What is the recommended management for hyperglycemia (high blood sugar) in inpatients?

Inpatient Hyperglycemia Management

Basal-bolus insulin regimens are the preferred treatment for inpatient hyperglycemia management with target blood glucose levels of 140-180 mg/dL for most hospitalized patients. 1 This approach is significantly more effective than sliding scale insulin alone, which is strongly discouraged in the hospital setting. 2

Target Blood Glucose Range

• General target: 140-180 mg/dL for most hospitalized patients 1, 2
• More stringent targets (110-140 mg/dL): May be appropriate for select patients such as cardiac surgery patients 1
• Less stringent targets (up to 200 mg/dL): For terminally ill patients or those with severe comorbidities 1

Treatment Algorithm Based on Clinical Setting

Critical Care Setting

• Continuous intravenous insulin infusion is the most effective method for glycemic control 2
• Administer based on validated written or computerized protocols that allow for predefined adjustments 2
• Monitor blood glucose every 30 minutes to 2 hours until stable 2

Non-Critical Care Setting

Treatment should be stratified based on severity of hyperglycemia:

1. Mild Hyperglycemia (<200 mg/dL) 2:

   • Low-dose basal insulin (0.1-0.2 units/kg/day) or DPP-4 inhibitor
   • Correction doses with rapid-acting insulin before meals or every 6 hours

2. Moderate Hyperglycemia (200-300 mg/dL) 2:

   • Basal insulin with or without correction insulin
   • Starting dose: 0.2-0.3 units/kg/day
   • Reduce to 0.15 units/kg/day in elderly, frail patients, or those with renal impairment

3. Severe Hyperglycemia (>300 mg/dL) 2:

   • Basal-bolus regimen
   • Starting total daily dose: 0.3-0.5 units/kg/day
   • Distribute as 50% basal insulin and 50% prandial insulin

Specific Insulin Regimens

For Patients With Good Nutritional Intake

• Basal-bolus insulin regimen with three components 2:
  1. Basal insulin (glargine, detemir): Once or twice daily
  2. Prandial insulin (lispro, aspart): Before meals
  3. Correction insulin: To address hyperglycemia

For Patients With Poor or No Oral Intake

• Basal insulin with correction doses 2
• Reduce basal insulin dose to 0.1-0.15 units/kg/day 2
• Administer correction insulin for glucose >180 mg/dL 2

Monitoring and Adjustments

• For patients eating: Check blood glucose before meals 2
• For patients not eating: Check blood glucose every 4-6 hours 2
• For IV insulin: Monitor every 30 minutes to 2 hours until stable 2
• Adjust insulin doses based on glycemic response and clinical status 1

Hypoglycemia Prevention and Management

• Implement a standardized hospital-wide hypoglycemia treatment protocol 2
• Promptly treat blood glucose <70 mg/dL 2
• Review and modify insulin regimen after any hypoglycemic episode 1
• Recognize that hypoglycemia is associated with increased mortality 2

Role of Non-Insulin Agents

While insulin is the preferred treatment for inpatient hyperglycemia, certain non-insulin agents may be considered in specific situations:

• DPP-4 inhibitors (e.g., sitagliptin): May be used alone or with basal insulin in patients with mild-to-moderate hyperglycemia 2
• Metformin: Generally discontinued in hospitalized patients due to risk of lactic acidosis in patients with acute heart failure, renal or liver failure 2
• Thiazolidinediones: Avoid due to risk of precipitating or worsening heart failure and peripheral edema 2
• SGLT2 inhibitors: Should be avoided in the inpatient setting 1

Transition of Care and Discharge Planning

• For patients with HbA1c >10%, discharge on basal-bolus regimen or combination of pre-admission oral agents plus 80% of hospital basal insulin dose 2
• For patients with HbA1c between 8-10%, discharge on oral agents plus basal insulin at 50% of hospital dose 2
• For patients with HbA1c <7.5-8%, consider returning to pre-hospitalization regimen 2
• Schedule follow-up within 1 month of discharge 1

Common Pitfalls to Avoid

• Using sliding scale insulin as the sole treatment strategy 2, 1
• Premature discontinuation of insulin therapy 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, 3

By implementing these evidence-based strategies for inpatient hyperglycemia management, healthcare providers can improve glycemic control, reduce complications, and potentially improve patient outcomes.