Individualize Treatment of Inpatient Hyperglycemia

This complimentary article from Hospital Pharmacist’s Letter is being provided to readers of Prescriber’s Letter, who may find its content relevant to their practice.

 

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 meds 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 meds.

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 meds...stop inpatient insulin regimens...and document the plan. Also verify follow-up within 1 to 2 weeks if diabetes regimens are changed.

Key References
  • Ann Intern Med. 2021 Aug;174(8):HO2-HO4
  • J Hosp Med. 2021 Aug;16(8):462-468
  • J Endocr Soc. 2021 Jun 16;5(8):bvab101
  • J Endocr Soc. 2021 Aug 18;5(10):bvab134
  • Diabetes Care. 2022 Jan 1;45(Suppl 1):S244-S253
Prescriber’s Letter. May 2022, No. 380522


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