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  • Clinician

Inpatient management of hyperglycemia

Summary

Hyperglycemia is a common occurrence in hospitalized patients and for inpatients is defined as a blood glucose (BG) level > 140 mg/dL. Common causes of hyperglycemia in hospitalized patients include underlying diabetes mellitus, medications (e.g., corticosteroids, thiazide diuretics), parenteral nutrition, and stress (e.g., due to surgery, trauma, or sepsis). Regardless of the cause, hyperglycemia is associated with longer hospital stays and worse outcomes. A structured, methodical approach to hyperglycemia is key to good glycemic control in hospitalized patients. When managing blood sugar levels, special care should be taken to avoid potentially life-threatening hypoglycemia, which can occur as a complication of insulin therapy. For more information, see diabetes mellitus and insulin.

Clinical approach

  1. Rule out hyperglycemic crises (see hyperglycemic crises).
  2. Identify (and treat) the underlying cause.
  3. Determine whether to initiate insulin therapy.
    • Insulin therapy is generally recommended for persistently elevated glucose ≥ 180 mg/dL. [1]
    • The goal is moderate glycemic control (glucose range: 140–180 mg/dL). [1][2]
  4. Start an appropriate insulin regimen, if indicated (see insulin regimens).
  5. Monitor and adjust therapy as needed:
    • NPO or continuous enteral feeding: Check POC glucose every 4–6 hours.
    • Patient is eating: Check POC glucose before every meal and at bedtime.
    • Patients receiving intravenous insulin: Check POC glucose every 30–120 minutes.
    • BMP every 1–2 days to monitor creatinine and serum glucose.
  6. Avoid (and treat) hypoglycemia (generally defined as ≤ 70 mg/dL, see hypoglycemia). [1]
  7. Consider endocrine consult or hyperglycemia team consult if glucose is difficult to control.

Hyperglycemic crisis (DKA and HHS) must be ruled out in all hyperglycemic patients.

Target glucose may vary depending on individual patient factors (e.g., more liberal goals for terminally ill patients may be acceptable).

Patients with underlying diabetes mellitus

Critically-ill patients in the intensive care unit

  • Indication for insulin therapy: blood glucose > 180 mg/dL [1]
  • Recommended insulin regimen
    • Continuous intravenous insulin infusion (IIP) is preferable. [1][7]
    • Avoid IIP in the following situations:
      • Rapid normalization of glucose expected
      • Patients close to transfer to a general ward
      • Terminally-ill patients
      • Patients who are eating
    • For patients not on IIP, a basal-bolus insulin regimen is usually appropriate
  • Monitoring: POC glucose hourly, if on a continuous insulin infusion
  • Other considerations: Ideal glucose targets for critically ill patients are still under discussion.

Glucocorticoid-induced hyperglycemia

An individual approach is necessary. For example, a patient with mild hyperglycemia who is on a low dose of glucocorticoids that is being tapered will require a different approach than a patient with glucose levels > 300 mg/dL on chronic high-dose glucocorticoids.

Hyperglycemia during enteral or parenteral nutrition

Patients with type 1 diabetes mellitus require basal insulin even if (enteral) feeding is discontinued.

Other special patient groups

Stress-induced hyperglycemia

  • Many stressors can cause hyperglycemia (e.g., ACS, trauma, surgery). [12]
  • Attempts should be made to identify and treat the underlying stressor.
  • Glycemic management is otherwise similar to standard diabetes care (see “Patients with underlying diabetes mellitus” above).

Drug-induced hyperglycemia [8][9][13]

Patients on continuous subcutaneous insulin infusion (CSII) [14]

  • CSII (i.e., insulin pump) is usually discontinued when patients are admitted to the hospital.
  • Continuation of CSII may be considered in select patients if:
    • The patient demonstrates the capacity to use the pump correctly.
    • No contraindications for CSII are present, e.g.:
      • Patient unable to participate actively in blood sugar management
      • An altered state of consciousness
      • DKA
      • Severe illness (e.g., sepsis)
      • Need for MRI
      • Suicidal ideation
  • If CSII is discontinued, a basal-bolus insulin regimen is recommended.

Every patient switched from continuous subcutaneous insulin infusion to another insulin regimen should receive basal insulin.

Differential diagnoses

The differential diagnoses listed here are not exhaustive.

Acute management checklist

  • 1. American Diabetes Association. 15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2018; 42(Supplement 1): pp. S173–S181. doi: 10.2337/dc19-s015.
  • 2. NICE-SUGAR Study Investigators. Intensive versus Conventional Glucose Control in Critically Ill Patients. N Engl J Med. 2009; 360(13): pp. 1283–1297. doi: 10.1056/nejmoa0810625.
  • 3. Umpierrez GE, Smiley D, Zisman A, et al. Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT 2 Trial). Diabetes Care. 2007; 30(9): pp. 2181–2186. doi: 10.2337/dc07-0295.
  • 4. Roberts GW, Aguilar‐Loza N, Esterman A, Burt MG, Stranks SN. Basal–bolus insulin versus sliding‐scale insulin for inpatient glycaemic control: a clinical practice comparison. Med J Aust. 2012; 196(4): pp. 266–269. doi: 10.5694/mja11.10853.
  • 5. Kitabchi AE, Nyenwe E. Sliding-Scale Insulin: More evidence needed before final exit?. Diabetes Care. 2007; 30(9): pp. 2409–2410. doi: 10.2337/dc07-1141.
  • 6. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2012; 97(1): pp. 16–38. doi: 10.1210/jc.2011-2098.
  • 7. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Diabetes Care. 2009; 32(6): pp. 1119–1131. doi: 10.2337/dc09-9029.
  • 8. Fathallah N, Slim R, Larif S, Hmouda H, Ben Salem C. Drug-Induced Hyperglycaemia and Diabetes. Drug Safety. 2015; 38(12): pp. 1153–1168. doi: 10.1007/s40264-015-0339-z.
  • 9. Jain V, Patel RK, Kapadia Z, Galiveeti S, Banerji M, Hope L. Drugs and hyperglycemia: A practical guide. Maturitas. 2017; 104: pp. 80–83. doi: 10.1016/j.maturitas.2017.08.006.
  • 10. Gosmanov AR. A practical and evidence-based approach to management of inpatient diabetes in non-critically ill patients and special clinical populations. Journal of Clinical & Translational Endocrinology. 2016; 5: pp. 1–6. doi: 10.1016/j.jcte.2016.05.002.
  • 11. Gosmanov AR, Umpierrez GE. Management of Hyperglycemia During Enteral and Parenteral Nutrition Therapy. Curr Diab Rep. 2012; 13(1): pp. 155–162. doi: 10.1007/s11892-012-0335-y.
  • 12. Bogun M, Inzucchi SE. Inpatient Management of Diabetes and Hyperglycemia. Clin Ther. 2013; 35(5): pp. 724–733. doi: 10.1016/j.clinthera.2013.04.008.
  • 13. Rehman A, Setter SM, Vue MH. Drug-Induced Glucose Alterations Part 2: Drug-Induced Hyperglycemia. Diabetes Spectrum. 2011; 24(4): pp. 234–238. doi: 10.2337/diaspect.24.4.234.
  • 14. Thompson B, Korytkowski M, Klonoff DC, Cook CB. Consensus Statement on Use of Continuous Subcutaneous Insulin Infusion Therapy in the Hospital. Journal of Diabetes Science and Technology. 2018; 12(4): pp. 880–889. doi: 10.1177/1932296818769933.
  • 15. Dunaif A. Insulin Resistance and the Polycystic Ovary Syndrome: Mechanism and Implications for Pathogenesis. Endocr Rev. 1997; 18(6): pp. 774–800. doi: 10.1210/edrv.18.6.0318.
  • Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care. 2009; 32(7): pp. 1335–1343. doi: 10.2337/dc09-9032.
  • American Diabetes Association. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2018. Diabetes Care. 2017; 41(Supplement 1): pp. S144–S151. doi: 10.2337/dc18-s014.
  • Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes. The Journal of Clinical Endocrinology & Metabolism. 2002; 87(3): pp. 978–982. doi: 10.1210/jcem.87.3.8341.
  • Donihi et al. Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin. Quality and Safety in Health Care. 2006; 15(2): pp. 89–91. doi: 10.1136/qshc.2005.014381.
  • Shetty S, Inzucchi SE, Goldberg PA, Cooper D, Siegel MD, Honiden S. Adapting to the new consensus guidelines for managing hyperglycemia during critical illness: the updated Yale insulin infusion protocol. Endocr Pract. 2012; 18(3): pp. 363–70. doi: 10.4158/EP11260.OR.
  • Kwon S, Hermayer KL, Hermayer K. Glucocorticoid-Induced Hyperglycemia. Am J Med Sci. 2013; 345(4): pp. 274–277. doi: 10.1097/maj.0b013e31828a6a01.
last updated 07/22/2020
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