Step	Action	Comment
1	Measure blood glucose before meals and at bedtime, or every six hours if nothing by mouth; stop oral agents; order A1C if none obtained in past 30 days	Initiate protocol for patients with known diabetes mellitus and anyone with two or more random blood glucose readings > 180 mg per dL (9.99 mmol per L) or fasting glucose > 126 mg per dL (6.99 mmol per L)
2	Calculate initial total daily dose of insulin	0.3 units per kg: underweight; older age; hemodialysis
		0.4 units per kg: normal weight
		0.5 units per kg: overweight
		≥ 0.6 units per kg: obese; glucocorticoids; insulin resistance
3	Order 50 percent of the total daily dose as long-acting basal insulin	Insulin glargine (Lantus) every 24 hours, or insulin isophane (NPH) or detemir (Levemir) every 12 hours
4	Order 50 percent of the total daily dose as short-acting nutritional insulin given in three divided doses zero to 15 minutes before meals (if eating) or before bolus tube feeds	If continuous tube or parenteral feeds, consider every six hour dosing of short-acting or regular insulin; hold if nothing by mouth
5	Select a scale of short-acting correctional insulin given zero to 15 minutes before meals	Use patient's insulin sensitivity as a guide for initial scale selection
6	Subsequent daily adjustment of total daily dose based on previous day's total units given	—
example: A 50-year-old man with diabetes who is 180 cm (71 in) tall and weighs 90 kg (198 lb) is admitted for pneumonia treatment with a random blood glucose level of 300 mg per dL (16.65 mmol per L) and an A1C level of 10.8 percent; oral diabetic agents are discontinued, and blood glucose testing is ordered before meals and at bedtime.
Calculated total daily dose of insulin: 0.5 units per kg X 90 kg = 45 units
Ordered: 23 units of insulin glargine taken once daily (50 percent of total daily dose) and 7 units of insulin aspart (Novolog) taken zero to 15 minutes before meals (50 percent of total daily dose, in three divided doses); based on glucose readings, give additional aspart per standard correctional insulin schedule in Table 4.