Insulin Use in Hospitalized Patients With Diabetes: Navigate With Care

Practical Approach to Management of Inpatient Hyperglycemia in Select Patient Populations

“…1 Key steps in the glycemic management of hospitalized patients with diabetes include: 1) evaluation of the patient's pre-admission glycemic control with a quick review of glucose patterns (generally, by asking the patient, as the glucometer records are rarely available on admission) and current or recent glycated hemoglobin (HbA 1c ) levels; 2) discontinuation of non-insulin glucoselowering medications (in most cases); 3) ordering scheduled point-of-care glucose monitoring and scheduled insulin dosing, while keeping the patient's inpatient glucose goals in mind; 4) outlining clear parameters for the management of hypoglycemia; 5) evaluation of the daily blood glucose (BG) patterns with daily adjustments of insulin dose and type as needed; and 6) adequate planning for discharge. Because a single hospital stay may include multiple transitions between levels of care and among interventions and situations that result in changes in patient glucose metabolism (Figure 1), 1 the clinicians caring for patients with diabetes in the hospital setting must be aware of how these situations, along with transitions from one situation to another, may impact glycemic control, and what evidence there is to best manage these situations.…”

Medications affecting glycemic control

“…Regardless of the cause, the first step in managing patients with IGT, hyperglycemia or DM, should be preventing or mitigating modifiable risk factors through lifestyle modification including weight loss, maintaining a healthy diet, adequate physical activity and patient education. Clinical judgment along with continuous assessment of the patient's clinical status, illness severity, nutritional status, and concomitant medications potentially affecting glucose concentration should be incorporated into decisions to avoid, hold or continue therapy [7]. If DM develops, it may be appropriate to consider management with anti-diabetic agents.…”

“…Basal-bolus insulin (BBI) may be initiated with either neutral protamine Hagedorn (NPH) or glargine insulin for hospitalized patients on GC with persistent hyperglycemia above or equal 11.1 mmol/L [7,97]. Both types of insulin have been shown to be are equally effective in small retrospective studies [7,97]. Any of 3 approaches are acceptable for insulin dosing: weight based insulin regimen, steroid dose based regimen or focused prandial insulin therapy [88].…”

“…The treatment of choice for GC-induced hyperglycemia will vary depending on the GC used, frequency, duration of action, duration of therapy and current anti-diabetic regimen, if any (Table 1). Basal-bolus insulin (BBI) may be initiated with either neutral protamine Hagedorn (NPH) or glargine insulin for hospitalized patients on GC with persistent hyperglycemia above or equal 11.1 mmol/L [7,97]. Both types of insulin have been shown to be are equally effective in small retrospective studies [7,97].…”

“…-Basal-bolus regimen using long acting insulin [97,101] -In patients already on BBI regimen; use 140-150% of BBI [7] -Start NPH 3 units/mg of dexamethasone or equivalent in divided doses twice daily [7] Betamethasone 0.6 30 ? 36-72 Table 1.…”