Insulin Therapy in Hospitalized Patients

Abstract

Background: Hyperglycemia is prevalent and is associated with an increase in morbidity and mortality in hospitalized patients. Insulin therapy is the most appropriate method for controlling glycemia in hospital, but is associated with increased risk of hypoglycemia, which is a barrier to achieving glycemic goals. Areas of Uncertainty: Optimal glycemic targets have not been established in the critical and noncritical hospitalized patients, and there are different modalities of insulin therapy. The primary purpose of this review is to discuss controversy regarding appropriate glycemic targets and summarize the evidence about the safety and efficacy of insulin therapy in critical and noncritical care settings. Data Sources: A literature search was conducted through PubMed with the following key words (inpatient hyperglycemia, inpatient diabetes, glycemic control AND critically or non-critically ill patient, Insulin therapy in hospital). Results: In critically ill patient, blood glucose levels >180 mg/dL may increase the risk of hospital complications, and blood glucose levels <110 mg/dL have been associated with an increased risk of hypoglycemia. Continuous intravenous insulin infusion is the best method for achieving glycemic targets in the critically ill patient. The ideal glucose goals for noncritically ill patients remain undefined and must be individualized according to the characteristics of the patients. A basal-bolus insulin strategy resulted in better glycemic control than sliding scale insulin and lower risk of hypoglycemia than premixed insulin regimen. Conclusions: Extremes of blood glucose lead to poor outcomes, and target glucose range of 110–180 mg/dL may be appropriate for most critically ill patients and noncritically ill patients. Insulin is the most appropriate pharmacologic agent for effectively controlling glycemia in hospital. A continuous intravenous insulin infusion and scheduled basal-bolus-correction insulin are the preferred modalities for glycemic control in critically and noncritically ill hospitalized patients, respectively.

Efficacy and safety of insulin glargine 300 U/mL (Gla-300) during hospitalization and therapy intensification at discharge in patients with insufficiently controlled type 2 diabetes: results of the phase IV COBALTA trial

“…The growing evidence of the inpatient glycemic control benefits on morbimortality and associated costs 7 9 support hospitalization as an opportunity to evaluate the metabolic situation of insufficiently controlled patients and intensify their antidiabetic treatment at discharge. While prehospitalization treatment can be maintained when preadmission control is acceptable, insufficiently controlled patients will need their outpatient therapy intensification.…”

Consequences of COVID-19 on people with diabetes

“…Insulin is the drug of choice for the treatment of hyperglycemia in hospital, and the most effective and safe insulin administration regimens are continuous intravenous insulin infusion in critically ill patients and the subcutaneous dosing of insulin in a basal-bolus-correction regimen, adapted to the type of nutrition, in non-critically ill patients. 15 Considering that the success of a clinical management protocol is largely dependent upon the training of the staff in charge of applying it, and that the magnitude of the current pandemic situation implies that many of the healthcare professionals in first-line care are less experienced than previously, the participation of endocrinologists and nurses specializing in diabetes in adapting the protocols and in the care of hospitalized patients with hyperglycemia will undoubtedly contribute to improving the management of diabetic patients with COVID-19.…”

Considerations for Insulin-Treated Type 2 Diabetes Patients During Hospitalization: A Narrative Review of What We Need to Know in the Age of Second-Generation Basal Insulin Analogs

“…In the critical care setting, continuous intravenous insulin infusion is the preferred method for achieving glycemic targets, as it allows quick correction for any sudden changes in insulin requirements. For non-critical care, choosing the most appropriate insulin regimen is not as clear and the choice depends on the individual circumstances, including whether patients have good nutritional intake, but a basal-bolus regimen is often the preferred regimen of choice for non-critically ill hospitalized patients [14,29].…”