What is the management approach for hyperglycemia (high blood sugar) in an inpatient setting, excluding diabetic ketoacidosis (DKA)?

Management of Inpatient Hyperglycemia (Non-DKA)

For inpatient hyperglycemia management, use a basal-bolus insulin regimen with target glucose levels of 140-180 mg/dL for most patients, avoiding sliding scale insulin alone as the primary treatment strategy. 1

Glycemic Targets

• Target blood glucose range: 140-180 mg/dL for most hospitalized patients 1
• More stringent goals (110-140 mg/dL) may be appropriate for select patients, such as cardiac surgery patients and those with acute ischemic cardiac or neurological events, provided hypoglycemia can be avoided 1
• Higher targets (up to 200 mg/dL) may be acceptable in terminally ill patients or those with severe comorbidities 1

Management Approach by Setting

Critical Care Setting (ICU)

1. Continuous intravenous insulin infusion is the treatment of choice 1

   • Initiate when glucose levels exceed 180 mg/dL 1
   • Target glucose range: 140-180 mg/dL 1
   • Use validated written or computerized protocols for adjustments 1
   • Allows for rapid dose titration with changes in clinical status 1

2. Monitoring:

   • Frequent blood glucose monitoring (typically hourly until stable)
   • Computer-based algorithms may reduce hypoglycemia risk and glycemic variability 1

Non-Critical Care Setting

1. Preferred regimen: Basal-bolus insulin 1

   • Starting total daily dose: 0.3-0.5 units/kg/day based on patient's weight and insulin sensitivity
   • Distribution: 50% as basal insulin, 50% as prandial insulin 1
   • Add correction insulin for hyperglycemia

2. For patients with poor or no oral intake:

   • Basal insulin with correction doses 1
   • Consider reducing basal dose (0.1-0.2 units/kg/day) 1

3. For patients with mild hyperglycemia (<200 mg/dL):

   • Consider basal insulin with correction doses or basal plus DPP-4 inhibitor approach 1
   • Starting basal dose: 0.1-0.2 units/kg/day 1

4. Avoid sliding scale insulin alone as it results in undesirable glycemic control and increased complications 1

Special Patient Populations

Type 1 Diabetes

• Always maintain basal insulin even when NPO 1
• Basal-bolus insulin is mandatory; never discontinue basal insulin 1
• Policies should be in place to ensure basal insulin is not held during transitions of care 1

Elderly Patients

• Follow general guidelines but with emphasis on preventing hypoglycemia 1
• Consider lower insulin doses (0.1-0.2 units/kg/day) 1
• Higher risk of hypoglycemia requires careful monitoring 1

Monitoring Recommendations

• Frequency: Before meals and at bedtime for patients who are eating 1
• For NPO patients: Every 4-6 hours 1
• Target: 140-180 mg/dL for most patients 1

Hypoglycemia Prevention and Management

• Implement a standardized hospital-wide hypoglycemia treatment protocol 1
• Treat blood glucose <70 mg/dL promptly 1
• Review and modify treatment regimens after hypoglycemic episodes 1
• Avoid or reduce medications with increased hypoglycemia risk 1

Role of Non-Insulin Medications

• Generally, insulin is the preferred agent for inpatient hyperglycemia management 1
• In certain circumstances, continuing or initiating non-insulin agents may be appropriate:
  • DPP-4 inhibitors may be used in selected patients with type 2 diabetes 1
  • Metformin should be discontinued in patients with:
    • eGFR <30 mL/min/1.73m² 1
    • Risk for lactic acidosis (sepsis, hypoxia, liver failure) 1
    • Before iodinated contrast procedures if eGFR <60 mL/min/1.73m² 1
  • SGLT2 inhibitors should be avoided in the inpatient setting 1

Transitions of Care

• Return to home regimen from the day prior to discharge 1
• Schedule follow-up within 1 month of discharge 1
• Consider changes to outpatient regimens based on inpatient glycemic control and HbA1c 1

Common Pitfalls to Avoid

• Using sliding scale insulin as the sole treatment strategy 1
• Premature discontinuation of intravenous insulin before establishing adequate subcutaneous insulin coverage 1
• Holding basal insulin in patients with type 1 diabetes 1
• Inadequate monitoring of potassium levels during insulin therapy 1
• Failing to adjust insulin doses in patients with renal insufficiency 1

By following these evidence-based guidelines, clinicians can effectively manage inpatient hyperglycemia while minimizing the risks of hypoglycemia and other complications, ultimately improving patient outcomes.