Inpatient hyperglycemia management: A practical review for primary medical and surgical teams

M. Cecilia Lansang; Guillermo E. Umpierrez

doi:10.3949/ccjm.83.s1.06

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FIGURE 1
Initial insulin treatment for patients with type 2 diabetes in the non-intensive care setting.

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TABLE 1

Major guidelines for treatment of hyperglycemia in a hospital setting

Organization	Intensive care unit	Non-intensive care unit
American Diabetes Association/American Association of Endocrinologists¹³	Initiate insulin therapy for persistent hyperglycemia (glucose > 180 mg/dL [10 mmol/L]). Treatment goal: For most patients, target a glucose level between 140 and 180 mg/dL. More stringent goals (110–140 mg/dL) may be appropriate for select patients, if achievable without significant risk of hypoglycemia.	No specific guidelines. If treated with insulin, premeal glucose targets should generally be < 140 mg/dL, with random glucose levels < 180 mg/dL.
American College of Physicians⁴⁶	Recommends against intensive insulin therapy in patients with or without diabetes in surgical or medical intensive care. Treatment goal: Target glucose level is between 140 and 200 mg/dL in patients with or without diabetes in surgical or medical intensive care.
Critical Care Society²⁹	Glucose level > 150 mg/dL should trigger insulin therapy. Treatment goal: Maintain glucose level < 150 mg/dL for most adult patients in intensive care. Maintain glucose level < 180 mg/dL while avoiding hypoglycemia.
Endocrine Society²⁶		Premeal glucose target < 140 mg/dL. Random glucose < 180 mg/dL. A lower target range may be appropriate in patients able to achieve and maintain glycemic control without hypoglycemia. Glucose < 180–200 mg/dL is appropriate in patients with terminal illness or with limited life expectancy or at high risk for hypoglycemia. Adjust antidiabetic therapy when glucose falls < 100 mg/dL to avoid hypoglycemia.
Society of Thoracic Surgeons²⁸	Guidelines specific to adult cardiac surgery. Continuous insulin infusion preferred over subcutaneous or intermittent intravenous boluses. Treatment goal: Recommend glucose < 180 mg/dL during surgery (≤ 110 mg/dL in fasting and premeal states).
Joint British Diabetes Societies²⁷		Target glucose levels in most patients are between 6 and 10 mmol/L (108–180 mg/dL) with an acceptable range of between 4 and 12 mmol/L (72–216 mg/dL).

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TABLE 2

Insulin classes: Onset-of-action profiles

Insulin class	Generic (brand)	Onset	Peak	Duration
Fast- or rapid-acting	Aspart (Novolog)	10–15 min	~60 min	3–4 hrs
	Lispro (Humalog)	10–15 min	~60 min	3–4 hrs
	Glulisine (Apidra)	10–15 min	~60 min	3–4 hrs
Short-acting	Regular insulin (Humulin R, Novolin R/ReliOn R)	30–60 min	2–4 hrs	6–8 hrs
Intermediate-acting	NPH insulin (Humulin N, Novolin N/ReliOn N)	1–2 hrs	3–8 hrs	12–15 hrs
Long-acting	Glargine (Lantus)	2 hrs	No real peak	22–24 hrs
	Glargine (Toujeo)	6 hrs	No real peak	22–24 hrs
	Glargine (Basaglar)^a	2 hrs	No real peak	24 hrs
	Detemir (Levemir)	3–8 hrs	No real peak	17–24 hrs
	Degludec (Tresiba)	1 hr	No real peak	42 hrs
Premixed	75% Insulin lispro protamine/25% insulin lispro (Humalog mix 75/25)	5–15 min	Dual	10–16 hrs
	50% Insulin lispro protamine/50% insulin lispro (Humalog mix 50/50)	5–15 min	Dual	10–16 hrs
	70% Insulin lispro protamine/30% insulin aspart (Novolog mix 70/30)	5–15 min	Dual	10–16 hrs
	70% NPH insulin/30% regular insulin (Humulin, Novolin/ReliOn)	30–60 min	Dual	10–16 hrs

↵a Approved by the US Food and Drug Administration; scheduled to be marketed December 2016.
NPH = neutral protamine Hagedorn.

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TABLE 3

Comparison of medications for the management of hyperglycemia in the hospital setting

Medication	Advantages	Disadvantages
Insulin	Extensive experience with glycemic control Protocols widely available Easy to adjust in the event of hypoglycemia, changes in nutrition, diagnostic procedures, or reduced kidney function	Hypoglycemia Common source of hospital errors Requires injection
GLP-1-based therapy	Good glucose-lowering effect Low risk for hypoglycemia Nonglycemic beneficial effects	Limited data on safety and efficacy Gastrointestinal side effects Injectable
Metformin	Good glucose-lowering effect Low risk for hypoglycemia Inexpensive Oral route	Limited experience Risk of lactic acidosis in patients with impaired kidney function, heart failure, hypoxemia, alcoholism, cirrhosis, contrast exposure, surgery, and shock Gastrointestinal side effects
Sulfonylureas	Good glucose-lowering effect Inexpensive Oral route	Risk for hypoglycemia especially in patients with reduced oral intake or impaired renal function.
Thiazolidinediones	Good glucose-lowering effect Low risk of hypoglycemia Oral route	Slow onset of action Contraindicated in patients with heart failure and hepatic dysfunction Fluid retention
Bromocriptine-quick release	Low risk of hypoglycemia Oral route	No studies in the hospital Risk of hypotension, dizziness
Colesevelam	Low risk of hypoglycemia Oral route	No studies in the hospital Constipation
DPP-4-inhibitors	Modest glucose-lowering effect Low risk of hypoglycemia No major side effects reported in pilot trial Oral route	Limited experience Contraindicated in patients with history of pancreatitis
SGLT-2-inhibitors	Good glucose-lowering effect Low risk of hypoglycemia Oral route	Limited experience Increase risk of urinary and genital tract infections Risk of dehydration, hypotension

DPP-4 = dipeptidyl peptidase-4; GLP-1 = glucagon-like peptide-1; SGLT-2= sodium-glucose cotransporter-2.

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TABLE 4

General contraindications to pump use in the hospital

Altered state of consciousness

Suicidal ideation

Prolonged instability of glucose levels

Diabetic ketoacidosis

Patient or family inability or refusal to participate in own care

Insulin pump malfunction

Lack of appropriate supplies for the insulin pump

Other circumstances as identified by the healthcare provider

Reprinted with permission from John Wiley and Sons (Lansang MC, Modic MB, Sauvey R, et al. Approach to the adult hospitalized patient on an insulin pump. J Hosp Med 2013; 8:721–727). © 2013 Society of Hospital Medicine.