What are the RSSDI (Research Society for the Study of Diabetes in India) guidelines for managing inpatient hyperglycemia in adult patients?

RSSDI Guidelines for Inpatient Hyperglycemia

I was unable to locate specific RSSDI (Research Society for the Study of Diabetes in India) guidelines in the provided evidence. However, I can provide you with the current international consensus recommendations that would apply to inpatient hyperglycemia management, which RSSDI guidelines would likely align with given the global standardization of inpatient diabetes care.

Blood Glucose Monitoring Indications

Monitor blood glucose in all hospitalized patients with known diabetes and those with admission hyperglycemia (random glucose >140 mg/dL). 1

• Initiate monitoring for patients on glucocorticoid therapy regardless of diabetes history 1
• Check admission HbA1c ≥6.5% to determine if diabetes preceded hospitalization 1

Blood Glucose Targets

Target blood glucose of 140-180 mg/dL for non-critically ill inpatients, with insulin initiation when glucose persistently exceeds 180 mg/dL. 1, 2

• Five major guidelines recommend a lower limit of 100 mg/dL, while three recommend 140 mg/dL 1
• Avoid targets below 110 mg/dL due to 10-15 fold increased hypoglycemia risk without mortality benefit 1, 2, 3
• For critically ill ICU patients, the same 140-180 mg/dL target applies 2, 4

Monitoring Frequency

Check blood glucose before meals (3 times daily) and at bedtime for patients eating regular meals. 1, 4

• For NPO or irregular intake patients, monitor every 4-6 hours 4
• Consider continuous glucose monitoring (CGM) only in stable patients already familiar with the technology in the outpatient setting 1

Insulin Regimen Selection

For Non-Critically Ill Patients with Good Oral Intake

Use basal-bolus insulin regimen with three components: basal insulin (glargine or detemir once daily), prandial insulin (rapid-acting analog before meals), and correction insulin. 1, 5, 6

• Rapid-acting analogs (aspart, lispro, glulisine) are preferred over regular insulin for prandial coverage 5
• Never use sliding scale insulin alone—this approach is strongly discouraged and associated with poor outcomes 1, 2, 3, 7

For Non-Critically Ill Patients with Poor or No Oral Intake

Use basal insulin alone (0.1-0.15 units/kg/day) plus correction insulin for glucose >180 mg/dL. 1, 2, 6

• Single daily dose of long-acting basal insulin is preferred 6
• Add correction doses with rapid-acting insulin as needed 2, 6

For Critically Ill ICU Patients

Use continuous intravenous insulin infusion as the preferred method. 2, 7, 8, 5

• IV insulin's short half-life (<15 minutes) allows rapid dose adjustments 2
• Avoid subcutaneous insulin in ICU patients, especially during hypotension or shock, due to unreliable absorption 2
• Achieve target glucose within 4-8 hours of starting IV insulin 2

Medications to Continue or Avoid

May Continue in Stable Patients

Consider continuing home oral antidiabetic medications or insulin regimens in stable patients eating regularly with well-controlled diabetes. 1

• DPP-4 inhibitors with correction insulin are acceptable alternatives 1
• Resume oral medications 1-2 days before discharge if held during hospitalization 1

Medications to Avoid

Discontinue SGLT2 inhibitors in all hospitalized patients. 1

• Avoid sliding scale insulin as monotherapy 1, 2, 3, 7
• Avoid premixed insulin (70/30) at discharge due to unacceptably high hypoglycemia rates 3

Hypoglycemia Management

Define moderate hypoglycemia as blood glucose <70 mg/dL and severe hypoglycemia as <54 mg/dL. 1

Treatment Protocol

• For conscious patients: administer oral carbohydrate or glucose 1
• For NPO patients: use intravenous glucose 1
• For patients without IV access: use intranasal or subcutaneous glucagon 1

Post-Hypoglycemia Actions

Reduce the responsible insulin component by 20-50% after any hypoglycemic episode. 1, 3

• Review and modify treatment regimens after hypoglycemia occurs 1
• Avoid or reduce sulfonylureas and excessive insulin doses 1

Diabetes Specialist Consultation

Consult inpatient diabetes specialist teams or endocrinologists for complex hyperglycemia management. 1

• Eight of ten major guidelines recommend specialist consultation 1
• Consider consultation for recurrent hypoglycemia, wide glucose excursions, or difficulty achieving targets 4

Transitions of Care

Arrange outpatient follow-up within 1 week to 1 month of discharge. 1

• Follow-up through primary care or diabetes specialist/endocrinologist 1
• Return to home regimens from the day prior to discharge to the day after discharge 1
• Modify outpatient regimens based on admission HbA1c, inpatient glucose control, and new diagnoses 1
• Provide oral and written instructions regarding insulin timing, dosing, and basic home management skills 1

Special Populations: Elderly and Frail Patients

Maintain the same 140-180 mg/dL target but with heightened vigilance for hypoglycemia prevention. 1, 2, 4

• Elderly patients have impaired hypoglycemia awareness and counterregulatory responses 1, 2, 4
• Risk factors include renal failure, malnutrition, malignancies, dementia, and frailty 1, 2, 4
• Start with reduced total daily insulin dose of 0.1-0.15 units/kg/day 2

Critical Safety Parameters

Blood glucose ≤70 mg/dL requires immediate treatment and provider notification. 4

• Glucose 70-100 mg/dL indicates increased hypoglycemia risk requiring closer monitoring 4
• Glucose >250 mg/dL within 24 hours or >300 mg/dL over 2 consecutive days requires urgent intervention 4
• Ensure potassium ≥4.0 mEq/L before starting insulin therapy 3

Common Pitfalls to Avoid

• Never pursue glucose targets <110 mg/dL—associated with increased mortality 1, 2, 3
• Never use sliding scale insulin as sole therapy 1, 2, 3, 7
• Never use subcutaneous insulin in hemodynamically unstable ICU patients 2
• Do not discharge patients on premixed insulin due to high hypoglycemia risk 3
• Avoid aggressive glucose lowering in the emergency department for glucose <300 mg/dL 3