Treatment of Hyperglycemia in Hospitalized Patients
For hospitalized patients with hyperglycemia, initiate insulin therapy when blood glucose persistently exceeds 180 mg/dL on two separate measurements within 24 hours, targeting a glucose range of 140-180 mg/dL for most patients. 1
Glycemic Targets
Non-Critically Ill Patients
- Start insulin therapy at a threshold of ≥180 mg/dL confirmed on two occasions within 24 hours 1, 2
- Target glucose range: 140-180 mg/dL (7.8-10.0 mmol/L) for the majority of patients 1
- Some guidelines suggest a lower limit of 100 mg/dL, while others recommend 140 mg/dL as the lower target 1
Critically Ill (ICU) Patients
- Target glucose range: 140-180 mg/dL (7.8-10.0 mmol/L) for most critically ill patients 1, 2
- More stringent targets of 110-140 mg/dL (6.1-7.8 mmol/L) may be appropriate for select patients (e.g., post-cardiac surgery) only if achievable without significant hypoglycemia 1, 2
- Avoid targets <140 mg/dL in most ICU patients due to 10- to 15-fold increased hypoglycemia rates and higher mortality demonstrated in the NICE-SUGAR trial 1, 3
Insulin Regimens
For Patients with Good Nutritional Intake
- Basal-bolus regimen is preferred: scheduled basal insulin + prandial insulin + correction doses 1, 2, 4
- All major guidelines (AACE, ADA, ADS, DC, IDF, JBDS-IP, JDC, SHM) recommend this as routine treatment for non-critically ill patients 1
- Starting dose for insulin-naive patients: 0.3-0.5 U/kg total daily dose, with half as basal and half divided before meals 2
For Patients with Poor or No Oral Intake
- Basal insulin plus correction insulin is the preferred approach 2, 4
- Avoid full basal-bolus regimens in patients not eating to reduce hypoglycemia risk 2
For Patients with Mild Hyperglycemia
- For blood glucose <200 mg/dL, consider basal-plus approach with corrective doses rather than full basal-bolus to minimize hypoglycemia 2
High-Risk Patients
- Use lower starting doses (0.1-0.25 U/kg) for elderly patients (>65 years), those with renal failure, or poor oral intake 2
Critical Pitfalls to Avoid
Sliding Scale Insulin Alone
- Avoid sliding scale insulin as monotherapy - it is specifically contraindicated by multiple guidelines (ADA, ADS, DC, IDF) 1
- Sliding scale insulin alone is associated with 20 mg/dL higher mean glucose levels compared to scheduled insulin regimens 5
SGLT2 Inhibitors
- Avoid SGLT2 inhibitors in hospitalized patients due to increased risk of diabetic ketoacidosis 1
- Must be discontinued 3-4 days before surgery 1
Overly Aggressive Targets
- Do not target glucose <110 mg/dL in most hospitalized patients - this increases mortality without benefit 1, 3
Glucose Monitoring
Frequency
- Before meals for patients who are eating 1
- Every 4-6 hours for patients not eating 1, 2
- Every 30 minutes to 2 hours for patients on intravenous insulin 1
Hypoglycemia Prevention
- Reassess insulin regimen when glucose falls below 100 mg/dL, as this predicts hypoglycemia within 24 hours 2
- Modify regimen when glucose <70 mg/dL unless easily explained by missed meals 2
Alternative Therapies for Stable Patients
When to Consider Non-Insulin Agents
- Stable patients eating regularly with blood glucose <180 mg/dL on admission may continue home oral medications 1
- Options include: continuation of oral antihyperglycemic medications, DPP-4 inhibitors with correction insulin, or premixed insulin 1
- Metformin should be held on the day of surgery 1
Specialist Consultation
- Eight guidelines recommend consulting diabetes specialists for inpatient hyperglycemia management 1
- Consider consultation for complex cases, recurrent hypoglycemia, or difficulty achieving glycemic targets 1