Hyperglycemia in the Hospital
(Updated April 28, 2022)
The information below is provided to help you prevent and treat hyperglycemia in the hospital. Most suggestions are based on expert opinion. Additional information about diabetes care can be found in the 2022 American Diabetes Association (ADA) guidelines at https://diabetesjournals.org/care/issue/45/Supplement_1.
Question |
Answer/Pertinent Information |
Should non-insulin diabetes medications be discontinued when a patient is admitted to the hospital? |
Non-insulin antihyperglycemics may be appropriate.1 Individualize.
|
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
|
Which insulin or insulin regimen should be used? |
Insulin infusion is preferred for critical care patients.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
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
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 |
Levels of Evidence
In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.
Level |
Definition |
Study Quality |
A |
Good-quality patient-oriented evidence.* |
|
B |
Inconsistent or limited-quality patient-oriented evidence.* |
|
C |
Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening. |
*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).
[Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. https://www.aafp.org/afp/2004/0201/p548.pdf.]
References
- Standards of medical care in diabetes – 2022. Diabetes Care 2022;45(Suppl 1):S1-264 .
- Milligan PE, Bocox MC, Pratt E, et al. Multifaceted approach to reducing occurrence of severe hypoglycemia in a large healthcare system. Am J Health Syst Pharm 2015;72:1631-41.
- Minnesota Hospital Association. Hypoglycemic agent adverse drug event gap analysis. Component of the medication safety road map. http://www.mnhospitals.org/Portals/0/Documents/ptsafety/ade/Medication-Safety-Gap-Analysis-Hypoglycemic.pdf. (Accessed December 14, 2021).
- Food and Drug Administration. FDA Drug Safety Communication: FDA revises warnings regarding use of the diabetes medicine metformin in certain patients with reduced kidney function. April 8, 2016. http://www.fda.gov/Drugs/DrugSafety/ucm493244.htm. (Accessed December 16, 2021).
- Clinical Pharmacology powered by ClinicalKey. Tampa (FL): Elsevier. 2021. http://www.clinicalkey.com. (Accessed December 22, 2021).
- Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care 2013;36:2169-74.
- The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009;360:1283-97.
- Bogun M, Inzucchi SE. Inpatient management of diabetes and hyperglycemia. Clin Ther 2013;35:724-33.
- ISMP. Adverse glycemic events and critical emergencies. December 1, 2021. https://www.ismp.org/resources/adverse-glycemic-events-and-critical-emergencies. (Accessed December 20, 2021).
- Migdal AL, Idrees T, Umpierrez GE. Selecting insulin regimens for the management of non-ICU patients with type 2 diabetes. J Endocr Soc 2021;5:bvab134.
- Migdal AL, Fortin-Leung C, Pasquel F, et al. Inpatient glycemic control with sliding scale insulin in noncritical patients with type 2 diabetes: who can slide? J Hosp Med 2021;16:462-8.
- Sadhu AR, Patham B, Vadhariya A, et al. Outcomes of "real-world" insulin strategies in the management of hospital hyperglycemia. J Endocr Soc 2021;5:bvab101.
- Pasquel FJ, Umpierrez GE. Web exclusive. Annals for Hospitalists Inpatient Notes - How we treat hyperglycemia in the hospital. Ann Intern Med 2021;174:HO2-HO4.
Cite this document as follows: Clinical Resource, Hyperglycemia in the Hospital. Hospital Pharmacist’s Letter/Pharmacy Technician’s Letter. January 2022. [380125]