How to manage hyperglycemia in an institutionalized patient?

From the Guidelines

Managing hyperglycemia in institutionalized patients requires initiating insulin therapy for persistent hyperglycemia starting at a threshold ≥180 mg/dL and targeting a glucose range of 140–180 mg/dL for the majority of patients. This approach is based on the most recent and highest quality study available, which prioritizes minimizing morbidity, mortality, and improving quality of life 1.

Key Considerations

• Establishing glycemic targets should be individualized based on the patient's age, comorbidities, and life expectancy.
• Implement a monitoring schedule with capillary blood glucose checks before meals and at bedtime initially, adjusting frequency based on stability.
• For medication management, insulin is the preferred treatment for hyperglycemia in hospitalized individuals, with basal insulin dosing based on body weight and expected sensitivity to insulin.
• Ensure proper nutrition with consistent carbohydrate meal plans and moderate physical activity as appropriate.
• Hypoglycemia prevention is crucial, so establish protocols for treating low blood glucose (<70 mg/dL) with 15-20g of fast-acting carbohydrates.

Nutrition and Lifestyle Modifications

• Provide nutritionally balanced meals rather than fluids with high sugar content to prevent glycemic spikes 1.
• Consider challenges to food intake, such as decreased appetite, swallowing difficulties, and trouble keeping food down, and manage hydration actively.
• Safety protocols should be in place to avoid hypoglycemia if feeding of patients on enteral or parenteral nutrition is abruptly stopped.

Ongoing Management

• Regular reassessment of the regimen is essential, with medication adjustments every 3-7 days until targets are reached.
• More stringent goals, such as <140 mg/dL, may be appropriate for selected patients, as long as this can be achieved without significant hypoglycemia 1.
• Clinical judgment combined with ongoing assessment of clinical status, including changes in the trajectory of glucose measures, illness severity, nutritional status, or concomitant medications, may be incorporated into day-to-day decisions regarding insulin dosing.

From the FDA Drug Label

In initiating treatment for type 2 diabetes, diet should be emphasized as the primary form of treatment Caloric restriction and weight loss are essential in the obese diabetic patient. Proper dietary management alone may be effective in controlling the blood glucose and symptoms of hyperglycemia. The importance of regular physical activity should also be stressed, and cardiovascular risk factors should be identified and corrective measures taken where possible Use of glipizide or other antidiabetic medications must be viewed by both the physician and patient as a treatment in addition to diet and not as a substitution or as a convenient mechanism for avoiding dietary restraint.

To manage hyperglycemia in an institutionalized patient, dietary management should be the primary form of treatment, with an emphasis on caloric restriction and weight loss for obese patients. Regular physical activity is also important, and cardiovascular risk factors should be identified and addressed. Additionally, antidiabetic medications such as glipizide should be used as an adjunct to diet, not as a replacement for it 2.

• Key considerations:
  • Dietary management
  • Regular physical activity
  • Cardiovascular risk factor identification and management
  • Antidiabetic medication as an adjunct to diet
• Important warnings:
  • Hypoglycemia risk with glipizide
  • Importance of monitoring blood glucose and adjusting treatment as needed
  • Potential interactions with other medications 2

From the Research

Managing Hyperglycemia in Institutionalized Patients

To manage hyperglycemia in institutionalized patients, several strategies can be employed:

• Confirm the diagnosis of diabetes or hyperglycemia before initiating treatment 3
• Use insulin as the primary treatment for patients with type 1 diabetes mellitus (T1DM) and consider it for patients with type 2 diabetes mellitus (T2DM) who have not achieved glycemic goals with oral antidiabetic medications 3
• Individualize the insulin regimen to resemble a natural physiologic state and avoid wide fluctuating glucose levels 3
• Monitor blood glucose levels regularly to titrate insulin doses and adjust the treatment plan as needed 3, 4

Insulin Therapy

Insulin therapy can be initiated with:

• Multiple daily injections of short-acting or rapid-acting insulin analogue for patients with T1DM 3
• Long-acting (basal) insulin or once-daily premixed/co-formulation insulin for patients with T2DM 3
• Addition of rapid-acting or short-acting insulin at mealtime to control postprandial glucose levels 3

Combination Therapy

Combination therapy with oral antidiabetic medications and insulin can be effective in managing hyperglycemia:

• Metformin combined with insulin can decrease weight gain, lower insulin dose, and reduce hypoglycemia 3
• Triple combination therapy with a dipeptidyl peptidase-4 inhibitor, metformin, and sulfonylurea can markedly improve HbA1c levels in patients with T2DM 5

Hospital Management

In the hospital setting, managing hyperglycemia in non-critically ill patients can be achieved through:

• Use of emerging diabetes technologies such as continuous glucose monitoring and insulin pump therapy 4
• Insulin regimens for prandial insulin dosing, glucocorticoid, and enteral nutrition-associated hyperglycemia 4
• Conditional recommendations for hospital use of noninsulin therapies and correctional insulin 4