What is the appropriate care for a diabetic patient who is Nil Per Os (NPO) in the hospital?

From the Guidelines

When caring for a diabetic patient who is NPO (nothing by mouth) in the hospital, blood glucose monitoring should be performed every 4-6 hours, with more frequent checks if values are unstable, and a basal plus correction insulin regimen is the preferred treatment, as stated in the 2016 American Diabetes Association standards of medical care in diabetes 1.

Key Considerations

• Long-acting insulin (such as insulin glargine or detemir) should generally be continued at 80-100% of the patient's home dose to maintain basal coverage.
• Oral hypoglycemic medications should be held while the patient is NPO.
• For glucose management, an intravenous insulin infusion is preferred for critically ill patients, typically starting at 0.05-0.1 units/kg/hour and titrated according to hospital protocol, as recommended by the American Diabetes Association 1.
• For non-critically ill patients, subcutaneous insulin using a basal-bolus correction approach is appropriate, with correction insulin (such as insulin lispro, aspart, or regular) administered every 4-6 hours based on blood glucose readings.

Insulin Regimen

• A basal plus correction insulin regimen is the preferred treatment for patients with poor oral intake or who are NPO, as stated in the 2016 American Diabetes Association standards of medical care in diabetes 1.
• The sole use of sliding-scale insulin in the inpatient hospital setting is strongly discouraged, as it may lead to hyperglycemia and increased morbidity 1.

Hypoglycemia Treatment

• Hypoglycemia treatment should be readily available, using IV dextrose 50% (25-50 mL) or glucagon 1 mg IM/SC if glucose falls below 70 mg/dL, as recommended by the American Diabetes Association 1.
• A standardized hospital-wide and nurse-initiated hypoglycemia treatment protocol should be in place to immediately address hypoglycemia, as stated in the 2016 American Diabetes Association standards of medical care in diabetes 1.

Glycemic Targets

• Inpatient glucose targets of 7.8 to 10 mmol/L (140 to 180 mg/dL) are recommended for most noncritical and critically ill patients, as stated in the 2016 American Diabetes Association standards of medical care in diabetes 1.
• However, glucose targets of 6.1 to 7.8 mmol/L (110 to 140 mg/dL) may be appropriate for some patients, such as cardiac surgery patients or those with acute ischemic cardiac or neurologic events, if the targets can be achieved without significant hypoglycemia, as recommended by the American Diabetes Association 1.

From the FDA Drug Label

Medication Insulin requirements may be increased if you are taking other drugs with blood-glucose-raising activity... Hypoglycemia (too little glucose in the blood) is one of the most frequent adverse events experienced by insulin users. It can be brought about by: Missing or delaying meals. Hyperglycemia (too much glucose in the blood) may develop if your body has too little insulin

The appropriate care for a diabetic patient who is Nil Per Os (NPO) in the hospital is not directly addressed in the provided drug label. However, it can be inferred that blood glucose monitoring and adjustment of insulin regimen may be necessary to prevent hypoglycemia or hyperglycemia.

• Key considerations for a diabetic patient who is NPO include:
  • Monitoring blood glucose levels frequently
  • Adjusting insulin doses as needed to prevent hypoglycemia or hyperglycemia
  • Providing alternative sources of glucose if the patient is unable to eat However, the exact approach to care would depend on individual patient factors and clinical judgment. 2

From the Research

Appropriate Care for Diabetic Patients who are NPO in the Hospital

• Diabetic patients who are Nil Per Os (NPO) in the hospital require careful management of their blood glucose levels to prevent hyperglycemia and hypoglycemia 3, 4, 5.
• The American Diabetes Association and the American College of Endocrinology have developed guidelines for optimal control of hyperglycemia in hospitalized patients, targeting critically ill patients 3.
• Conventional blood glucose values of 140-180 mg/dL are considered desirable and safely achievable in most patients, while more aggressive control to <110 mg/dL remains controversial but has shown benefits in certain patients 3, 4, 5.

Insulin Therapy for NPO Diabetic Patients

• Insulin therapy is the most appropriate method for controlling glycemia in hospital, but is associated with increased risk of hypoglycemia 4, 5.
• Continuous intravenous insulin infusion is the best method for achieving glycemic targets in critically ill patients, while scheduled basal-bolus-correction insulin is preferred for non-critically ill patients 4, 5.
• Modern insulin analogs offer advantages over older human insulins, with a lower propensity for inducing hypoglycemia 4.

Glucose Monitoring and Target Levels

• Frequent and effective glucose monitoring is critical for avoiding wide deviations from acceptable glucose levels, with targets ranging between 140 mg/dL and 180 mg/dL 4, 6.
• Glucose targets near 140 mg/dL are recommended as being the most appropriate for all hospitalized patients, while extremes of blood glucose lead to poor outcomes 4, 5.
• A target glucose range of 110-180 mg/dL may be appropriate for most critically ill patients and non-critically ill patients 5.

Special Considerations for NPO Diabetic Patients

• Infection is a common precipitating condition for hyperglycemic crisis in diabetic patients, and individualized insulin dosing is necessary to achieve optimal glycemic control 7.
• Intravenous insulin dosing should be based on the patient's condition, as well as their blood glucose levels, to minimize the risk of hypoglycemia 7.