Inpatient Management of Hyperglycemia

Critical Care Setting

• The American Diabetes Association recommends continuous intravenous insulin infusion as the preferred treatment for critically ill patients with hyperglycemia, targeting blood glucose 140-180 mg/dL 1, 2
• The American Diabetes Association suggests starting IV insulin when blood glucose exceeds 180 mg/dL in critically ill patients 1, 3
• The American Diabetes Association recommends using validated written or computerized protocols that allow predefined adjustments based on glycemic fluctuations and current insulin infusion rates 1, 2
• The American Diabetes Association advises avoiding subcutaneous insulin in critically ill patients, particularly during hypotension or shock 3
• The short half-life of IV insulin (<15 minutes) allows rapid dose titration with changing clinical status, according to the American Diabetes Association 3
• Targeting euglycemia (80-110 mg/dL) substantially increases iatrogenic hypoglycemia risk and is strongly discouraged by The Lancet Diabetes and Endocrinology 4

Non-Critical Care Setting

• The American Diabetes Association recommends that all patients with known diabetes or admission blood glucose >140 mg/dL require blood glucose monitoring 5, 6
• The American Diabetes Association suggests targeting blood glucose 100-180 mg/dL for non-critically ill patients 1, 5, 6
• The American Diabetes Association recommends pre-meal targets should be <140 mg/dL 5, 6
• The American Diabetes Association advises monitoring blood glucose before meals and at bedtime 6
• For patients with adequate oral intake, a basal-bolus-correction regimen is the preferred treatment, according to the American Diabetes Association 1, 2, 5
• The starting total daily dose for insulin-naive patients or those on low-dose insulin is 0.3-0.5 units/kg, as recommended by the American Diabetes Association 7
• The American Diabetes Association suggests dividing the total daily dose as 50% basal insulin (glargine or detemir) once daily + 50% prandial insulin (lispro, aspart, or glulisine) divided before three meals 3, 5, 8
• The American Diabetes Association recommends adding correction doses of rapid-acting insulin for blood glucose >180 mg/dL 1, 5
• For patients with poor or no oral intake, basal insulin plus correction doses is preferred, according to the American Diabetes Association 1, 2, 5
• The single dose of basal insulin for patients with poor or no oral intake is 0.1-0.25 units/kg/day, as recommended by The Lancet Diabetes and Endocrinology 4
• The American Diabetes Association advises adding correction doses of rapid-acting insulin before meals or every 6 hours if NPO 4
• High-risk patients require reduced insulin doses to prevent hypoglycemia, according to the American Diabetes Association 7
• The American Diabetes Association recommends starting elderly patients (>65 years) at 0.1-0.15 units/kg/day 7, 8
• The American Diabetes Association suggests reducing doses by 20% for patients with renal failure (eGFR <30 mL/min) 7
• The American Diabetes Association advises using 0.1-0.25 units/kg/day for patients with poor oral intake 7
• The American Diabetes Association recommends reducing total daily dose by 20% to prevent hypoglycemia for patients on high-dose home insulin (≥0.6 units/kg/day) 7

Non-Insulin Medications

• Recent evidence supports selective use of non-insulin medications in hospitalized patients with type 2 diabetes and mild-to-moderate hyperglycemia, according to The Lancet Diabetes and Endocrinology 4, 8
• The American Diabetes Association recommends using DPP-4 inhibitors (sitagliptin) alone or with basal insulin in non-cardiac patients with type 2 diabetes 8
• The dose of DPP-4 inhibitors is 50-100 mg daily based on kidney function, as recommended by the American Diabetes Association 8
• The American Diabetes Association suggests that DPP-4 inhibitors result in similar glycemic control as basal-bolus regimens with lower hypoglycemia risk 8
• Metformin should be discontinued in patients at risk for lactic acidosis, according to The Lancet Diabetes and Endocrinology 4
• The American Diabetes Association recommends reducing metformin dose if eGFR 30-45 mL/min per 1.73 m² 4
• The American Diabetes Association advises discontinuing metformin before iodinated contrast procedures in patients with eGFR <60 mL/min, liver disease, alcoholism, or acute heart failure 4
• Sulfonylureas are not recommended due to hypoglycemia risk and inability to rapidly adjust doses, according to the American Diabetes Association 8

Hypoglycemia Management

• Every hospital must implement a standardized hypoglycemia management protocol, according to the American Diabetes Association 1, 2, 9
• The American Diabetes Association defines moderate hypoglycemia as blood glucose <70 mg/dL 10
• The American Diabetes Association defines severe hypoglycemia as blood glucose <54 mg/dL or requiring assistance 10
• The American Diabetes Association recommends treating with oral carbohydrate or glucose for conscious patients 10
• The incidence of mild hypoglycemia with basal-bolus regimens is 12-30% in controlled settings, according to The Lancet Diabetes and Endocrinology 4, 9

Discharge Planning

• Transition to outpatient regimens should begin 1-2 days before discharge, according to the American Diabetes Association 8, 10
• The American Diabetes Association recommends resuming home oral medications 1-2 days before discharge if suspended during hospitalization 5, 8
• The American Diabetes Association advises obtaining HbA1c if not available from previous 3 months 8
• For patients with HbA1c >10%, the American Diabetes Association recommends discharging on basal-bolus regimen or previous oral agents plus 80% of hospital basal insulin dose 8
• The American Diabetes Association suggests scheduling outpatient follow-up within 1 week to 1 month 10

Glucocorticoid-Induced Hyperglycemia

• Patients on steroids require specific insulin adjustments, according to the American Diabetes Association 7
• For patients without diabetes, a single morning dose of NPH may be appropriate, as recommended by the American Diabetes Association 7
• For patients with diabetes, the American Diabetes Association advises adding 0.1-0.3 units/kg/day glargine to usual insulin regimen, with doses determined by steroid dose and oral intake 7