Inpatient Diabetes Management

Admission & Targets - Glucose Goals

• Initial Assessment:
  • Check: HbA1c, Random Plasma Glucose (RPG) / Fasting Plasma Glucose (FPG).
  • Identify: Prior Diabetes Mellitus (DM), new hyperglycemia, stress-induced hyperglycemia.
• Glucose Targets (Non-Critically Ill Patients):
  • Standard Range: 140-180 mg/dL (7.8-10.0 mmol/L).
    • Pre-meal: <140 mg/dL (7.8 mmol/L).
    • Random: <180 mg/dL (10.0 mmol/L).
  • Stricter Range (for select patients*): 110-140 mg/dL (6.1-7.8 mmol/L).
    • *Criteria: Younger, few comorbidities, low hypoglycemia risk; if achievable without significant hypoglycemia.
  • ⚠️ Hypoglycemia: Avoid <70 mg/dL (3.9 mmol/L).

⭐ For most hospitalized non-critically ill patients, the recommended glycemic target is 140-180 mg/dL (7.8-10.0 mmol/L). For selected patients (e.g. younger, few comorbidities, low hypoglycemia risk), a target of 110-140 mg/dL (6.1-7.8 mmol/L) may be considered if achievable without significant hypoglycemia.

Insulin Therapy - Sweet Control

⭐ Basal-bolus insulin regimen (long-acting basal + rapid-acting prandial) is the preferred method for glycemic control in most hospitalized, non-critically ill patients with good nutritional intake, over sliding scale insulin (SSI) alone.

• Insulin Categories & Use:
  • Basal: Long-acting (Glargine, Detemir) or Intermediate (NPH). Controls fasting BG.
  • Prandial (Bolus): Rapid-acting (Lispro, Aspart) or Short-acting (Regular). Covers meals.
  • Correction: Rapid/Short-acting for pre-meal hyperglycemia. Adjust based on BG.
• Key Regimens:
  • Basal-Bolus: Preferred. TDD 0.3-0.5 U/kg/day (split 50% basal, 50% prandial).
  • SSI: Reactive, use cautiously, often supplemental.
• IV Insulin: For DKA, HHS, critically ill, perioperative. Regular insulin.
• ⚠️ Hypoglycemia (BG < 70 mg/dL): Treat with 15g fast-acting carbs. 📌 Rule of 15.

Special Scenarios - Tricky Sugars

• NPO / Poor Intake:
  • Hold prandial insulin.
  • Basal insulin: continue, may ↓ 20-50% (if prolonged NPO or high hypoglycemia risk).
  • Correction insulin PRN. Monitor BG q4-6h.
  • Treat hypoglycemia if BG < 70 mg/dL.
• Steroid-Induced Hyperglycemia:
  • Typical: Afternoon/evening ↑BG.
  • NPH insulin can be effective (peak action may coincide).
  • Anticipate ↑ insulin requirements.

  ⭐ In patients receiving high-dose glucocorticoids, hyperglycemia typically peaks in the afternoon and evening. Using NPH insulin once or twice daily can be effective as its peak action may coincide with the peak glucocorticoid effect.

• DKA/HHS (Initial Steps):
  • IVF (0.9% NS initially).
  • IV Regular Insulin (e.g., 0.1 U/kg/hr).
  • K+ monitoring & replacement crucial.
• Perioperative Management:
  • Target BG: 140-180 mg/dL.
  • AM of Surgery: Hold oral antidiabetic agents. Basal insulin: give 50-75% of usual dose. Hold prandial insulin.
  • Intra/Post-op: IV insulin infusion or adjust regimen based on oral intake.

Monitoring & Discharge - Safe Send-off

• Ongoing Monitoring:
  • Regular SMBG (pre-meal, bedtime); adjust therapy to trends.
  • Target: Most inpatients 70-180 mg/dL.
  • Review HbA1c (if not recent).
• Discharge Essentials:
  • Glycemic stability for ≥24-48h pre-discharge.
  • Detailed medication reconciliation & clear instructions.
  • Scheduled follow-up: PCP/Endocrinologist within 1-4 weeks.
• Patient Empowerment:

  ⭐ Before discharge, all patients on new or significantly changed insulin regimens must receive education on 'survival skills,' including insulin administration, SMBG, signs/symptoms and treatment of hypoglycemia, and sick day rules.

High‑Yield Points - ⚡ Biggest Takeaways

• Target blood glucose for most hospitalized patients: 140-180 mg/dL.
• Basal-bolus insulin (BBI) is standard; avoid sliding scale insulin alone.
• Discontinue most oral hypoglycemic agents (OHAs) upon hospital admission.
• Treat hypoglycemia (BG <70 mg/dL) promptly with the Rule of 15.
• DKA/HHS: Prioritize IV fluids, then insulin; closely monitor potassium.
• Anticipate and manage steroid-induced hyperglycemia with appropriate insulin.
• Maintain perioperative glucose <180 mg/dL to reduce surgical complications.