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.

  • 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

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.*

  1. High-quality randomized controlled trial (RCT)
  2. Systematic review (SR)/Meta-analysis of RCTs with consistent findings
  3. All-or-none study

B

Inconsistent or limited-quality patient-oriented evidence.*

  1. Lower-quality RCT
  2. SR/Meta-analysis with low-quality clinical trials or of studies with inconsistent findings
  3. Cohort study
  4. Case control study

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

  1. Standards of medical care in diabetes – 2022. Diabetes Care 2022;45(Suppl 1):S1-264 .
  2. 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.
  3. 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).
  4. 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).
  5. Clinical Pharmacology powered by ClinicalKey. Tampa (FL): Elsevier. 2021.  http://www.clinicalkey.com.  (Accessed December 22, 2021).
  6. 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.
  7. The NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients.  N Engl J Med 2009;360:1283-97.
  8. Bogun M, Inzucchi SE. Inpatient management of diabetes and hyperglycemia. Clin Ther 2013;35:724-33.
  9. 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).
  10. 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.
  11. 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.
  12. 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.
  13. 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]

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