Optimizing glycemic control should be a priority for all health care providers in the inpatient setting.
Uncontrolled hyperglycemia in hospitalized patients with or without a previous diagnosis of diabetes is associated with adverse outcomes and longer lengths of hospital stay. It is estimated that one-third of hospitalized patients will experience significant hyperglycemia, and the cost associated with hospitalization for patients with diabetes accounts for half of all health care expenditures for this disease. Optimizing glycemic control should be a priority for all health care providers in the inpatient setting. Appropriate management strategies should include identification of appropriate glycemic targets, prevention of hypoglycemia, initiation of appropriate basal-plus-bolus insulin regimens, and planning for the transition from inpatient to outpatient therapy before hospital discharge.
Uncontrolled hyperglycemia in hospitalized patients with or without a previous diagnosis of diabetes is associated with adverse outcomes and longer lengths of hospital stay. It is estimated that one-third of hospitalized patients will experience significant hyperglycemia, and the cost associated with hospitalization for patients with diabetes accounts for half of all health care expenditures for this disease. Many patients without preexisting diabetes will also experience stress-related hyperglycemia while hospitalized. Optimizing glycemic control should be a priority for all health care providers in the inpatient setting.
Consensus Guidelines Exist for the Management of Inpatient Hyperglycemia
The American Diabetes Association and the American Association of Clinical Endocrinologists released a consensus statement on inpatient glycemic control in 2009. These guidelines note that insulin therapy is the preferred method for achieving inpatient glycemic control. In the intensive care unit, intravenous (IV) infusion is the preferred route of insulin administration. Outside of critical care units, scheduled subcutaneous administration of insulin consisting of basal, nutritional, and supplemental (correction) components is preferred.
Glycemic Targets Vary by Patient Population
In critically ill patients on IV insulin therapy, the blood glucose (BG) level should be maintained between 140 and 180 mg/dL. Targets <110 mg/dL are not recommended for this patient population. For noncritically ill patients treated with subcutaneous insulin, premeal glucose targets should generally be <140 mg/dL in conjunction with random glucose targets <180 mg/dL, as long as these targets can be safely achieved. Higher glucose ranges may be acceptable in terminally ill patients or patients with severe comorbidities. Consideration should be given to reassessing the insulin regimen if BG levels are consistently <100 mg/dL, for avoidance of hypoglycemia.
Inpatient Hyperglycemia Is Best Managed with Insulin
Typically, oral agents have a limited role in the inpatient setting and should be discontinued during acute illness unless it is a very brief hospitalization. Metformin cannot be used when there is any possibility of the need for iodinated contrast studies or renal insufficiency. Sulfonylureas and metaglinides can cause unpredictable hypoglycemia in patients who are not eating consistently. Thiazolidinediones cause fluid retention (especially in combination with insulin) and parenteral glucagon-like peptide-1, and amylin agonists can cause nausea and should be withheld in acutely ill patients. Insulin works reliably and can be quickly titrated based on changes in diet or glucose levels, making it ideal in the inpatient setting. The Table and the Figure detail the onset and duration of action characteristics by insulin type.
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-William B. Horton, MD, Jose S. Subauste, MD
This article originally appeared in the February 2016 issue of The American Journal of Medicine.
