-1RAs is currently being extensively discussed.^16
–18 These variations again speak to the need for further evaluation and consensus-based recommendations.

There are several limitations of this survey. First, it is unclear how often these internal algorithms are used clinically. Clinicians are more likely to use those algorithms that are incorporated into the electronic medical order system compared with those in the format of separate protocols. Second, we did not obtain data from community hospitals. As there is a great deal of variability in the algorithms used in academic hospitals, it is unlikely that community hospitals have a consistent algorithm. Third, our survey was limited to the United States and, therefore, the results may not apply in other countries. Finally, given the variable algorithms used by academic hospitals, it is important to know what their glycemic outcomes were. As the current survey did not include glycemic outcomes, we do not know whether certain algorithms are potentially better than others.

Conclusions

Among 20 academic hospitals in the United States, there is great variability in determining starting insulin dosing on admission for noncritically ill patients. If glycemic outcomes are varied or suboptimal, more standardized algorithms based on evidence could be beneficial.

Footnotes

Acknowledgments

We thank all the members of the academic hospitals that provided their algorithms for our survey.

Authors’ Contributions

I.B.H. conceptualized the study. H.-H.C. conducted the survey, curated data, and wrote the original draft. I.B.H. and S.E.K. developed the methodology of the survey and reviewed/edited the article. All authors critically reviewed the article before publication and contributed to the interpretation of the results. H.-H.C. had full access to all the data in the study and takes responsibility for the integrity of the data. H.-H.C. had access to all the data and is thus the guarantor of this work.

Author Disclosure Statement

H.-H.C. has no relevant conflicts of interest to declare. S.E.K. reports advisory board/consulting fees from AltPep, Biomea Fusion, Boehringer Ingelheim, Eli Lilly, Merck, Novo Nordisk, Oramed, and Pfizer. I.B.H. receives research support from Tandem Diabetes, MannKind, and Dexcom, and he consults with Abbott Diabetes Care, Roche, Hagar, and Vertex.

Funding Information

H.-H.C. was supported by the National Institutes of Health (T32DK007247). S.E.K. was supported by the Department of Veterans Affairs.

Supplementary Material

Supplementary Figure S1

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Supplementary Material

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