⚙ Master Workflow: Define the patient baseline, then select the required clinical pathway (Initiation, Titration, Transitions, or Steroids). Renal adjustments and Correction Scales (ISF) are generated automatically.
1. Patient Baseline & Renal Status
2. Clinical Pathway
⚠ SEPSIS/CRITICAL ILLNESS PROTOCOL: Stop all Sulfonylureas and SGLT2 inhibitors immediately. Hold Metformin if haemodynamically unstable or eGFR < 30. Expect high insulin resistance.
Parameter
Morn (Reg)
Aft (Reg)
Night (Premix)
Current Dose (U)
Crossover GRBS (mg/dL)
Hypoglycaemia? (< 70 mg/dL)
Parameter
Basal
Morn Bolus
Aft Bolus
Night Bolus
Current Dose (U)
Crossover GRBS (mg/dL)
Hypoglycaemia?
⚠ CRITICAL OVERLAP: The first SC dose MUST be administered 1 to 2 hours BEFORE stopping the IV insulin infusion to prevent rebound DKA.
⚙ Transition Logic: Inpatient insulin doses are typically 20 to 30% higher than outpatient needs due to stress hyperglycaemia and inactivity. A safety reduction is mandatory for home use.
❗ TYPE 1 DM RULE: NEVER omit peakless basal insulin in a Type 1 Diabetic, even if NPO. Hold prandial doses only. Check ketones if GRBS > 250 mg/dL.
Morning Dose (U)
Afternoon Dose (U)
Night Dose (U)
Basal Dose (U)
Morn Bolus (U)
Aft Bolus (U)
Night Bolus (U)
⚠ Key Principle: Steroid hyperglycaemia peaks 8 to 12 hours after the dose. Morning Prednisolone = Afternoon/Evening glucose peaks. Dexamethasone = Sustained 36h effect. Insulin distribution MUST match the steroid's specific pharmacokinetic footprint.
⚙ Action Profiles of Common Insulins
Insulin Type
Onset
Peak
Duration
Rapid-Acting (Lispro, Aspart)
10-15 mins
1-2 hours
3-5 hours
Short-Acting (Regular / Actrapid)
30-60 mins
1-2 hours
6-8 hours
Intermediate (NPH / Insulatard)
1-2 hours
4-8 hours
12-18 hours
Long-Acting (Glargine / Lantus)
1-2 hours
Peakless
20-24 hours
Ultra-Long (Degludec / Tresiba)
1-2 hours
Peakless
> 42 hours
Crucial Timing of Insulin vs. Meals
Rapid-Acting (Lispro/Aspart/Glulisine): Give 10 to 15 mins before eating. (May give immediately after eating if oral intake is highly unpredictable).
Short-Acting (Regular): MUST be given 30 to 45 mins before the meal. Giving it at the time of eating causes a post-prandial spike (before the insulin peaks) followed by delayed hypoglycaemia.
Intermediate (NPH) / Premix: Give 30 mins before breakfast and dinner.
Basal (Glargine/Degludec): Can be given at any time of day, but must be given at the exact same time every day.
Clinical Diagnostics & Alerts
⚠ Hypoglycaemia Begets Hypoglycaemia Unawareness
Repeated hypoglycaemic events blunt the autonomic warning signs (sweating, palpitations, tremors). Patients may suddenly develop severe neuroglycopenia (confusion, seizures, coma) without any prior symptoms. Action: If unawareness is suspected, strictly avoid hypoglycaemia for 2 to 3 weeks by raising target GRBS to restore autonomic warning mechanisms.
Somogyi Effect (Rebound Hyperglycaemia): High morning GRBS caused by an undetected nocturnal hypoglycaemic event (usually around 3 AM) which triggers counter-regulatory hormones (glucagon, cortisol, epinephrine) to spike the sugar. Treatment: Decrease the night NPH/Premix dose or give a bedtime snack.
Dawn Phenomenon: High morning GRBS caused by a normal physiological surge of growth hormone and cortisol in the early morning hours, creating insulin resistance. 3 AM sugars will be normal or high. Treatment: Increase the night NPH/Premix or shift it closer to bedtime.
Rule of 15 for Hypoglycaemia: If GRBS < 70 mg/dL: Administer 15 grams of fast-acting carbohydrate (e.g., 3 tsp sugar in water, 1/2 cup juice). Recheck GRBS in exactly 15 minutes. Repeat if still < 70 mg/dL. Once > 70, follow with a complex carb snack to prevent recurrence.
American Diabetes Association. Standards of Care in Diabetes - 2025. Diabetes Care 2025;48(Suppl 1).
Umpierrez GE et al. Randomised study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care 2007;30(9):2181-2186.
Riddle MC et al. The treat-to-target trial: randomised addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients (AT.LANTUS). Diabetes Care 2003;26(11):3080-3086.
Roberts A et al. Management of hyperglycaemia and steroid therapy: a guideline from the Joint British Diabetes Societies (JBDS). Diabet Med 2018;35(8):1011-1017.
How to Cite This Tool
AMA Style:
Umakanth S. Inpatient Basal-Bolus Insulin Protocol. MEDiscuss. Published 2026. Accessed .
Vancouver Style:
Umakanth S. Inpatient Basal-Bolus Insulin Protocol [Internet]. MEDiscuss.org; 2026 [cited ]. Available from:
