What is the significance of persistent hyperglycemia despite insulin administration?

From the Guidelines

Persistent hyperglycemia despite insulin administration is a significant concern that requires immediate medical attention, as it may indicate insulin resistance, infection, or another acute illness causing stress hyperglycemia. The blood glucose level should be closely monitored, and the patient should receive IV fluids, higher doses of insulin via continuous infusion, and monitoring for complications. According to the most recent and highest quality study 1, insulin is the preferred therapy for persistent hyperglycemia, and the treatment goals for blood glucose levels should be individualized based on the patient's condition.

Some key points to consider in the management of persistent hyperglycemia include:

• Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold of no greater than 180 mg/dL (10 mmol/L) 1
• A glucose range of 140–180 mg/dL (7.8–10 mmol/L) is recommended for the majority of critically ill patients 1
• Critically ill patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia 1
• The lack of response to subcutaneous insulin suggests possible insulin resistance, infection, medication effect, or another acute illness causing stress hyperglycemia, and at home management is not appropriate at these glucose levels, especially with the demonstrated lack of response to insulin.

The patient's diabetes medication regimen may need to be adjusted, and precipitating factors should be evaluated and addressed. Close follow-up with their healthcare provider is essential to prevent long-term complications of diabetes, such as retinopathy, nephropathy, and neuropathy 1.

In terms of specific treatment, the patient may require a basal-plus-correction insulin regimen, and consistent carbohydrate meal plans can facilitate matching the prandial insulin dose to the amount of carbohydrate consumed 1. The sole use of sliding-scale insulin in the inpatient hospital setting is strongly discouraged, and a standardized hospital-wide and nurse-initiated hypoglycemia treatment protocol should be in place to immediately address hypoglycemia 1.

From the FDA Drug Label

Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin Hyperglycemia can be brought about by any of the following: Omitting your insulin or taking less than your doctor has prescribed. In patients with type 1 or insulin-dependent diabetes, prolonged hyperglycemia can result in DKA (a life-threatening emergency)

The significance of persistent hyperglycemia despite insulin administration is that it may indicate inadequate insulin dosage or insulin resistance, and if left uncorrected, can lead to Diabetic Ketoacidosis (DKA), a life-threatening emergency 2.

• Key factors that can contribute to hyperglycemia include omitting insulin or taking less than prescribed, and developing a fever, infection, or other significant stressful situation.
• Severe symptoms of uncorrected hyperglycemia or DKA can include nausea, vomiting, stomach pain, dehydration, loss of consciousness, or death.

From the Research

Significance of Persistent Hyperglycemia

• Persistent hyperglycemia despite insulin administration is a significant concern in hospitalized patients, as it is associated with increased morbidity and mortality 3.
• The presence of hyperglycemia in hospitalized patients can be due to various factors, including infection, which is a common precipitating condition for hyperglycemic crisis 4.
• Insulin therapy is the most appropriate method for controlling glycemia in hospital, but it is associated with increased risk of hypoglycemia, which is a barrier to achieving glycemic goals 3.

Factors Contributing to Persistent Hyperglycemia

• Infection is a major condition that can lead to hyperglycemic crisis, and intravenous insulin dosing may be required to control blood glucose levels 4.
• The effectiveness of insulin therapy can be influenced by various clinical findings, including the patient's condition, and the dosage of insulin may need to be individualized 4, 5.
• Sliding-scale insulin regimens may not be effective in achieving good glycemic control, and adjustments to the timing or dose of insulin may be necessary 5.

Consequences of Persistent Hyperglycemia

• Persistent hyperglycemia can lead to poor outcomes, including increased risk of hospital complications and mortality 3.
• Extremes of blood glucose can lead to poor outcomes, and targeting a glucose range of 110-180 mg/dL may be appropriate for most critically ill patients and noncritically ill patients 3.
• Normalization of fasting blood glucose can minimize glucotoxicity and insulin resistance, and profoundly influence daytime glycemic control, reducing the risk of complications of diabetes 6.