Is it advisable to cease Gliclazide (a sulfonylurea) and initiate insulin therapy via a sliding scale (subcutaneous insulin) regimen to control blood glucose levels (BGL) in a hospitalized patient?

Management of Hospitalized Patient with Diabetes: Transitioning from Gliclazide to Insulin

Yes, it is advisable to cease Gliclazide and initiate insulin therapy via a sliding scale regimen to control blood glucose levels in a hospitalized patient. 1, 2

Rationale for Discontinuing Sulfonylureas in Hospital

• Oral antihyperglycemic medications, including sulfonylureas like Gliclazide, should generally be held during hospitalization according to American Diabetes Association guidelines 2
• Sulfonylureas carry an unacceptably high risk of iatrogenic hypoglycemia in the hospital setting, especially when combined with changes in nutritional status and other acute illness factors 1
• Unpredictable absorption and effect during acute illness, as well as potential drug interactions with other medications administered during hospitalization, are concerns with oral hypoglycemic agents 2

Recommended Inpatient Insulin Regimen

• For most hospitalized patients, insulin therapy is the preferred method for glycemic control 1
• A basal plus correction insulin regimen is the preferred treatment for noncritically ill hospitalized patients with poor oral intake or those who are taking nothing by mouth (NPO) 1
• An insulin regimen with basal, prandial, and correction components is the preferred treatment for noncritically ill hospitalized patients with good nutritional intake 1

Implementation of Insulin Therapy

• When transitioning from oral agents to insulin, start with a basal insulin dose of 0.2-0.3 units/kg/day for patients with moderate hyperglycemia (BG 201-300 mg/dL) 1
• For patients with severe hyperglycemia (BG >300 mg/dL), a basal-bolus regimen is recommended, starting at 0.3 units/kg/day (with half as basal and half as bolus) 1
• Sliding scale insulin alone (without basal insulin) is strongly discouraged as the sole method of insulin treatment in hospitalized patients 1

Blood Glucose Targets and Monitoring

• Target blood glucose range of 140-180 mg/dL (7.8-10.0 mmol/L) is recommended for most hospitalized patients 1, 3
• Point-of-care glucose testing should be performed before meals for patients who are eating, or every 4-6 hours for patients who are not eating 1
• Consider reassessing the insulin regimen if blood glucose levels fall below 100 mg/dL (5.6 mmol/L) to avoid hypoglycemia 1

Hypoglycemia Prevention

• A standardized hospital-wide, nurse-initiated hypoglycemia treatment protocol should be in place to immediately address blood glucose levels <70 mg/dL (3.9 mmol/L) 1
• The risk of hypoglycemia with basal-bolus insulin is about 4-6 times higher than with sliding scale insulin therapy alone, requiring careful monitoring 1
• Premixed insulin formulations (e.g., 70/30 NPH/regular insulin) should be avoided due to significantly increased hypoglycemia risk compared to basal-bolus therapy 1

Transitioning Back to Oral Medications

• If oral medications are held in the hospital, there should be a protocol for resuming them 1–2 days before discharge 1, 2
• For patients who had good glycemic control on oral agents before admission and have recovered from their acute illness, transitioning back to their home regimen before discharge is appropriate 2

Special Considerations

• For patients with type 1 diabetes, an insulin regimen with basal and correction components is necessary at all times, with the addition of prandial insulin if the patient is eating 1
• Recent research suggests that some non-insulin agents (particularly DPP-4 inhibitors) may be safe in specific hospitalized patient populations, but insulin remains the standard of care 1

By following these guidelines, you can safely transition your hospitalized patient from Gliclazide to an appropriate insulin regimen, minimizing the risks of both hyperglycemia and hypoglycemia while in the hospital.