What is the optimal rate for reducing glucose levels in hyperglycemia (high blood sugar)?

From the Guidelines

In hyperglycemia, the optimal rate for reducing glucose levels is to initiate insulin therapy for persistent hyperglycemia ≥180 mg/dL and target a glucose range of 140–180 mg/dL for most critically ill individuals. This approach is based on the most recent and highest quality study, which found that more aggressive glycemic management goals were associated with higher rates of hypoglycemia and mortality compared to moderate glycemic goals 1.

Key Considerations

• The findings from the NICE-SUGAR trial, supported by several meta-analyses and a randomized controlled trial, showed higher rates of hypoglycemia and an increase in mortality with more aggressive glycemic management goals compared to moderate glycemic goals 1.
• More stringent glycemic goals, such as 110–140 mg/dL, may be appropriate for selected individuals, such as critically ill patients undergoing cardiac surgery, if they 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 that might affect glucose levels, should be incorporated into the day-to-day decisions regarding insulin dosing 1.

Treatment Approach

• Insulin therapy should be initiated for treatment of persistent hyperglycemia ≥180 mg/dL and targeted to a glucose range of 140–180 mg/dL for the majority of critically ill patients 1.
• For inpatient management of hyperglycemia in noncritical care, a target range of 100–180 mg/dL may be appropriate for noncritically ill patients with “new” hyperglycemia as well as people with known diabetes prior to admission 1.
• Glycemic levels >250 mg/dL may be acceptable in terminally ill patients with short life expectancy, and less aggressive insulin regimens may be used to minimize glucosuria, dehydration, and electrolyte disturbances 1.

From the Research

Optimal Rate for Reducing Glucose Levels

The optimal rate for reducing glucose levels in hyperglycemia is a topic of ongoing research and debate. Several studies have investigated the best approach to managing hyperglycemia in various settings, including hospitals and outpatient care.

Key Findings

• The American Diabetes Association (ADA) and American College of Endocrinology (ACE) recommend intensive control of glycosylated hemoglobin and plasma glucose at specified goals 2.
• Insulin remains the most appropriate agent for managing hyperglycemia in hospitalized patients, with continuous intravenous (IV) infusion preferred in critically ill patients and scheduled subcutaneous (SC) basal-bolus insulin regimens supplemented with correction doses as needed in non-critically ill patients 3.
• The use of sliding-scale insulin as the sole therapy for inpatient hyperglycemia is discouraged, as it is ineffective and potentially dangerous 4, 2, 3.
• Optimal glycemic management in the hospital setting requires judicious treatment of hyperglycemia while avoiding hypoglycemia, with glucose targets near 140 mg/dL recommended as being the most appropriate for all hospitalized patients 3.
• Insulin infusion algorithms have been shown to be safe and effective, but a major obstacle in their implementation is their complexity, highlighting the need for simple and comprehensive guidelines for treatment of hyperglycemia 5.

Recommended Approaches

• Basal-bolus plus correction insulin therapy, which usually involves a single daily dose of insulin glargine at bedtime to prevent gluconeogenesis and ketogenesis, bolus injections of a rapid-acting insulin shortly before or after meals to meet prandial requirements, and correction bolus injections of rapid-acting insulin as needed for blood glucose elevations before or between meals 4.
• The use of modern insulin analogs, such as long-acting basal insulin analogs (glargine, detemir) and rapid-acting insulin analogs (aspart, lispro, glulisine), which offer advantages over older human insulins and have a lower propensity for inducing hypoglycemia 3.
• Frequent and effective glucose monitoring is critical for avoiding wide deviations from acceptable glucose levels 3.