What is the recommended glycemic target range and management strategy for hospitalized patients with hyperglycemia?

Glycemic Target Range and Management Strategy for Hospitalized Patients with Hyperglycemia

Recommended Glycemic Targets

For hospitalized patients with hyperglycemia, insulin therapy should be initiated when blood glucose exceeds 180 mg/dL (10.0 mmol/L), with a target glucose range of 140-180 mg/dL (7.8-10.0 mmol/L) for both critically ill and non-critically ill patients. 1, 2

This target range is supported by multiple guidelines:

• The American Diabetes Association (ADA) Standards of Medical Care 1
• The American College of Physicians clinical guidelines 3
• International consensus statements from multiple organizations 1, 2

More stringent targets (110-140 mg/dL or 6.1-7.8 mmol/L) may be appropriate for selected patients but only if achievable without significant hypoglycemia 1.

Management Strategy Algorithm

1. Initial Assessment

• Evaluate for hyperglycemic crisis (DKA or HHS)
• Assess mental status, dehydration signs, vital signs
• Check blood glucose, electrolytes, BUN, creatinine, venous blood gases
• Identify potential precipitating factors (infection, MI, stroke) 2

2. Treatment Based on Clinical Setting

For Critically Ill Patients:

• Use continuous IV insulin infusion 1, 2
• Monitor blood glucose hourly until stable, then every 2 hours
• Adjust insulin doses based on validated protocols 1

For Non-Critically Ill Patients:

• Implement basal-bolus insulin regimen (NOT sliding scale alone) 2, 4
• Distribution: 50% basal insulin + 50% prandial insulin 2
• Preferred insulins:
  • Basal component: Long-acting analogs (glargine, detemir)
  • Prandial/correction: Rapid-acting analogs (aspart, lispro, glulisine) 2, 4
• Monitor pre-meal and bedtime glucose levels

3. Nutritional Considerations

• For patients on enteral nutrition (EN):

  • Target glucose range: 140-180 mg/dL 5
  • Consider diabetes-specific EN formulas 5
  • Synchronize insulin dosing with feeding schedule 2

• For patients on parenteral nutrition (PN):

  • Consider lower dextrose content in PN formulations
  • Target glucose range: 140-180 mg/dL 5

4. Monitoring and Adjustment

• Check glucose before meals and at bedtime for patients who are eating
• For NPO patients, monitor every 4-6 hours 1
• Adjust insulin doses every 2-3 days based on glucose patterns 2
• Modify insulin regimen if glucose falls below 100 mg/dL 2

Special Considerations

Hypoglycemia Prevention

• Hypoglycemia is an independent risk factor for poor outcomes 6
• Implement hypoglycemia protocols and treatment algorithms 6
• Use modern insulin analogs which have lower risk of hypoglycemia than human insulins 4

Transition from IV to Subcutaneous Insulin

• Ensure overlap between IV insulin discontinuation and first subcutaneous dose 2
• Calculate 24-hour insulin requirements from IV infusion to guide subcutaneous dosing

Discharge Planning

• Begin discharge planning at admission 2
• Provide clear written and oral instructions on insulin dosing
• Schedule follow-up appointment within 1 month 2

Common Pitfalls to Avoid

1. Using sliding-scale insulin alone - This approach is ineffective and should be avoided; always include basal insulin 4

2. Overly aggressive glucose targets - Earlier recommendations for tight control (80-110 mg/dL) have been revised due to hypoglycemia risk 7, 3

3. Abrupt discontinuation of IV insulin without proper transition to subcutaneous regimen 2

4. Completely discontinuing basal insulin - This increases risk of ketoacidosis 2

5. Failing to identify and treat underlying causes of hyperglycemia 2

6. Inadequate monitoring - Frequent glucose monitoring is essential for safe and effective glycemic management 2

The evidence clearly supports a target glucose range of 140-180 mg/dL for most hospitalized patients with hyperglycemia, using structured insulin protocols tailored to the clinical setting and nutritional status.