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Inpatient management of hyperglycemia

Last updated: February 9, 2021

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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.

  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:
  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).

  • 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.

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.

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

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.

The differential diagnoses listed here are not exhaustive.

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