How to manage hyperglycemia in hospitalized patients already on insulin?

Management of Persistent Hyperglycemia in Hospitalized Patients Already on Insulin

For hospitalized patients already on insulin with persistent hyperglycemia (≥180 mg/dL on two occasions), you must intensify the insulin regimen by increasing the total daily dose by 10-20% and ensure proper distribution across basal, prandial, and correction components rather than relying on sliding scale alone. 1, 2

Initial Assessment and Insulin Regimen Optimization

Verify Current Insulin Strategy

• Immediately discontinue sliding scale insulin (SSI) as the sole method if this is what the patient is receiving - SSI is strongly discouraged and ineffective for managing persistent hyperglycemia 1
• Assess whether the patient has a proper basal-bolus regimen or only correction doses 1, 3

Determine Nutritional Status and Appropriate Regimen

For patients with good oral intake:

• Implement or optimize a basal-bolus-correction regimen with scheduled insulin that delivers all three components 1, 3
• Distribute total daily dose (TDD) as approximately 50% basal insulin and 50% divided among three prandial doses 2

For patients with poor or no oral intake (NPO):

• Use basal plus correction insulin regimen rather than full basal-bolus to reduce hypoglycemia risk 1, 3
• Avoid prandial insulin when nutritional intake is unreliable 1, 3

Insulin Dose Adjustment Strategy

Calculate and Increase Total Daily Dose

• If patient is already on insulin with persistent hyperglycemia, increase TDD by 10-20% 2
• For insulin-naive patients being started, use 0.3-0.5 units/kg/day as initial TDD 2
• Use lower doses (0.1-0.25 units/kg) for high-risk patients: elderly (>65 years), renal failure, or poor oral intake 2

Redistribute the Increased Dose Appropriately

• Split the new TDD: 50% as basal insulin (given once or twice daily depending on insulin type) 2
• Remaining 50% divided equally before three meals as prandial insulin (if eating well) 2
• Add correction doses on top of scheduled insulin, not as replacement 1, 3

Target Glucose Ranges

Standard Targets for Most Patients

• Initiate insulin therapy when glucose persistently ≥180 mg/dL on two separate measurements 1, 3, 2
• Target range: 140-180 mg/dL for both critically ill and noncritically ill patients 1, 3, 2
• Premeal glucose should be <140 mg/dL and random glucose <180 mg/dL 1, 3

More Stringent Targets (Select Patients Only)

• Consider 110-140 mg/dL for post-cardiac surgery patients or those with prior tight outpatient control, only if achievable without significant hypoglycemia 1, 2

Liberalized Targets (High-Risk Patients)

• Accept 180-250 mg/dL in patients with severe comorbidities or where frequent monitoring is not feasible 1
• Even higher targets (>250 mg/dL) may be acceptable in terminally ill patients with short life expectancy 1

Critical Care vs. Non-Critical Care Settings

Critical Care (ICU) Patients

• Use continuous intravenous insulin infusion as the most effective method 1, 3, 2
• Administer via validated written or computerized protocols allowing predefined rate adjustments 1
• Monitor glucose every 30 minutes to 2 hours during IV insulin infusion 1, 3

Non-Critical Care Patients

• Use subcutaneous scheduled insulin regimens (basal-bolus or basal-plus) 1, 3
• Monitor glucose before meals if eating, or every 4-6 hours if NPO 1, 3

Identifying and Addressing Contributing Factors

Medication-Induced Hyperglycemia

• Assess for glucocorticoids, octreotide, or other hyperglycemia-inducing medications and anticipate need for higher insulin doses 1
• Consider temporary discontinuation of home oral agents that may be contraindicated (metformin in sepsis, renal failure) 3

Nutritional Changes

• Adjust insulin when transitioning between oral intake, enteral nutrition, parenteral nutrition, or NPO status 1
• Reduce or hold prandial insulin if meals are missed or intake is poor 1

Hypoglycemia Prevention During Intensification

Monitoring Thresholds

• Reassess the insulin regimen when glucose falls below 100 mg/dL as this predicts hypoglycemia within 24 hours 1, 2
• Modify the regimen when glucose <70 mg/dL unless easily explained by missed meals 1, 2

Risk Mitigation

• Implement a hospital-wide hypoglycemia protocol 3, 2
• Increase monitoring frequency when intensifying insulin therapy 1
• Document and track all hypoglycemic episodes for quality improvement 3

Common Pitfalls to Avoid

• Never rely on sliding scale insulin alone - it is reactive rather than proactive and strongly discouraged 1
• Do not use overly aggressive targets (<110 mg/dL) - this increases mortality and severe hypoglycemia 10-15 fold 1
• Avoid continuing oral agents in unstable patients - insulin is preferred in most hospital situations 1, 3
• Do not forget to adjust insulin when transitioning off IV insulin - precautions are needed to prevent rebound hyperglycemia 1

Transition Planning

• If oral medications were held during hospitalization, resume them 1-2 days before discharge 1, 3
• Use admission HbA1c to guide discharge regimen: patients with HbA1c >10% should be discharged on basal-bolus insulin or combination therapy with 80% of hospital basal dose 3