What is the recommended blood glucose target range for hospital patients and how to manage insulin, specifically NovoRapid (aspart) and basal insulin, in patients with diabetes?

Blood Glucose Management in Hospitalized Patients

For most hospitalized patients, blood glucose should be maintained within a target range of 140-180 mg/dL, with insulin therapy initiated when blood glucose levels are ≥180 mg/dL (checked on two occasions). 1, 2

Target Blood Glucose Ranges

Critical and Non-Critical Care Settings

• Primary target range: 140-180 mg/dL for most critically ill and non-critically ill patients 1, 2
• More stringent goals (110-140 mg/dL) may be appropriate for selected patients such as:
  • Post-surgical patients
  • Cardiac surgery patients
  • Only if achievable without significant hypoglycemia 1, 2
• Higher targets (up to 200-250 mg/dL) may be appropriate for:
  • Patients with severe comorbidities
  • Terminally ill patients (to minimize glucosuria, dehydration, and electrolyte disturbances) 2

Caution

• Targets below 110 mg/dL should be avoided due to increased risk of hypoglycemia and mortality 2
• The NICE-SUGAR trial demonstrated that intensive glycemic control (80-110 mg/dL) resulted in significantly higher mortality (27.5% vs. 25%) and 10-15 fold greater rates of hypoglycemia compared to more moderate targets 1

Insulin Management Strategies

Critical Care Setting

• Continuous intravenous insulin infusion is the preferred regimen for ICU patients 2
• Initiate when blood glucose is ≥180 mg/dL (confirmed on two occasions) 1, 2

Non-Critical Care Setting

• Basal-bolus insulin regimen is strongly preferred over sliding scale insulin alone 2
• Components of basal-bolus regimen:
  1. Basal insulin: Long-acting insulin analogs (glargine, detemir) are preferred 2, 3
  2. Bolus insulin: Rapid-acting insulin analogs (aspart/NovoRapid, lispro, glulisine) for mealtime coverage 2, 3
  3. Correction doses: Additional rapid-acting insulin for hyperglycemia 2

NovoRapid (insulin aspart) Management

• Use as the bolus component of the basal-bolus regimen
• Administer before meals for patients who are eating
• For patients on enteral/parenteral nutrition, coordinate NovoRapid dosing with feeding schedule 4
• Advantages over regular human insulin: faster onset, shorter duration, and lower risk of hypoglycemia 3

Blood Glucose Monitoring Protocol

• Point-of-care blood glucose monitoring:
  • Before meals for patients who are eating
  • Every 4-6 hours for patients who are not eating 2
• Daily review of blood glucose values until stabilized 2
• Adjust insulin doses every 2-3 days based on glucose patterns 2

Hypoglycemia Prevention

• Define and recognize hypoglycemia:
  • Level 1: 54-70 mg/dL (3.0-3.9 mmol/L)
  • Level 2: <54 mg/dL (<3.0 mmol/L) - threshold for neuroglycopenic symptoms
  • Level 3: Clinical event requiring assistance from another person 1
• Risk factors for hypoglycemia:
  • Advanced age
  • Recent trauma
  • Interrupted nutrition during perioperative period 2
• Fasting glucose levels <100 mg/dL predict hypoglycemia within the next 24 hours 1

Special Considerations

Enteral and Parenteral Nutrition

• Maintain target glucose range of 140-180 mg/dL for patients receiving artificial nutrition 4
• Consider diabetes-specific enteral formulas or lower dextrose content in parenteral nutrition 4
• Synchronize insulin dosing with nutrition delivery schedule 4

Discharge Planning

• Begin diabetes discharge planning at hospital admission 2
• Provide clear written and oral instructions for insulin dosing and timing 2
• Establish thresholds for contacting healthcare providers (e.g., BG >350 mg/dL or <70 mg/dL) 2

Common Pitfalls to Avoid

1. Using sliding scale insulin alone - ineffective and should not be used as monotherapy 2, 5
2. Targeting overly tight glycemic control (<110 mg/dL) - increases risk of severe hypoglycemia and mortality 1, 6
3. Failing to adjust insulin when nutritional status changes - can lead to severe hypo/hyperglycemia 2, 4
4. Overlooking the importance of basal insulin - essential component of effective glycemic management 3, 5
5. Inconsistent monitoring - can miss important glucose trends and lead to delayed interventions 2

By following these evidence-based recommendations for blood glucose targets and insulin management, clinicians can effectively control hyperglycemia while minimizing the risk of hypoglycemia in hospitalized patients, ultimately improving patient outcomes.