What are the recommended management strategies for an inpatient with type 2 diabetes mellitus (DM), considering their individual needs, medical history, and potential comorbidities such as cardiovascular disease (CVD)?

Inpatient Type 2 Diabetes Management

Insulin-Based Regimens: The Cornerstone of Inpatient Care

For most hospitalized patients with type 2 diabetes, temporary insulin therapy is the preferred approach, with basal-bolus regimens providing superior glycemic control compared to sliding scale insulin alone. 1

Glycemic Targets

• Target glucose 140-180 mg/dL in critically ill patients 1
• Target <140 mg/dL fasting and <180 mg/dL postprandial in stable patients 1
• Avoid targeting euglycemia (80-110 mg/dL) as this substantially increases hypoglycemia risk 1

Insulin Regimen Selection

Basal-bolus insulin regimen:

• Use for patients with moderate-to-severe hyperglycemia (glucose >200 mg/dL) 1
• Start with 0.1-0.25 U/kg/day of basal insulin plus correctional doses before meals 1
• Accept the 4-6 times higher hypoglycemia risk compared to sliding scale, but recognize superior glycemic control 1

Basal-plus approach (preferred for specific situations):

• Use for patients with mild hyperglycemia, decreased oral intake, or undergoing surgery 1
• Single daily basal insulin dose (0.1-0.25 U/kg/day) plus correctional insulin every 6 hours or before meals 1
• Lower hypoglycemia risk than full basal-bolus 1

Sliding scale insulin alone:

• Reserve only for patients without prior diabetes or those with excellent home control on oral agents 1
• May require addition of basal insulin if unable to maintain glucose <180 mg/dL 1

Avoid premixed insulin (70/30):

• Unacceptably high hypoglycemia rates in hospital settings 1

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Non-Insulin Medications: When to Continue or Discontinue

Metformin

Discontinue metformin in the following high-risk situations: 1

• eGFR <30 mL/min/1.73 m² (absolute contraindication) 1
• eGFR 30-45 mL/min/1.73 m² (reduce dose) 1
• Sepsis, hypoxia, or shock (risk of lactic acidosis) 1
• Acute kidney injury or liver failure 1
• Before iodinated contrast procedures if eGFR <60 mL/min/1.73 m² 1
• Acute heart failure 1

Monitor lactate levels in fragile patients on metformin and withdraw if elevated 1

Sulfonylureas

• Generally discontinue during hospitalization due to hypoglycemia risk 1
• Particularly problematic in patients with variable oral intake or acute illness 1

GLP-1 Receptor Agonists and SGLT2 Inhibitors

• Recent evidence supports continuation in stable patients with mild-to-moderate hyperglycemia 1
• Discontinue SGLT2 inhibitors in critically ill patients or those at risk for ketoacidosis 1
• Consider continuing in stable patients to maintain home regimen benefits 1

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Special Clinical Situations

Patients with Cardiovascular Disease

For patients with established atherosclerotic cardiovascular disease (ASCVD):

• Prioritize GLP-1 receptor agonists over insulin when transitioning from inpatient to outpatient care 1, 2
• Consider combination SGLT2 inhibitor + GLP-1 RA for additive cardiovascular and renal protection 2
• Tirzepatide demonstrates superior glycemic control and weight loss compared to other GLP-1 RAs 2

Patients with Chronic Kidney Disease

For eGFR <30 mL/min/1.73 m²:

• GLP-1 receptor agonists (including tirzepatide) preferred over SGLT2 inhibitors 2
• Adjust insulin doses carefully as renal clearance affects insulin metabolism 1

Perioperative Management

• Use basal-plus regimen (basal insulin + correctional doses) 1
• Hold oral agents on day of surgery 1
• Transition to IV insulin for major operations or metabolic decompensation 3

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Hypoglycemia Prevention Strategies

Critical prevention measures: 1

• Reduce insulin doses by 20-50% when adding GLP-1 RA or when patient becomes NPO 1, 2
• Reassess sulfonylureas and insulin doses when initiating tirzepatide 2
• Monitor for overbasalization: basal insulin >0.5 U/kg/day, high bedtime-morning glucose differential, or recurrent hypoglycemia 1
• Treat hypoglycemia with 15-20g rapid-acting glucose 4

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Discharge Planning and Transition

Medication reconciliation at discharge: 1

• Metformin remains first-line unless contraindicated 1
• Add GLP-1 RA (preferably tirzepatide) or SGLT2 inhibitor based on comorbidities 1, 2
• For patients with ASCVD or high cardiovascular risk, prioritize GLP-1 RA with proven cardiovascular benefit 1, 2
• Avoid delaying treatment intensification if targets not met 1

Patient education priorities: 4

• Hypoglycemia recognition and treatment 4
• Medication administration technique 4
• Blood glucose monitoring schedule 4
• When to contact provider (illness, reduced oral intake) 1

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Multidisciplinary Team Coordination

Essential team members for inpatient diabetes management: 4

• Endocrinology consultation for complex cases 4
• Diabetes care and education specialists for discharge teaching 4
• Pharmacists for medication reconciliation 4
• Dietitians for meal planning and carbohydrate counting 4

Common pitfalls to avoid:

• Using premixed insulin in hospital settings (high hypoglycemia risk) 1
• Continuing metformin in patients with acute kidney injury or sepsis 1
• Targeting euglycemia in critically ill patients 1
• Delaying insulin initiation in severely hyperglycemic patients (glucose >300 mg/dL or A1C >10%) 1
• Combining tirzepatide with DPP-4 inhibitors (no additional benefit) 2