What is the recommended management strategy for diabetes in inpatients?

From the Guidelines

The recommended management strategy for diabetes in inpatients involves using a basal-bolus insulin regimen, which has been shown to improve glycemic control and reduce hospital complications compared to sliding scale insulin regimens. This approach is supported by a randomized controlled trial that demonstrated the effectiveness of basal-bolus treatment in general surgery patients with type 2 diabetes 1. The basal-bolus regimen typically includes a basal insulin component, such as glargine or detemir, and a prandial insulin component, such as lispro, aspart, or glulisine, which is administered before meals.

Key Considerations

• For patients who are eating, insulin injections should align with meals, and point-of-care glucose testing should be performed immediately before meals 1.
• If oral intake is poor, a safer procedure is to administer prandial insulin immediately after the patient eats, with the dose adjusted to be appropriate for the amount ingested 1.
• Prolonged use of sliding scale insulin regimens as the sole treatment of hyperglycemic inpatients is strongly discouraged due to the increased risk of hypoglycemia and poor glycemic control 1.

Additional Recommendations

• Blood glucose monitoring should occur before meals and at bedtime for patients who are eating, or every 4-6 hours for those not eating 1.
• Hypoglycemia protocols should be established, with treatment including 15-20g of glucose for conscious patients or IV dextrose/glucagon for unconscious patients 1.
• A comprehensive discharge plan should include medication reconciliation, patient education, and clear follow-up instructions to ensure continuity of care.

Preferred Treatment Regimens

• An insulin regimen with basal, prandial, and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake 1.
• A basal-plus-correction insulin regimen is the preferred treatment for patients with poor oral intake or those who are receiving nothing by mouth 1.

From the FDA Drug Label

Adjustment of dosage of any insulin may be necessary if patients change their physical activity or their usual meal plan.

Information for Patients LEVEMIR must only be used if the solution appears clear and colorless with no visible particles

Patients should be informed about potential risks and advantages of LEVEMIR therapy, including the possible side effects

Patients should be offered continued education and advice on insulin therapies, injection technique, life-style management, regular glucose monitoring, periodic glycosylated hemoglobin testing, recognition and management of hypo- and hyperglycemia, adherence to meal planning, complications of insulin therapy, timing of dosage, instruction for use of injection devices and proper storage of insulin

The recommended management strategy for diabetes in inpatients involves:

• Individualized dosage adjustment based on the patient's metabolic needs, blood glucose monitoring results, and glycemic control goals 2
• Regular glucose monitoring to prevent hypoglycemia and hyperglycemia
• Patient education on insulin therapy, injection technique, lifestyle management, and recognition of hypo- and hyperglycemia
• Close medical supervision when making changes to a patient's insulin regimen
• Consideration of factors that may affect insulin requirements, such as changes in physical activity, meal patterns, or concomitant medication use 3

From the Research

Management of Diabetes in Inpatients

The management of diabetes in inpatients is crucial to prevent hyperglycemia and its associated complications. The following are key points to consider:

• A diagnosis of diabetes or hyperglycemia should be confirmed prior to ordering, dispensing, or administering insulin 4.
• Insulin is the primary treatment in all patients with type 1 diabetes mellitus (T1DM) 4.
• For patients with type 2 diabetes mellitus (T2DM), indications for exogenous insulin therapy include acute illness or surgery, pregnancy, glucose toxicity, contraindications to or failure to achieve goals with oral antidiabetic medications, and a need for flexible therapy 4.
• The preferred method of insulin initiation in T2DM is to begin by adding a long-acting (basal) insulin or once-daily premixed/co-formulation insulin or twice-daily premixed insulin, alone or in combination with glucagon-like peptide-1 receptor agonist (GLP-1 RA) or in combination with other oral antidiabetic drugs (OADs) 4.

Insulin Regimens

The following insulin regimens can be used in inpatients:

• Basal-bolus insulin therapy, which includes basal insulin, nutritional insulin, and supplemental, or correctional, insulin 5.
• Insulin analogs, which provide a more physiologic action than human insulin regimens, are associated with a lower risk of hypoglycemia, and are more convenient to administer than human insulins 5.
• Insulin detemir, a basal insulin analog, which provides effective therapeutic options for patients with type 1 and type 2 diabetes 6, 7.

Blood Glucose Monitoring

Blood glucose monitoring is an integral part of effective insulin therapy and should not be omitted in the patient's care plan 4.

• Fasting plasma glucose (FPG) values should be used to titrate basal insulin, whereas both FPG and postprandial glucose (PPG) values should be used to titrate mealtime insulin 4.

Special Considerations

• For patients unable to eat, the American Diabetes Association recommends basal insulin or basal plus correctional insulin regimen 8.
• No differences were observed in hypoglycemic events for patients unable to eat receiving various basal insulin dose reductions 8.
• Metformin combined with insulin is associated with decreased weight gain, lower insulin dose, and less hypoglycemia when compared with insulin alone 4.