Hyperglycemia management in the hospital setting

Purpose. Recommendations for target blood glucose concentrations; factors that can complicate glycemic control; considerations that determine the aggressiveness of therapy to manage blood glucose levels; the role of oral antihyperglycemic drug therapy, sliding-scale insulin, continuous intravenous (i.v.) insulin infusion, and basal-bolus insulin therapy; the the pharmacodynamics of various insulin products; computer decision support systems; and discharge planning for hospitalized patients with hyperglycemia are described. Summary. Target blood glucose concentrations depend on whether patients are critically ill or not. Factors that can complicate glycemic control include the severity of illness, medications, and inconsistent dietary intake. The expected course of treatment, anticipated length of stay, and preadmission of glycemic control influence the aggressiveness of therapy to manage hyperglycemia. The usefulness of oral antihyperglycemic agents for managing hospital hyperglycemia is limited by difficulty titrating the dosage and promptly achieving target blood glucose concentrations. Sliding scale insulin is not recommended because it is ineffective and potentially dangerous. Continuous i.v. insulin therapy or intermittent subcutaneous (s.c.) basal-bolus plus correction injections is preferred. Basal-bolus plus correction-insulin therapy usually involves a single daily dose of insulin glargine at bedtime to prevent gluconeogenesis and ketogenesis, bolus injections of a rapid-acting insulin shortly before or after meals to meet prandial requirements, and correction bolus injections of rapid-acting insulin as needed for blood glucose elevations before or between meals. Hypoglycemia is the primary limiting factor for achieving optimal glycemic control with insulin therapy. Computer decision support systems can help reduce the risk of insulin infusion rate calculation errors and standardize insulin therapy. Communication with the primary care physician in the outpatient setting is an important part of discharge planning. Conclusion. Sliding-scale insulin is not effective. Continuous i.v. insulin therapy or intermittent s.c. basal-bolus plus correction injections is preferred. Proactive management of hyperglycemia using these methods is needed to achieve and maintain glycemic control in hospitalized patients.