What are the guidelines for charting and managing hyperglycemia?

Guidelines for Charting and Managing Hyperglycemia

Blood glucose monitoring at meals and bedtime with basal-bolus insulin regimens is the standard of care for inpatient hyperglycemia management, targeting blood glucose levels between 140-180 mg/dL for most hospitalized patients. 1, 2

Blood Glucose Monitoring Protocol

Who to Monitor

• All patients with known diabetes 1
• Patients with admission hyperglycemia (random blood glucose >140 mg/dL) 1
• Patients on glucocorticoid therapy 1

Monitoring Frequency

• Monitor blood glucose at meals and bedtime 1, 2
• For critically ill patients: more frequent monitoring (initially hourly until stable) 2
• For patients on insulin pumps: check glucose levels more frequently 3

Monitoring Method

• Capillary blood glucose monitoring is the standard method 1
• Continuous glucose monitoring (CGM) may be considered for stable patients already familiar with the technology 1

Target Blood Glucose Range

• Target range: 140-180 mg/dL for most hospitalized patients 1, 2
• More stringent goals (110-140 mg/dL) may be appropriate for select patients (e.g., cardiac surgery) 2
• Higher targets (up to 200 mg/dL) for terminally ill patients or those with severe comorbidities 2

Treatment Recommendations

Insulin Regimens

• Basal-bolus insulin is the preferred treatment strategy 1, 2

  • Starting total daily dose: 0.3-0.5 units/kg/day 2
  • Distribution: 50% basal insulin, 50% prandial insulin 2

• Avoid sliding scale insulin as the sole treatment strategy 1, 2

  • This approach is consistently advised against in guidelines 1

For Patients with Poor Oral Intake

• Use basal insulin with correction doses 2
• Consider reducing basal dose (0.1-0.2 units/kg/day) 2

For Patients with Mild Hyperglycemia (<200 mg/dL)

• Consider basal insulin with correction doses 2
• Alternative: basal insulin plus DPP-4 inhibitor approach 2
• Starting basal dose: 0.1-0.2 units/kg/day 2

Hypoglycemia Management

• Implement a standardized hospital-wide hypoglycemia treatment protocol 2
• Promptly treat blood glucose <70 mg/dL 1, 2
• Moderate hypoglycemia defined as <70 mg/dL or <72 mg/dL 1
• Severe hypoglycemia defined as <54 mg/dL 1
• Treatment:
  • Oral carbohydrate/glucose for conscious patients 1
  • IV glucose for NPO patients 1
  • Intranasal or subcutaneous glucagon for patients without IV access 1
• Review and modify treatment regimens after hypoglycemic episodes 1, 2

Non-Insulin Medications

• Insulin is the preferred agent for inpatient hyperglycemia management 2
• Guidance on use of oral diabetes medications is inconsistent across guidelines 1
• DPP-4 inhibitors may be used in selected patients with type 2 diabetes 2
• Medications to avoid or discontinue:
  • Metformin: discontinue in patients with eGFR <30 mL/min/1.73m² 2
  • SGLT2 inhibitors: avoid in the inpatient setting 2
  • Sulfonylureas: consider withholding in patients with limited caloric intake 4
  • Thiazolidinediones: temporarily stop in patients with cardiovascular conditions 4

Transition of Care

• Return to home medication regimen from the day prior to discharge 1, 2
• Schedule follow-up within 1 month of discharge 2
• Consider changes to outpatient regimens based on:
  • Inpatient glycemic control 2
  • HbA1c levels 1, 2

Charting Requirements

• Document blood glucose values at each measurement
• Record insulin doses administered
• Note any episodes of hypoglycemia and interventions taken
• Document patient's response to treatment
• Use visual charting that makes sudden changes in blood glucose levels obvious 5

Common Pitfalls to Avoid

• Using sliding scale insulin as the sole treatment strategy 2
• Premature discontinuation of intravenous insulin 2
• Holding basal insulin in patients with type 1 diabetes 2
• Inadequate monitoring of potassium levels during insulin therapy 2
• Failing to adjust insulin doses in patients with renal insufficiency 2
• Prolonged hyperglycemia, which can worsen insulin resistance and lead to complications 6, 7

By following these evidence-based guidelines for charting and managing hyperglycemia, healthcare providers can reduce the risk of both hyperglycemia and hypoglycemia, potentially improving patient outcomes and reducing complications.