Insulin use for hospitalised adults with type 1 diabetes
Particular care must be taken with insulin use in hospitalised adults with type 1 diabetes because deliberate or inadvertent interruption of their insulin treatment can lead to development of life-threatening diabetic ketoacidosis (DKA). Basal insulin should never be withheld because this can quickly lead to DKA. If possible, the endocrinology team should be involved in the management of hospitalised adults with type 1 diabetes.
Ensure that patients who are fasting continue to receive carbohydrates to reduce the development of ketones; see information for fasting before a procedure in Instructions for patients with type 1 diabetes who are fasting before a procedure.
All hospitalised adults with type 1 diabetes who have persistent hyperglycaemia, are unwell or fasting for a prolonged period (more than 24 hours) should have blood ketone concentrations measured to check for developing DKA. An adult with type 1 diabetes who is unwell and not eating is often best managed with an intravenous insulin and glucose infusion. For an example of an intravenous insulin infusion with a concurrent glucose infusion, see Preprocedural intravenous insulin infusion for adults with type 1 diabetes.
Most adults with type 1 diabetes are accustomed to self-managing their diabetes at home with regular insulin adjustment according to carbohydrate intake and blood glucose concentrations. When in hospital, the adult should be individually assessed to decide whether it is appropriate for them to continue to self-manage their diabetes. The assessment and the extent of their self-management must be clearly documented and communicated to all the treating team. For specific considerations when insulin is not self-administered, see here.
Hospitalised adults managed on a continuous subcutaneous insulin infusion (CSII) pump need special consideration. When the rapid-acting insulin used in the CSII pump is stopped, the patient quickly becomes insulin deficient (within 2 to 3 hours) and is at high risk of DKA unless an alternative insulin regimen is started immediately.
The decision on whether to continue insulin delivery via the CSII pump depends on the:
- metabolic stability of the patient
- anticipated duration of hospital stay
- likely ability of the patient to self-manage the CSII pump while in hospital—consider potential sedative effects of anaesthetics, opioid analgesia or other drugs.
If there are concerns about any of these factors, it may be safer to change to a multiple daily injection (basal–bolus) insulin regimen or an intravenous insulin infusion. If uncertain about how to proceed, seek specialist advice.
To maintain continuity of care, communication with the adult’s general practitioner and multidisciplinary diabetes team should occur during the hospital admission and before they are discharged.