Treatment of inpatient HYPERglycemia

New data will fuel debate about sliding scale insulin for inpatient hyperglycemia in patients withOUT type 1 diabetes. Guidelines continue to recommend basal or basal-bolus insulin instead of sliding scale to reduce HYPERglycemia. But this is driven by limited evidence. And many clinicians haven't embraced basal-bolus, since it can increase HYPOglycemia risk and is labor intensive. 

          Now TWO studies in non-ICU patients add real-world perspective. Both generally support a role for sliding scale alone, especially when admission glucose is under 180 mg/dL. And one suggests that basal-bolus may not be a preferred regimen. These data are limited. But they reinforce current practice of individualizing hyperglycemia treatment, based on the patient's current blood glucose, home management, hypoglycemia risk, etc.

Keep aiming for a blood glucose under 180 mg/dL for most floor and ICU patients, while avoiding HYPOglycemia. But use a higher goal in some cases, such as under 250 mg/dL for an asymptomatic floor patient with severe kidney disease. Start with sliding scale for many non-ICU patients, especially if they're well managed on 1 or 2 non-insulin medications at home or don't have diabetes.

If hyperglycemia persists for 24 to 48 hours, add a once-daily basal insulin dose, such as 0.15 to 0.25 units/kg. Or consider starting with basal plus sliding scale for patients well managed at home on insulin or several non-insulin medications. Save basal-bolus plus sliding scale for patients with good enteral intake who use this regimen at home, or have uncontrolled glucose on higher insulin doses, such as more than 0.6 units/kg/day.

Ensure your protocol provides clear instructions for basal-bolus plus sliding scale and review steps with nursing to avoid errors. Before discharge, generally restart home diabetes medications, stop inpatient insulin regimens and document the plan. Also verify follow-up within 1 to 2 weeks if diabetes regimens are changed. Get our resource, "Manage HYPERglycemia in hospital", for more answers. And use our "Diabetes Resources", to find additional practice tools.

REFERENCES

• American Diabetes Association Professional Practice Committee; American Diabetes Association Professional Practice Committee:, Draznin B, Aroda VR, Bakris G, Benson G, Brown FM, Freeman R, Green J, Huang E, Isaacs D, Kahan S, Leon J, Lyons SK, Peters AL, Prahalad P, Reusch JEB, Young-Hyman D, Das S, Kosiborod M. 16. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022 Jan 1;45(Suppl 1):S244-S253. Available at: https://pubmed.ncbi.nlm.nih.gov/34964884

  Migdal AL, Idrees T, Umpierrez GE. Selecting Insulin Regimens for the Management of Non-ICU Patients With Type 2 Diabetes. J Endocr Soc. 2021 Aug 18;5(10):bvab134. Available at: https://academic.oup.com/jes/article/5/10/bvab134/6354345?login=false

  Pasquel FJ, Umpierrez GE. Web Exclusive. Annals for Hospitalists Inpatient Notes - How We Treat Hyperglycemia in the Hospital. Ann Intern Med. 2021 Aug;174(8):HO2-HO4. Available at: https://www.acpjournals.org/doi/10.7326/M21-2789

  Migdal AL, Fortin-Leung C, Pasquel F, Wang H, Peng L, Umpierrez GE. Inpatient Glycemic Control With Sliding Scale Insulin in Noncritical Patients With Type 2 Diabetes: Who Can Slide? J Hosp Med. 2021 Aug;16(8):462-468. Available at: https://shmpublications.onlinelibrary.wiley.com/doi/full/10.12788/jhm.3654

  Sadhu AR, Patham B, Vadhariya A, Chikermane SG, Johnson ML. Outcomes of "Real-World" Insulin Strategies in the Management of Hospital Hyperglycemia. J Endocr Soc. 2021 Jun 16;5(8):bvab101. Available at: https://academic.oup.com/jes/article/5/8/bvab101/6300202?login=false