Hyperglycemia in the Hospital

Should non-insulin diabetes medications be discontinued when a patient is admitted to the hospital?

Non-insulin antihyperglycemics may be appropriate.¹ Individualize.

• Sulfonylureas: hold if no or poor nutritional intake, age 75 years or older, CrCl <30 mL/min (<50 mL/min for glyburide), body weight <75 kg, or blood glucose <70 mg/dL.^2,3
• SGLT-2: may be best to hold during hospitalization due to risk of ketoacidosis and urosepsis.¹
• Metformin:
  • hold for eGFR <30 mL/minute/1.73 m² (severe renal impairment).^4,5
  • hold for at least 48 hrs after receiving iodinated contrast in patients with eGFR 30 to 60 mL/min/1.73 m² and a history of heart failure, alcoholism, or liver disease.^4,5
  • avoid if there is laboratory or clinical evidence of liver disease.⁵
  • hold for any condition associated with hypoxemia (e.g., heart failure), dehydration, or sepsis.⁵
• Gliptins: consider stopping saxagliptin or alogliptin if heart failure develops.¹
• Pioglitazone: stop in the event of symptomatic heart failure.¹
• GLP-1 agonist: May be useful in certain groups of hospitalized patients.¹
• For patients needing surgery see our chart, Perioperative Management of Diabetes, for guidance on managing non-insulin diabetes medications before and after surgery.
• If a medication is held, restart it one to two days before discharge.¹
• Consider re-titrating held diabetes meds to improve tolerance, particularly metformin and GLP-1 agonists. See our algorithm, Improving Tolerability to Metformin and chart, Comparison of GLP-1 Agonists, for dosing help.

What if the patient is admitted on an insulin pump?

ISMP (Institute for Safe Medication Practices) guidelines for use of insulin pumps during hospitalization in general are available at https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=1151.

See our chart, Insulin Pumps: What You Need to Know. It covers insulin pumps during hospitalization, surgery, and radiology procedures; pump basics; insulin stability in the pump; pump problems; hypoglycemia; calculations; disconnecting the pump, and more. And our FAQ, Insulin Pump Use and Transitions of Care, provides answers to questions that can come up from admission to discharge.

What if the patient is admitted on non-formulary insulin?

See our chart, How to Switch Insulin Products, for help.

What level of hyperglycemia requires treatment in hospitalized patients?

Treat symptomatic patients (e.g., polyuria, polydipsia), or those with ketosis.¹

Experts suggest treating blood glucose persistently ≥180 mg/dL.¹

Once treatment is started, consider a target of 140 to 180 mg/dL for most patients [Evidence level B-1].^1,7,8 However, the goal must be individualized.¹

• A goal of 110 to <140 mg/dL may be appropriate if hypoglycemia can be avoided and is already being successfully achieved.^1,8
• A goal >180 mg/dL may be appropriate for patients with limited life expectancy, patients with serious comorbidities, and in situations where frequent monitoring is not available.¹

Which insulin or insulin regimen should be used?

Insulin infusion is preferred for critical care patients.¹

• Adjust infusion rate per protocol.¹
• Switch patients from insulin infusions to subcutaneous insulin by starting basal insulin two hours before stopping the insulin drip, calculated on the insulin infusion rate administered over a six hour period when blood glucose targets were met.¹

In non-ICU patients, start with a regimen containing basal insulin, such as 0.15 to 0.25 units/kg/day [Evidence level B-1].^6,10

• A basal plus sliding scale (i.e., short-acting correction doses) regimen may be more appropriate for certain patients, such as those who use more than two antidiabetes meds at home.¹³
• A basal-bolus plus sliding scale regimen may be more appropriate for patients with good nutritional intake and who use this regimen at home.^1,13
• Check a premeal fingerstick before administering nutritional insulin doses.^1,9 Consider waiting until after the meal to give insulin if the patient may eat poorly.^1,9

If admission blood glucose is under 180 mg/dL, consider starting with sliding scale insulin as an alternative to basal regimens in non-ICU patients [Evidence level B-3].11-13

• May be most appropriate for certain patients, such as those who are insulin-naïve or at higher risk for hypoglycemia (e.g., elderly, kidney failure).¹³
• Add basal insulin if hyperglycemia persists for 24 to 48 hours.¹¹

Patients receiving bolus or continuous enteral nutrition will need basal, nutritional, and correction doses. Patients receiving parenteral nutrition or not eating will need basal plus correction doses. Check fingersticks every four to six hours and give a correction dose of rapid- or short-acting insulin if needed.¹  The ADA has suggestions for insulin dosing in patients receiving parenteral or enteral nutrition at http://professional.diabetes.org/sites/professional.diabetes.org/files/media/dc_40_s1_final.pdf (see Table 14.1).

Avoid use of premixed insulin in the hospital due to hypoglycemia risk.¹

Will patients who need insulin in the hospital need it upon discharge?

An A1c of 6.5 mg/dL or higher on admission suggests that the patient had diabetes preadmission.¹

Consider initial combination therapy for A1c >9%.  Consider insulin as a component, such as if A1c is >10%.¹

Consider NPH over newer basal insulin analogues for lower cost, especially in those without hypoglycemia history.¹

Schedule follow-up within one month or earlier, such as within 1 to 2 weeks, for suboptimal glucose control at discharge or if diabetes regimens are changed.¹