Diabetes and Hyperglycemia in the Hospital Setting

How does the inpatient diabetes-management environment differ from the outpatient environment?

Inpatient care is controlled/observable with acute hyperglycemia causes and complex dosing; outpatient is unverified with chronic management.

Approximately what percentage of hospitalized patients with hyperglycemia do NOT have a prior diagnosis of diabetes?

30%.

Why is newly diagnosed hyperglycemia clinically important in hospitalized patients?

It is an independent risk factor for poor outcomes, including increased mortality and lower functional status.

What adverse outcomes are associated with inpatient hyperglycemia?

Prolonged hospital stay, increased ICU admission, surgical infection, LTC facility discharge, and increased morbidity/mortality.

What are major causes of hyperglycemia in hospitalized patients?

Uncontrolled diabetes, variable food intake, stress-related cortisol/catecholamine release, and medications.

What medications or therapies can contribute to inpatient hyperglycemia?

Thiazides, steroids, dextrose-containing solutions (TPN), vasopressors, atypical antipsychotics, and phenytoin.

What glucose screening should patients receive upon hospital admission?

A blood glucose test regardless of prior diabetes diagnosis.

Which hospitalized patients should have an A1C measured?

Patients with known diabetes or BG ≥140 mg/dL if no A1C was measured in the past 3 months.

What A1C suggests that diabetes preceded the hospitalization rather than representing acute stress hyperglycemia?

A1C ≥6.5%.

How often should point-of-care glucose be checked in hospitalized patients who are eating?

Before meals (AC).

How often should glucose be checked in patients who are NPO, receiving TPN, or receiving continuous enteral feeding?

Every 4-6 hours.

How often should glucose be monitored during an IV insulin infusion?

Approximately every 30 minutes to 2 hours.

Is continuous glucose monitoring (CGM) FDA-approved for inpatient use according to the lecture?

No.

Can a hospitalized patient continue using their own CGM?

Yes, with confirmatory point-of-care testing according to hospital protocol.

At what persistent blood glucose level should insulin or other therapy generally be initiated in hospitalized adults?

>180 mg/dL.

What is the blood glucose target for most critically ill/ICU patients?

140-180 mg/dL.

What alternative glucose target may be appropriate for selected critically ill patients?

110-140 mg/dL, while avoiding hypoglycemia.

What is the blood glucose target for patients in noncritical care settings?

100-180 mg/dL.

Are perioperative patients included in the noncritical inpatient glucose target of 100-180 mg/dL?

Yes.

Why aren't extremely tight glucose targets routinely used in hospitalized patients?

Intensive control can increase mortality and severe hypoglycemia.

What did the NICE-SUGAR trial compare?

Intensive glucose control (81-108 mg/dL) vs conventional control (144-180 mg/dL) in ICU patients.

What were the major findings of the NICE-SUGAR trial?

Intensive therapy increased mortality by 2.6% and severe hypoglycemia (<40 mg/dL) by 6.3%

What medication is preferred for managing hyperglycemia in hospitalized patients?

Insulin.

What type of insulin therapy is preferred in critically ill patients?

Continuous IV insulin.

What insulin regimen is preferred for noncritically ill patients with poor oral intake or who are NPO?

Basal insulin or basal + correction insulin (Basal-Plus).

What insulin regimen is preferred for noncritically ill patients with good nutritional intake?

Basal + prandial + correction insulin (Basal-Bolus).

What components make up a Basal-Plus regimen?

Basal insulin + correction insulin.

What components make up a Basal-Bolus regimen?

Basal + prandial + correction insulin.

What best practices does the ADA recommend for inpatient insulin use?

Use standardized ordering/administration protocols and consult a glucose-management team if available.

What is an insulin drip?

A continuous IV insulin infusion.

What is the standard concentration of an IV insulin infusion?

1 unit/mL.

How is the standard IV insulin concentration commonly prepared?

100 units regular insulin in 100 mL 0.9% NaCl (normal saline).

What type of insulin is used for standard IV insulin infusion?

Regular insulin.

Is an IV insulin bolus always required before beginning the infusion?

No, an IV bolus is optional.

How are IV insulin infusions generally adjusted?

According to blood glucose levels using an institutional protocol.

How frequently should glucose initially be checked during an insulin drip?

Every hour initially.

What happens once a patient on IV insulin becomes stable?

Transition to subcutaneous insulin.

What is the purpose of basal insulin in a basal-bolus regimen?

To provide background/basal insulin requirements.

How often is basal insulin generally administered in the hospital?

1-2 times per day.

Which basal insulins are specifically listed in the basal-bolus regimen?

Insulin glargine and insulin degludec.

Which basal insulins are preferred over NPH according to the lecture?

Glargine and degludec.

When is prandial insulin administered?

At mealtimes.

Which rapid-acting insulins are listed for prandial therapy?

Aspart (NovoLog), lispro (Humalog), and glulisine (Apidra).

What type of insulin is preferred for prandial coverage over regular insulin?

Rapid-acting insulin analogs (aspart, lispro, glulisine).

What is correction insulin?

Insulin given at pre-specified times to correct elevated glucose levels.

What insulin should generally be used for correction doses?

The same insulin used for mealtime/bolus coverage.

What is the approximate total daily insulin dose (TDD) for an insulin-naïve hospitalized patient?

0.2-0.4 units/kg/day.

What initial basal insulin dose is recommended for an insulin-naïve inpatient?

0.1-0.2 units/kg/day.

How may glargine or degludec be administered for basal coverage?

SQ once daily, either QAM or QHS.

What initial prandial insulin dose is recommended for an insulin-naïve inpatient?

0.1-0.2 units/kg/day SQ divided between meals.

What type of insulin is preferred for prandial dosing?

A rapid-acting insulin analog.

What should generally be done with insulin in a patient who was already using insulin at home?

Continue home dose or slightly reduce if hypoglycemia is a concern.

What is the purpose of a correction factor?

To estimate how much 1 unit of insulin will lower blood glucose.

What rule is used to calculate a correction factor for rapid-acting analog insulin?

The 1800 rule.

How is the correction factor calculated using the 1800 rule?

1800 ÷ total daily insulin dose (TDD).

What does the result of the 1800 rule represent?

The expected mg/dL reduction in blood glucose per 1 unit of insulin.

For which insulins is the 1800 rule most accurate?

Rapid-acting analogs (aspart, lispro, glulisine).

What correction-factor rule was originally developed for regular insulin?

The 1500 rule.

What are examples of standardized correction-scale categories?

Low/medium/high or sensitive/usual/resistant.

Is sliding-scale-only insulin recommended for inpatient glucose management?

No, guidelines universally recommend against it.

Why is sliding-scale-only insulin considered reactive?

It treats hyperglycemia after it has already occurred.

What are major problems with sliding-scale-only insulin?

It is reactive, unaligned with meals, and not individualized.

What inpatient SQ insulin strategies are preferred over sliding-scale-only insulin?

Basal-bolus or basal-plus therapy.

What insulin regimen should be used when a hospitalized patient is NPO?

Basal-Plus (basal + correction insulin, no scheduled prandial).

Should basal insulin be stopped simply because a patient is NPO?

No, basal insulin should still be administered.

Can correction insulin still be given to an NPO patient?

Yes.

What insulin regimen may be used in patients receiving TPN or continuous enteral feedings?

Basal + correction insulin without scheduled prandial insulin.

What alternative insulin strategy may be used for patients receiving TPN?

Regular insulin added directly into the TPN solution.

What are examples of non-formulary insulin products that may require inpatient modification?

Premixed 70/30, U-300 insulin, and NPH.

What can be done if a stable patient uses a non-formulary insulin at home?

The patient may bring home insulin if hospital policy allows.

What should be done if a patient's non-formulary insulin cannot be continued?

Convert to formulary insulin using proper dose conversions.

When may a patient be allowed to self-manage an insulin pump while hospitalized?

When competent, with stable consciousness and stable dosing.

What is the alternative to allowing a patient to continue their insulin pump in the hospital?

Convert to basal-bolus-correction insulin.

When converting an insulin pump to injections, how should the pump's basal rate be replaced?

Administer basal insulin (glargine, degludec, or detemir).

When converting an insulin pump to injections, what should replace mealtime and correction doses?

Rapid-acting insulin (aspart, lispro, or glulisine).

Which oral diabetes medication classes are generally NOT recommended for inpatient use?

Sulfonylureas, meglitinides, TZDs, metformin (certain cases), and SGLT-2 inhibitors (certain cases).

Which oral agents may be considered in stable inpatients?

DPP-4 inhibitors, α-glucosidase inhibitors, and metformin when appropriate.

What is generally done when a patient's home oral medication is inappropriate for inpatient use?

Discontinue it and start basal/bolus/correction insulin.

If an oral medication is continued in a stable inpatient, what can be added if additional glucose control is needed?

Basal/bolus/correction insulin as needed.

Why are sulfonylureas generally avoided in hospitalized patients?

Risk of hypoglycemia.

Why are meglitinides generally avoided in hospitalized patients?

Risk of hypoglycemia.

Why are thiazolidinediones problematic in hospitalized patients?

Risk of edema and heart failure.

When is metformin NOT recommended in hospitalized patients?

With unstable renal function or when receiving IV contrast.

When may metformin be resumed after IV contrast according to the lecture?

48 hours post-contrast if serum creatinine is normal.

Can metformin be used in stable hospitalized patients?

Yes, when appropriate.

When may an SGLT-2 inhibitor be started or continued in a hospitalized patient?

In T2DM patients hospitalized for heart failure after recovering without contraindications.

What risks of SGLT-2 inhibitors are emphasized in the lecture?

UTI/infection and volume depletion/AKI.

Why may DPP-4 inhibitors be useful in stable hospitalized patients?

They carry minimal risk of hypoglycemia.

Which DPP-4 inhibitors should be considered for discontinuation in patients with heart failure according to the lecture?

Saxagliptin and alogliptin.

When may α-glucosidase inhibitors be appropriate in hospitalized patients?

In stable patients consuming meals at regular intervals.

Can GLP-1 receptor agonists be used in hospitalized patients?

Limited data suggest they may be appropriate for hospital use.

What should be verified if a GLP-1 receptor agonist is used in the hospital?

Verify correct formulation and previous home dose.

Should pramlintide be used in hospitalized patients?

Avoid due to hypoglycemia risk.

How is hypoglycemia defined in this lecture?

Blood glucose <70 mg/dL

Why is inpatient hypoglycemia clinically important?

It is associated with increased mortality risk.

Can inpatient hypoglycemia occur in patients without diabetes?

Yes.

What factors can contribute to hypoglycemia in hospitalized patients?

Altered nutrition, comorbidities, inappropriate insulin timing, and medication mismanagement.

What should be the primary goal regarding inpatient hypoglycemia?

Prevention.

What should hospitals do with hypoglycemic events as part of quality improvement?

Track and analyze them.

How should inpatient hypoglycemia protocols be structured?

Standardized and nurse-driven.