Review
Top 10 Facts to Know About Inpatient Glycemic Control

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Abstract

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.

Section snippets

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 2009.5 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

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

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.1, 5 Metformin cannot be used when there is any possibility of the need for iodinated contrast studies or renal insufficiency.1 Sulfonylureas and metaglinides can cause unpredictable hypoglycemia in patients who are not eating consistently.1 Thiazolidinediones cause fluid retention (especially in combination with insulin) and parenteral

Hypoglycemia Should Be Prevented

Hypoglycemia (both spontaneous and iatrogenic) has been associated with higher risk of complications among hospitalized patients, including longer and more expensive hospital stays and increased mortality rates.6, 7, 8 Hospitalized patients who are elderly or severely ill are especially vulnerable to the adverse effects of hypoglycemia.6 Hypoglycemia is defined as any BG <70 mg/dL.9 For avoidance of hypoglycemia, consideration should be given to reassessing the insulin regimen if BGs <100 mg/dL

Glycemic Monitoring Varies by Dietary Needs

Bedside capillary point-of-care (POC) testing is the preferred method for guiding ongoing glycemic management.10 Recommendations include POC testing before meals and at bedtime in patients who are eating usual meals.5, 10 POC testing should be performed every 4-6 hours in patients who are not allowed anything by mouth or who are receiving continuous enteral or parenteral nutrition.5, 10 More frequent POC testing, ranging from every 30 minutes to every 2 hours, is required for patients receiving

Treatment of Inpatient Hyperglycemia Is Cost-effective

In the Portland Diabetic Project, institution of continuous IV insulin therapy to achieve predetermined target BG values in diabetic patients undergoing open-heart surgical procedures reduced the incidence of deep sternal wound infections by 66%, resulting in a total net savings to the hospital of $4638 per patient.11 In another study, intensive glycemic control in 1600 patients treated in a medical ICU was associated with a total cost savings of $1580 per patient.12 Optimization of inpatient

Transitioning From Inpatient to Outpatient Glycemic Management Is Important

Hospitalization provides a unique opportunity for addressing a patient's education in diabetes management.2 Preparation for transition to the outpatient setting is an important goal of inpatient diabetes management and begins with hospital admission.5 Successful coordination of this transition requires a team approach that includes physicians, nurses, dietitians, case managers, and social workers.13 An outpatient follow-up visit with the primary care provider, endocrinologist, or diabetes

Clinicians Should Be Aware of Management for Special Clinical Situations

Patients who utilize continuous insulin infusion (pump) therapy in the outpatient setting can be considered for diabetes self-management while hospitalized, provided they have the mental and physical capacity to do so.5, 13, 14, 15 It should be noted that nursing personnel must document basal rates and bolus doses (at least daily) if this occurs.5 Persistent hyperglycemia in patients receiving enteral nutrition should be treated with scheduled insulin doses.1 Once-daily glargine insulin,

Sliding-scale Insulin Alone Is Insufficient Treatment for Sustained Hyperglycemia

Scheduled basal/bolus insulin regimens mimic normal pancreas hormonal physiology and are designed to prevent hyperglycemia, whereas sliding scale insulin (SSI) alone attempts to lower hyperglycemia only after it has occurred.1 A study comparing scheduled basal/bolus insulin to SSI alone showed a significantly higher percentage of patients achieving goal glucose levels in the basal/bolus group than in the SSI group (66% vs 38%) without an increase in hypoglycemia.18

Insulin-naïve Patients Can Safely Initiate Treatment by Calculating Total Daily Dose

For patients who are insulin naïve, insulin therapy can safely be initiated at a total daily dose of 0.3-0.6 units/kg body weight.19, 20 The lower starting dose is recommended for leaner patients and those with renal insufficiency, while the higher starting dose is recommended for obese patients and those on glucocorticoids.1 Fifty percent of the calculated total daily dose should be given as a basal component, and the remaining 50% should be split into thirds and given preprandially as the

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Funding: None.

Conflict of Interest: None to disclose.

Authorship: Both authors had access to data and contributed equally to writing the manuscript.

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