Es Add Scheduled Insulin After Correctional Start

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name: es-add-scheduled-insulin-after-correctional-start
description: In hospitalized adults initially managed with correctional insulin alone, persistent hyperglycemia is defined as two or more point-of-care blood glucose measurements ≥180 mg/dL within a 24‑hour period. When this pattern occurs, clinicians should consider adding scheduled (basal‑bolus or basal‑plus‑correction) insulin therapy to achieve glycemic targets of 100‑180 mg/dL, as triggered by the phrase “Started on correctional insulin alone, now BG ≥180 twice in 24h, add scheduled insulin?”.
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# Add scheduled insulin therapy if persistent hyperglycemia develops after starting on correctional insulin alone

## STEP 1 — Gather Information
Collect admission blood glucose, diabetes history, current insulin regimen (correctional insulin alone), frequency and timing of point‑of‑care glucose measurements, weight, renal function (eGFR), nutritional intake, and any hypoglycemia episodes. Record these data to proceed to persistence assessment.

## STEP 2 — Rule In / Rule Out
Determine if the patient has had ≥2 point‑of‑care blood glucose measurements ≥180 mg/dL within a 24‑hour period while receiving only correctional insulin. If yes, rule in persistent hyperglycemia and proceed to classification; otherwise, continue correctional insulin alone and reassess in 12‑24h.

## STEP 3 — Classify or Stratify
Stratify by admission blood glucose: if admission BG ≥180 mg/dL, initiate scheduled insulin immediately; if admission BG <180 mg/dL but persistent hyperglycemia is confirmed, add scheduled insulin to the existing correctional regimen.

## STEP 4 — Decide
Prescribe basal insulin (e.g., glargine 0.1‑0.2 units/kg once daily) plus continue correctional insulin before meals and at bedtime; adjust dose based on glucose trends and renal function, aiming for pre‑meal and bedtime targets of 100‑180 mg/dL.

## Clinical Guardrails / Mimics / Pitfalls
Avoid using sliding scale insulin alone when hyperglycemia persists; do not delay initiation beyond 24 h of confirmed persistence; monitor for hypoglycemia, especially in patients with renal impairment or variable oral intake; do not add scheduled insulin in patients who are NPO without adjusting basal insulin; avoid overlapping insulin products that increase hypoglycemia risk.

## Concrete Clinical Example
A 68‑year‑old woman admitted for community‑acquired pneumonia with no known diabetes had admission BG 162 mg/dL and was started on correctional insulin alone. Over the next 18 h she recorded POC‑BG of 188 and 194 mg/dL. Weight 70 kg, eGFR 55 mL/min/1.73 m2. Decision: initiate glargine 10 units nightly (0.14 units/kg) and continue correctional insulin before meals and at bedtime; recheck BG q6h and adjust dose if fasting BG <80 or >180 mg/dL.

**Source:** Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2022, https://doi.org/10.1210/clinem/dgac278
> **TODO:** consider adding scripts/calc.py for the es-add-scheduled-insulin-after-correctional-start calculator