What is the target glucose range for inpatient diabetes management?

Target Glucose Range for Inpatient Diabetes Management

The correct answer is 140-180 mg/dL, which is the recommended target range for the majority of both critically ill and non-critically ill hospitalized patients. 1, 2, 3

Evidence-Based Rationale

The American Diabetes Association guidelines establish 140-180 mg/dL as the standard target range for inpatient glucose management across all hospitalized patients, with insulin therapy initiated when glucose persistently exceeds 180 mg/dL (checked on two occasions). 1, 2, 3

Why Not 80-110 mg/dL?

This range is explicitly contraindicated and dangerous. The landmark NICE-SUGAR trial demonstrated that intensive glycemic control targeting 80-110 mg/dL resulted in:

• Significantly higher mortality compared to the 140-180 mg/dL target 1
• 10- to 15-fold greater rates of severe hypoglycemia 1, 3
• No treatment advantage over moderate targets 1

The Society of Critical Care Medicine specifically recommends never targeting glucose <110 mg/dL in critically ill patients due to increased mortality risk. 3

Why Not 160-200 mg/dL?

This range is too permissive. While the upper threshold of 180 mg/dL is appropriate, allowing glucose to reach 200 mg/dL exceeds evidence-based targets and increases the risk of hospital complications. 1, 4

Why Not 70-180 mg/dL?

The lower bound of 70 mg/dL is problematic because:

• 70 mg/dL is the hypoglycemia alert threshold requiring immediate treatment with 15-20 g of fast-acting carbohydrate 5
• Insulin regimens should be reassessed when glucose falls below 100 mg/dL to prevent hypoglycemia 5, 2, 6
• Fasting glucose <100 mg/dL predicts hypoglycemia within the next 24 hours 2

Application by Patient Population

Critically Ill Patients

• Target: 140-180 mg/dL for the majority 1, 2
• Initiate insulin therapy at threshold ≥180 mg/dL 1, 2
• Use validated intravenous insulin protocols 1, 2
• More stringent targets of 110-140 mg/dL may be appropriate only for select patients (post-cardiac surgery, critically ill postsurgical patients) if achievable without significant hypoglycemia 1, 2, 3

Non-Critically Ill Patients

• Target: 140-180 mg/dL (random blood glucose <180 mg/dL) 1, 3
• Premeal targets <140 mg/dL are reasonable if safely achievable 1, 3
• Use scheduled subcutaneous basal-bolus insulin regimens 1
• Sliding scale insulin alone is strongly discouraged 1

Critical Safety Considerations

Hypoglycemia prevention is paramount and equally important to hyperglycemia management:

• Never administer insulin when blood glucose is <70 mg/dL 5
• Reassess insulin regimens when glucose falls to <100 mg/dL 5, 2, 6
• Patients with severe comorbidities may tolerate glucose between 180-250 mg/dL if frequent monitoring is not feasible 1

The 140-180 mg/dL target balances glycemic control with hypoglycemia risk, which is the fundamental principle established by the NICE-SUGAR trial and subsequent meta-analyses. 1, 2