Inpatient management of hyperglycemia

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Hyperglycemia occurs commonly in hospitalized patients and is defined as a blood glucose level > 140 mg/dL in inpatients. Common causes of hyperglycemia in hospitalized patients include underlying diabetes mellitus, medications (e.g., glucocorticoids, thiazide diuretics), parenteral nutrition, and stress (e.g., due to surgery, trauma, or sepsis). Regardless of the cause, hyperglycemia is associated with longer hospital stays and worse outcomes. A structured, methodical approach to hyperglycemia is key to good glycemic control in inpatients. When managing blood sugar levels, special care should be taken to avoid potentially life-threatening hypoglycemia, which can occur as a complication of insulin therapy. For more information, see “Diabetes mellitus” and “Insulin.”

Medications ^[2]

• Glucocorticoids
• Fluoroquinolones
• Beta blockers
• Thiazide diuretics and loop diuretics
• Heparin
• Calcineurin inhibitors
• Tricyclic antidepressants
• Antipsychotic drugs
• Lithium
• HIV-protease inhibitors
• Thyroid hormones (e.g., levothyroxine)
• Estrogen (contraceptives)
• Sympathomimetic drugs that interact with the beta-1 adrenergic receptor (e.g., dobutamine)
• Derivatives of nicotinic acid

Pancreatic disorders

• Acute pancreatitis
• Chronic pancreatitis
• Hemochromatosis
• Cystic fibrosis
• Pancreatic cancer
• Glucagonoma

Endocrine

• T1DM
• T2DM
• Gestational diabetes
• Hyperthyroidism
• Polycystic ovary syndrome (PCOS) ^[3]
• Primary hypercortisolism
  • Adrenal adenoma
  • Adrenal carcinoma
  • Macronodular adrenal hyperplasia
• Secondary hypercortisolism
  • Pituitary adenoma
  • Small cell lung cancer
  • Renal cell carcinoma
• Growth hormone-secreting pituitary adenoma (acromegaly)
• Pheochromocytoma

Stress

• Sepsis
• Trauma
• Recent surgery

• Rule out hyperglycemic crises.
• Identify and treat the underlying cause, e.g.:
  • Underlying diabetes or glucose intolerance
    • Patient history
      • Type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM), or prior episodes of hyperglycemia
      • On insulin or oral antidiabetic medications
    • Check HbA1c (if not done in the past 3 months). ^[4]
    • See also “Screening for diabetes mellitus.”
  • Medication-induced; see “Etiology.”
  • Enteral or parenteral nutrition
  • Stress-induced (e.g., sepsis, recent surgery, trauma)
• Initiate an insulin regimen if indicated. ^[4]
  • Indications ^[4][5]
    • Persistently elevated blood glucose ≥ 180 mg/dL in critically ill patients and/or those with pre-existing diabetes ^[4][5]
    • Persistently elevated blood glucose > 140 mg/dL in noncritically ill patients without pre-existing diabetes ^[5]
  • Glycemic targets ^[4][5]
    • 100–180 mg/dL in noncritically ill patients ^[5]
    • 140–180 mg/dL in critically ill patients ^[4]
• Monitor and adjust therapy as needed.
  • NPO or continuous enteral feeding: Check POC glucose every 4–6 hours.
  • Patient is eating: Check POC glucose before every meal and at bedtime.
  • Patients receiving intravenous insulin: Check POC glucose every 30–120 minutes.
  • BMP every 1–2 days to monitor creatinine and serum glucose.
• Avoid hypoglycemia. ^[4]
• Consider an endocrinology or glucose management team consult if glucose is difficult to control. ^[4]

Hyperglycemic crisis (DKA or HHS) must be ruled out in all hyperglycemic patients.

Target glucose may vary depending on individual patient factors (e.g., more liberal goals for terminally ill patients may be acceptable).

• Indications for insulin therapy
  • All patients with T1DM
  • Patients with T2DM with blood glucose ≥ 180 mg/dL on ≥ 2 occasions in 24 hours ^[4]
• Recommended insulin regimen ^[4][5]
  • Patients with inadequate or no oral intake: basal insulin or a basal-bolus insulin
  • Patients with adequate oral intake: basal-bolus insulin
  • Patients with an insulin pump: Continue insulin pump therapy whenever possible.
  • Consider correctional insulin alone in patients not on insulin at baseline and without persistent hyperglycemia while inpatient.
  • Avoid prolonged use of a sliding scale insulin regimen.
• Monitoring
  • Patient is NPO or on continuous enteral feeding: Check POC glucose every 4–6 hours.
  • Patient is eating: Check POC glucose before every meal and at bedtime.
  • Continuous glucose monitoring (CGM) if clinically appropriate and locally available ^[4][5]
  • BMP every 1–2 days to monitor creatinine and serum glucose
• Glycemic target: 100–180 mg/dL ^[4][5]
• Other considerations
  • Ensure the patient is on a consistent carbohydrate diet.
  • Hold metformin and sulfonylureas.
  • Continue SGLT2 therapy in patients with heart failure if there are no contraindications. ^[4]
  • A dipeptidyl peptidase-4 inhibitor (e.g., sitagliptin) may be considered in selected patients with T2DM. ^[4][5]
  • Check serum HbA1c if not checked within the past 3 months.

• Indications for insulin therapy: persistently elevated blood glucose > 140 mg/dL ^[5]
• Recommended insulin regimens ^[5]
  • Most patients: correctional insulin
  • Patients with persistent blood glucose ≥ 180 mg/dL: scheduled insulin therapy (e.g., basal-bolus insulin regimen)
• Glycemic target: 100–180 mg/dL ^[5]

• Indication for insulin therapy: blood glucose ≥ 180 mg/dL on ≥ 2 occasions in 24 hours ^[4]
• Recommended insulin regimen
  • Continuous intravenous insulin infusion (IIP) is preferred. ^[4][6]
  • Avoid IIP in the following situations:
    • Rapid normalization of glucose expected
    • Patients close to transfer to a general ward
    • Terminally-ill patients
    • Patients who are eating
  • For patients not on IIP, a basal-bolus insulin regimen is usually appropriate.
• Monitoring: POC glucose hourly in patients on a continuous insulin infusion
• Glycemic target: 140–180 mg/dL ^[4]

• Screening for hyperglycemia ^[7]
  • POC glucose every 6 hours for 24–48 hours
  • Discontinue screening if glucose levels are < 140 mg/dL for 48 hours in nondiabetic patients.
• Indications for insulin therapy: Consider insulin therapy if blood glucose levels are ≥ 140 mg/dL.
• Recommended insulin regimen (see “Insulin regimens for glucocorticoid-induced hyperglycemia” for details)
  • A basal-bolus regimen is preferred (especially for patients receiving dexamethasone).
  • A weight-based NPH insulin regimen for glucocorticoid-induced hyperglycemia may be considered (especially for patients receiving prednisone or prednisolone).
  • Correction only using a sliding-scale insulin regimen may be adequate for the short-term.
• Monitoring
  • Patients is NPO or on continuous enteral feeding: Check POC glucose every 4–6 hours.
  • Patients is eating: Check POC glucose before every meal and at bedtime.
  • BMP every 1–2 days to monitor creatinine and serum glucose
• Other considerations: Adjust the insulin regimen if changing the glucocorticoid dose.

Tailor treatment based on individual factors (e.g., blood glucose level, glucocorticoid regimen, severity of hyperglycemia).

• Screening for hyperglycemia ^[7]
  • POC glucose every 4–6 hours for 24–48 hours
  • Discontinue screening if glucose levels are < 140 mg/dL for 48 hours in nondiabetic patients.
• Indications for insulin therapy ^[8]
  • Blood glucose > 180 mg/dL once
  • Blood glucose 140–180 mg/dL ≥ 2 times
• Recommended insulin regimen ^[4][5][8]
  • An adapted basal-bolus insulin regimen or NPH insulin regimen is preferred in patients receiving enteral nutrition.
  • Regular insulin can be added to parenteral nutrition solutions.
  • Correctional insulin should be included for patients receiving enteral or parenteral nutrition.
  • See “Insulin regimens for enteral and parenteral nutrition.”
• Monitoring: POC glucose every 4–6 hours
• Other considerations
  • Provide diabetes-specific formulas of enteral or parenteral nutrition to help manage blood glucose levels.
  • Patients receiving enteral or parenteral nutrition are at high risk of hypoglycemia.

Patients with T1DM require basal insulin even if feeding is discontinued.

Stress-induced hyperglycemia

• Many stressors can cause hyperglycemia (e.g., ACS, trauma, surgery). ^[9]
• Attempts should be made to identify and treat the underlying stressor.
• Glycemic management is otherwise similar to standard diabetes care (see “Patients with underlying diabetes mellitus”).

Drug-induced hyperglycemia ^[2][10][11]

• Many drugs are associated with hyperglycemia (see “Etiology of hyperglycemia”).
• The decision to reduce or discontinue a drug should be made on an individual basis.
• Glycemic management is otherwise similar to standard diabetes care (see “Patients with underlying diabetes mellitus”).

Patients on continuous subcutaneous insulin infusion (CSII) ^[12]

• Continuation of CSII may be considered in select patients if:
  • The patient demonstrates the capacity to use the pump correctly.
  • No contraindications for CSII are present, e.g.:
    • Patient unable to participate actively in blood sugar management
    • An altered state of consciousness
    • DKA
    • Severe illness (e.g., sepsis)
    • Need for MRI
    • Suicidal ideation
• If CSII is discontinued, a basal-bolus insulin regimen is recommended.

Every patient switched from continuous subcutaneous insulin infusion to another insulin regimen should receive basal insulin.

• Rule out hyperglycemic crisis.
• Rule out sepsis, other reversible causes of hyperglycemia.
• Check HbA1c.
• Hold any medications that may be contributing.
• Ensure patient is on the correct diet (e.g., consistent carbohydrate).
• Start insulin therapy if indicated (see “Insulin regimens”).
• Order monitoring parameters.
• Order hypoglycemia treatment protocol.
• Consider endocrine consult or hyperglycemia team consult if glucose is difficult to control despite appropriate insulin regimen.

• One-Minute Telegram 85-2023-3/3: Liberal vs. tight glucose control in the ICU: The sugar saga continues.

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