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Review Article

Management of Hyperglycemia in Hospitalized Noncritical Patients

Nasser Mikhail, MD, MSc
Volume: 106 Issue: 3 March, 2013

Abstract:

Randomized trials designed to determine optimum blood glucose (BG) levels among hospitalized noncritically ill patients are limited. In this group of patients, experts generally recommend premeal BG targets of 100 to 140 mg/dL, and random BG <180 mg/dL. Scheduled insulin is the mainstay therapy to control hyperglycemia in patients admitted to general wards and should include three components: basal, prandial, and correction insulin. Insulin doses should take into account the severity of hyperglycemia, weight, type of diabetes, age, caloric intake, renal function, and propensity for hypoglycemia. Limited data suggest that the traditional mixed-split insulin regimen formed of neutral protamine hagedorn-regular insulin is similar in efficacy and frequency of hypoglycemia to a more expensive and complex insulin analog regimen formed of twice-daily detemir and mealtime glulisine; however, based on extrapolation of data derived from trials of diabetic outpatients, basal insulin analogs such as glargine or detemir may be used instead of neutral protamine hagedorn insulin if there is concern about hypoglycemia. In patients with erratic meal intake, the use of short-acting insulin analogs may be preferred to regular insulin. Further studies are required to determine the ideal glycemic goals and insulin treatment strategies for control of hyperglycemia in hospitalized noncritically ill patients.

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References:

1. NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360: 1283–1297.
 
2. American Diabetes Association. Executive summary: standards of medical care in diabetes—2011. Diabetes Care 2011; 34 (1 suppl): S4–S10.
 
3. Murad MH, Coburn JA, Coto-Yglesias F, et al. Glycemic control in non-critically ill hospitalized patients: a systemic review and meta-analysis. J Clin Endocrinol Metab 2012; 97: 49–58.
 
4. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2012; 97: 16–38.
 
5. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009; 32: 1119–1131.
 
6. Dungan KM, Braithwaite SS, Preiser J. Stress hyperglycemia. Lancet 2009; 373: 1789–1807.
 
7. DeWitt DE, Hirsch IB. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review. JAMA 2003; 289: 2254–2264.
 
8. Plank J, Bodelenz M, Sinner F, et al. A double-blind, randomized, dose-response study investigating the pharmacodynamic and pharmacokinetic properties of the long-acting insulin analog detemir. Diabetes Care 2005; 28: 1107–1112.
 
9. Umpierrez GE, Hor T, Smiley D, et al. Comparison of inpatient insulin regimens with detemir plus aspart versus neutral protamine hagedorn plus regular in medical patients with type 2 diabetes. J Clin Endocrinol Metab 2009; 94: 564–569.
 
10. Meyer C, Boron A, Plummer E, et al. Glulisine versus human regular insulin in combination with glargine in noncritically ill hospitalized patients with type 2 diabetes: a randomized double-blind study. Diabetes Care 2010; 33: 2496–2501.
 
11. Guerra YS, Lacuesta EA, Yrastorva EA, et al. Insulin injections in relation to meals in the hospital medicine ward: comparison of 2 protocols. Endocr Pract 2011; 17: 737–746.
 
12. Bernard JB, Munoz C, Harper J, et al. Treatment of inpatient hyperglycemia beginning in the emergency department: a randomized trial using insulins aspart and detemir compared with usual care. J Hosp Med 2011; 6: 279–284.
 
13. Horvarth K, Jeitler K, Berghold A, et al. Long-acting insulin analogues versus NPH insulin (human isophane insulin) for type 2 diabetes mellitus. Cochrane Database Syst Rev 2007; 2: CD005613.
 
14. Swinnen SG, Simon ACR, Holleman F, et al. Insulin detemir versus insulin glargine for type 2 diabetes mellitus. Cochrane Database Syst Rev 2011; 7: CD006383.
 
15. Inzucchi SE. Management of hyperglycemia in the hospital setting. N Engl J Med 2006; 355: 1903–1911.
 
16. Uy J, Fogelfeld L, Guerra Y. Cumulative clinical experience with use of insulin lispro: critical appraisal, role in therapy, and patient considerations. Diabetes Metab Syndr Obes 2012; 5: 1–10.
 
17. Hirsch IB. Sliding scale insulin—time to stop sliding. JAMA 2009; 301: 213–214.
 
18. Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care 2007; 30: 2181–2186.
 
19. Umpierrez GE, Smiley D, Jacobs S, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 Surgery). Diabetes Care 2011; 34: 256–261.
 
20. Rubin DJ, Rybin D, Doros G, et al. Weight-based, insulin dose-related hypoglycemia in hospitalized patients with diabetes. Diabetes Care 2011; 34: 1723–1728.
 
21. Shrishrimal K, Hart P, Michota F. Managing diabetes in hemodialysis patients: observations and recommendations. Clev Clin J Med 2009; 76: 649–655.
 
22. Biesenbach G, Raml A, Schmekal B, et al. Decreased insulin requirement in relation to GFR in nephropathic type 1 and insulin-treated type 2 diabetic patients. Diabet Med 2003; 20: 642–645.
 
23. Baldwin D, Zander J, Munoz C, et al. A randomized trial of two weight-based doses of insulin glargine and glulisine in hospitalized subjects with type 2 diabetes and renal insufficiency. Diabetes Care 2012; 35: 1970–1974.
 
24. Bakatselos SO. Hypoglycemia unawareness. Diab Res Clin Pract 2011; 93: S92–S96.
 
25. Bremer JP, Jaugh-Chara K, Hallschmid M, et al. Hypoglycemia unawareness in older compared with middle-aged patients with type 2 diabetes. Diabetes Care 2009; 32: 1513–1517.
 
26. Cranston I, Lomas J, Maran A, et al. Restoration of hypoglycemia awareness in patients with long-duration insulin-dependent diabetes. Lancet 1994; 344: 283–287.
 
27. Ismail-Beigi F. Glycemic management of type 2 diabetes mellitus. N Engl J Med 2012; 366: 1319–1327.
 
28. Pradhan AD, Everett BM, Cook NR, et al. Effects of initiating insulin and metformin on glycemic control and inflammatory biomarkers among patients with type 2 diabetes: the LANCET randomized trial. JAMA 2009; 302: 1186–1194.
 
29. Heller S, Buse J, Fisher M, et al. Insulin degludec, an ultra-longacting basal insulin, versus insulin glargine in basal-bolus treatment with mealtime insulin aspart in type 1 diabetes (BEGIN Basal-Bolus Type 1): a phase 3, randomised, open-label, treat-to-target non-inferiority trial. Lancet 2012; 379: 1489–1497.
 
30. Garber AJ, King AB, Del Prato S, et al. Insulin degludec, an ultra-longacting basal insulin, versus insulin glargine in basal-bolus treatment with mealtime insulin aspart in type 2 diabetes (BEGIN Basal-Bolus Type 2): a phase 3, randomised, open-label, treat-to-target non-inferiority trial. Lancet 2012; 379: 1498–1507.

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