How to manage hyperglycemia in the ward?

Management of Elevated Blood Glucose in the Ward

For non-critically ill hospitalized patients with hyperglycemia, implement a scheduled basal-bolus insulin regimen with basal insulin (glargine or detemir), prandial rapid-acting insulin (lispro, aspart, or glulisine) before meals, and correction doses—targeting blood glucose 100-180 mg/dL, while avoiding sliding scale insulin alone. 1

Initial Assessment and Monitoring

Who Requires Blood Glucose Monitoring

• All patients with known diabetes 1
• Patients with admission blood glucose >140 mg/dL (7.8 mmol/L) 1
• Patients receiving glucocorticoid therapy 1

Monitoring Frequency

• For patients eating: Check blood glucose before each meal and at bedtime 1
• For patients NPO (nothing by mouth): Check every 4-6 hours 1, 2
• Consider continuous glucose monitoring (CGM) in stable patients already familiar with the technology 1

Blood Glucose Targets

Non-Critically Ill Patients

• Upper limit: <180 mg/dL (10.0 mmol/L) 1
• Lower limit: 100-140 mg/dL 1
  • Five high-quality guidelines recommend 100 mg/dL as the lower target 1
  • Three guidelines recommend 140 mg/dL as the lower target 1
• Pre-meal targets should be <140 mg/dL (7.8 mmol/L) 1

Critically Ill Patients

• Start insulin infusion when blood glucose ≥150-180 mg/dL 1, 3
• Maintain glucose 140-180 mg/dL (7.8-10.0 mmol/L) 1, 3
• Avoid targets <110 mg/dL due to increased mortality risk 1

Insulin Regimen Selection

For Patients with Good Oral Intake

Basal-bolus insulin regimen is the gold standard 1, 2:

• Basal insulin: Glargine or detemir once daily at 0.2-0.25 units/kg 2, 3
• Prandial insulin: Lispro, aspart, or glulisine before each meal at 0.1-0.15 units/kg divided into three doses 2, 3
• Correction insulin: Rapid-acting insulin for blood glucose >180 mg/dL 1, 2
  • Use 2 units for glucose >250 mg/dL 2
  • Use 4 units for glucose >350 mg/dL 2

For Patients with Poor or No Oral Intake

• Single dose of long-acting basal insulin plus correction insulin 1, 4
• Basal insulin at 0.2-0.25 units/kg once daily 2, 3
• Correction doses every 4-6 hours as needed 1, 2

For Critically Ill Patients

• Continuous intravenous insulin infusion is the preferred method 1, 3
• Use validated written or computerized protocols for dose adjustments 1, 3
• Monitor blood glucose every 30 minutes to 2 hours 1, 3

What NOT to Do: Critical Pitfalls

Sliding Scale Insulin Alone is Strongly Discouraged

• Never use sliding scale insulin (SSI) as the sole treatment 1, 2
• SSI leads to poor glycemic control and increased complications 1, 2
• SSI is reactive rather than proactive, resulting in glucose variability 2, 5

Medications to Avoid in Hospital

• SGLT2 inhibitors: Should be avoided due to DKA risk 1
• Sulfonylureas: Withhold to prevent hypoglycemia in patients with limited intake 1, 6
• Premixed insulin: Not routinely recommended due to increased hypoglycemia risk 2

Continuation of Home Medications

When to Continue Outpatient Regimens

• Stable patients eating regularly may continue home oral medications or insulin 1
• Patients with well-controlled diabetes (stable renal/hepatic function, no acute illness) 1
• DPP-4 inhibitors can be continued with correction insulin 1

When to Hold Home Medications

• Metformin: Hold if worsening renal function or contrast imaging planned 6
• Thiazolidinediones: Consider stopping in patients with cardiovascular conditions to avoid heart failure 6
• Sulfonylureas: Hold in patients with limited caloric intake 1, 6

Hypoglycemia Management

Definition and Recognition

• Moderate hypoglycemia: Blood glucose <70 mg/dL 1
• Severe hypoglycemia: Blood glucose <54 mg/dL or requiring assistance 1

Treatment Protocol

• For conscious patients: Oral carbohydrate or glucose 1
• For NPO patients: Intravenous glucose 1
• For patients without IV access: Intranasal or subcutaneous glucagon 1

Post-Hypoglycemia Management

• Review and modify insulin regimen after hypoglycemic episodes 1
• Reduce or avoid sulfonylureas and insulin doses 1
• Monitor blood glucose more frequently 1, 7

Specialist Consultation

Consult diabetes specialists or inpatient glucose management teams for 1:

• Complex hyperglycemia management
• Recurrent hypoglycemia
• Patients requiring intensive insulin therapy
• Transition planning for complex cases

Transition of Care at Discharge

Timing and Follow-up

• Return to home regimens 1-2 days before discharge 1
• Schedule outpatient follow-up within 1 week to 1 month 1
• Follow-up through primary care or diabetes specialist 1

Discharge Planning

• Adjust outpatient regimens based on HbA1c and inpatient glucose control 1
• Provide diabetes self-management education 3
• Consider maintaining insulin therapy long-term for patients with HbA1c >10% 3

Severe Hyperglycemia (>300-500 mg/dL)

Initial Management

• Evaluate for diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) 3, 7
• Check for mental status changes, dehydration, fruity breath, abdominal pain 3, 7
• Obtain complete metabolic panel, serum ketones, arterial blood gas 3

Treatment Approach

• Initiate IV fluid resuscitation with 0.9% sodium chloride 3, 7
• Start continuous IV insulin infusion targeting 140-180 mg/dL 3, 7
• Monitor blood glucose every 1-2 hours initially 3, 7
• Transition to subcutaneous insulin at 60-80% of daily IV dose when stable 7

Common Clinical Scenarios

Patient on Glucocorticoids

• Initiate blood glucose monitoring even without prior diabetes 1
• Expect increased insulin requirements 8
• Use basal-bolus regimen with higher correction doses 2

Patient with Variable Oral Intake

• Administer prandial insulin after meals to match carbohydrate consumption 7
• Use basal insulin plus correction doses 2, 4
• Monitor more frequently for hypoglycemia 7

Postoperative Patient

• Use IV insulin infusion during and immediately after surgery 5
• Transition to subcutaneous basal-bolus regimen in post-operative period 5
• Target glucose <180 mg/dL 5