NICE-SUGAR Trial: Inpatient Glycemic Targets and Insulin Regimens
Based on the NICE-SUGAR trial findings, start insulin therapy when blood glucose persistently exceeds 180 mg/dL (checked twice), then target 140-180 mg/dL for both critically ill and non-critically ill patients—this applies universally regardless of ICU status. 1
Key Findings from NICE-SUGAR
The NICE-SUGAR trial fundamentally changed inpatient glycemic management by demonstrating that intensive glucose control (80-110 mg/dL) resulted in higher mortality (27.5% vs 24.9%) and 10- to 15-fold greater rates of hypoglycemia compared to moderate targets (140-180 mg/dL). 1, 2 This landmark multicenter study involving over 6,000 critically ill patients directly contradicted earlier enthusiasm for tight glycemic control.
Universal Target Ranges
For Both Critically Ill AND Non-Critically Ill Patients:
Initiation Threshold:
- Start insulin when blood glucose ≥180 mg/dL on two separate occasions 1
Standard Target Range:
- 140-180 mg/dL (7.8-10.0 mmol/L) for the majority of patients 1
Alternative Targets (Selected Patients Only):
- More stringent: 110-140 mg/dL (6.1-7.8 mmol/L) for critically ill postsurgical or cardiac surgery patients—only if achievable without significant hypoglycemia 1
- For non-critically ill: 100-180 mg/dL (5.6-10.0 mmol/L) is acceptable, particularly for patients with new hyperglycemia 1
Recommended Insulin Regimens
Critically Ill Patients:
- Continuous intravenous insulin infusion using validated protocols 3, 4
- Monitor blood glucose every 30 minutes to 2 hours during IV insulin therapy 1
Non-Critically Ill Patients:
For patients with good oral intake:
- Basal-bolus regimen (basal + prandial + correction insulin) is preferred 3, 4, 5
- Point-of-care glucose testing before each meal 1
For patients with poor/no oral intake:
Critical Pitfall: Sliding-scale insulin alone is strongly discouraged in all inpatient settings 3, 4, 5
Important Clinical Caveats
Hypoglycemia Risk: The NICE-SUGAR trial's mortality increase was likely driven by severe hypoglycemia rates in the intensive control group. 1, 2 Fasting glucose <100 mg/dL predicts hypoglycemia within 24 hours. 1
Special Populations:
- Terminally ill patients: Glucose levels up to 250 mg/dL may be acceptable to minimize treatment burden 1
- Patients with severe comorbidities: 180-250 mg/dL may be acceptable where frequent monitoring is not feasible 6
Monitoring Requirements:
- Eating patients: Before each meal
- NPO/tube feeding: Every 4-6 hours
- IV insulin: Every 30 minutes to 2 hours 1
The evidence consistently demonstrates that moderate glycemic control (140-180 mg/dL) reduces mortality compared to intensive targets, making this the evidence-based standard for virtually all hospitalized patients regardless of critical illness status. 1, 2