Inpatient Basal-Bolus Insulin Protocol v6.0
Dynamic Titration, NPO Management & Acute Glycaemic Clearances
📈 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
📚 Action Profiles of Common Insulins
Crucial Timing of Insulin vs. MealsClinical Diagnostics & Alerts
| 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 | 2-4 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 |
- 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.
⚠ 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.
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.
Abbreviations: GRBS (Glucometer Random Blood Sugar) · TDD (Total Daily Dose) · ISF (Insulin Sensitivity Factor) · ICR (Insulin-to-Carb Ratio) · RRP (Regular-Regular-Premix) · NPO (Nil Per Os) · NPH (Neutral Protamine Hagedorn)
⚠ Clinical Disclaimer: This algorithm is validated for adults (≥ 18 years). It provides starting-point estimates based on published guidelines. Doses must be rounded to the nearest practical unit. The algorithm assumes the user will monitor GRBS closely per institutional protocol after every dose change.
© 2026 Dr Shashikiran Umakanth · MEDiscuss.org · All rights reserved.
Inpatient Basal-Bolus Insulin Protocol — Clinical decision support for educational purposes. Unauthorised reproduction, redistribution, or modification of this tool is prohibited. For permissions, contact mediscuss.org/contact.
Algorithm References & Evidence Base
- 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.
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