How to manage fluctuating hypoglycemia and hyperglycemia in a patient?

Management of Fluctuating Hypoglycemia and Hyperglycemia in Hospitalized Patients

Basal-bolus insulin therapy with scheduled insulin (basal, prandial, and correction) is the recommended approach for managing fluctuating blood glucose levels in hospitalized patients, with a target glucose range of 140-180 mg/dL. 1

Blood Glucose Targets and Monitoring

Target Glucose Ranges

• Non-critically ill inpatients: 140-180 mg/dL (upper limit) 1
• Lower limit: 100-140 mg/dL (varies by guideline) 1
• More stringent targets (110-140 mg/dL) may be appropriate for select patients with cardiac or neurological events, if achievable without significant hypoglycemia 2

Monitoring Frequency

• Monitor blood glucose at meals and bedtime 1
• Individualize monitoring frequency based on clinical status
• Consider continuous glucose monitoring (CGM) for stable patients familiar with the technology 1
  • CGM provides comprehensive glucose profiles and can help detect hypoglycemia/hyperglycemia trends 3, 4
  • However, CGM accuracy may be affected by acute physiological disturbances (hypoxemia, vasoconstriction, dehydration) 1

Treatment Algorithm for Glycemic Management

Step 1: Assess Patient Risk Factors

• Evaluate history of hypoglycemia/hyperglycemia
• Check renal and hepatic function
• Review current medications (especially steroids)
• Determine pre-admission diabetes regimen

Step 2: Select Appropriate Insulin Regimen

For Most Non-Critically Ill Patients:

• Basal-bolus insulin regimen (basal, prandial, correction insulin) 1
  • Basal: Long-acting insulin (e.g., detemir) - typically 0.2-0.3 units/kg/day 1, 5
  • Prandial: Rapid-acting insulin before meals - typically 0.05-0.1 units/kg/meal 1, 6
  • Correction: Additional rapid-acting insulin based on pre-meal glucose levels

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

• Consider low-dose basal insulin (0.1-0.2 units/kg/day) with correction insulin 1
• DPP-4 inhibitors may be added for patients with mild hyperglycemia 1

For Patients with Severe Hyperglycemia (>300 mg/dL):

• More aggressive basal-bolus regimen with higher insulin doses 1

Step 3: Adjust Treatment Based on Response

• Review blood glucose patterns daily
• Adjust basal and bolus insulin doses separately based on patterns:
  • For fasting hyperglycemia: Increase basal insulin by 10-20%
  • For post-meal hyperglycemia: Increase prandial insulin by 10-20%
  • For hypoglycemia: Reduce corresponding insulin doses by 20-40%

Management of Hypoglycemia (<70 mg/dL)

1. Immediate treatment:

   • For conscious patients: Administer 15-20g of rapid-acting glucose 1
   • For unconscious patients or those NPO: IV glucose (D50W 25-50 mL) or glucagon 1
   • Recheck blood glucose after 15 minutes; repeat treatment if still <70 mg/dL 1

2. Post-hypoglycemia management:

   • Review and modify insulin regimen after hypoglycemic episodes 1
   • Reduce or avoid medications with increased hypoglycemia risk (sulfonylureas, insulin) 1
   • For recurrent hypoglycemia, consider raising glycemic targets temporarily 1
   • For hypoglycemia unawareness, implement a 2-3 week period of strict hypoglycemia avoidance 7

Special Considerations

Technology Use

• Insulin pumps may be continued in appropriate hospitalized patients with proper support 1
  • Requires hospital policies, inpatient diabetes management teams, and patient agreement
  • Alternative: Switch to basal-bolus insulin therapy using 24-hour total basal dose from pump settings

Nutrition Considerations

• Implement consistent carbohydrate meal plan 2
• Synchronize insulin dosing with nutrition delivery schedule 2
• Consider diabetes-specific enteral formulas if on tube feeding 2

Consultation and Follow-up

• Consider consulting diabetes specialists for inpatient management 1
• Begin discharge planning at admission 2
• Schedule follow-up appointment within 1 month of discharge 2

Common Pitfalls and How to Avoid Them

1. Relying solely on sliding scale insulin:

   • Avoid using sliding scale insulin alone, as it's reactive rather than preventative 1
   • Always combine with scheduled basal insulin

2. Failing to adjust for changing insulin requirements:

   • Reassess insulin needs with changes in clinical status, steroid doses, or nutrition
   • Monitor for insulin resistance during acute illness

3. Overlooking hypoglycemia risk factors:

   • Be vigilant with patients who have renal impairment, liver disease, or are elderly 5
   • Adjust insulin doses in patients with impaired awareness of hypoglycemia 7

4. Medication errors:

   • Avoid SGLT2 inhibitors in hospitalized patients due to risk of euglycemic diabetic ketoacidosis 1
   • Be cautious with sulfonylureas due to hypoglycemia risk 1

5. Inadequate monitoring during high-risk periods:

   • Increase monitoring frequency during medication changes, NPO status, or procedure recovery
   • Set appropriate alerts for CGM if used 1, 8

By following this structured approach to managing fluctuating blood glucose levels in hospitalized patients, you can reduce the risk of both hypoglycemia and hyperglycemia while optimizing patient outcomes.