The Complexities of Inpatient Glucose Management

Innovations in Diabetes & Metabolic Care | Fall 2023

Glycemic management of hospitalized patients requires a nuanced, multidisciplinary approach. While glucose goals may vary depending on the individual’s condition and hospital protocols, it is crucial to stabilize blood sugar, avoid hyper- or hypoglycemic episodes and prepare the patient to successfully transition to an outpatient or subacute care setting.  

Patients with Type 1 or Type 2 diabetes are often admitted to the hospital for treatment of another medical condition. “The first consideration is understanding the reason for admission and underlying cause of high blood sugar,” says Ebne Rafi, PharmD, a specialty pharmacist within the University Hospitals Diabetes and Metabolic Care Center. He highlights some key considerations for the care team.

Determine the Diagnosis

Dr. Rafi points out that not all patients who have elevated blood sugar have diabetes. In the inpatient setting, hyperglycemia can occur independent of a diabetes mellitus diagnosis. “Physical stress or trauma can cause glucose levels to rise,” he says. “As that stress resolves, blood sugar will often normalize.”

Patients may also experience medication-induced hyperglycemia. Drugs commonly used in the inpatient setting — most notably, steroids — may promote hyperglycemia. “People with asthma, chronic obstructive pulmonary disease or COVID-19 might be put on high-dose steroids, which could warrant concomitant insulin therapy,” says Dr. Rafi. Conditions including inflammation, allergic reaction, lupus and multiple sclerosis could also require steroid and insulin dosing.

Define Protocols

When indicated, exogenous insulin must meet patients’ basal, nutritional and correctional needs. “Broadly speaking, most patients will require some combination of long- and short-acting insulin,” says Dr. Rafi. “Regardless of the reason for admission or nutritional status, individuals with Type 1 diabetes are completely dependent on exogenous basal insulin.” 

While specific targets may vary among institutions, the American Diabetes Association recommends glucose levels stay below 180 mg/dL for the management of noncritical inpatient diabetes. Patients in the ICU or cardiac patients may require stricter glucose management. For patients designated nothing-by-mouth (NPO) or receiving continuous tube feeds or total parental nutrition (TPN), blood sugar should be checked every four to six hours. 

Address Insulin Pumps

Increasingly, people with diabetes who are admitted to the hospital rely on insulin pumps and want to continue to utilize them during their hospitalization. “Establishing clear guidelines can enable patients to stay on their pump,” says Dr. Rafi. “From a pharmacist’s standpoint, cross-training with the nursing team is crucial to ensure there is always someone knowledgeable at the bedside who is able to adjust the pump or change cartridges.” 

Other considerations include whether patients are permitted to bring their own supplies and how they will be labeled, stored and documented in their electronic medical record. Although each hospital sets policies on managing pumps and supplies, Dr. Rafi notes that insulin administered through a patient’s pump should always be controlled and distributed by the inpatient pharmacy.

Evaluate Non-insulin Therapies

Typically, non-insulin therapies are only prescribed for people with Type 2 diabetes. “The reason is that starting non-insulin therapies can take weeks to go into full effect and do not lead to immediate glycemic control,” says Dr. Rafi. “If patients are admitted while on these medications, the care team will determine whether they should be continued during hospitalization.” 

Potentially dangerous interactions warrant holding non-insulin therapies. For example, metformin can lead to acute kidney damage if used with radioactive contrast media. “Things change rapidly in the inpatient setting,” says Dr. Rafi. “If there is concern that a patient may need emergent MRIs or other imaging requiring contrast dyes, holding metformin for 48 hours prior is recommended.”

Similarly, providers may choose to halt SGLT2 inhibitors during a hospital stay. “These medications may lead to acute dehydration,” says Dr. Rafi. “If someone has an underlying kidney issue, heart failure exacerbation or other risk of dehydration, holding this class of medications is indicated.”

Absent these risks, Dr. Rafi notes that SGLT2 inhibitors need not be interrupted in the inpatient setting. “These agents provide effective glycemic control and notable cardiovascular benefits,” he says.

Coordinate Transition of Care

Communication between inpatient and outpatient providers is essential to ensure proper transition of care. “One of the things we do very well in our program is triage patients to appropriate outpatient care,” says Dr. Rafi. “Following their hospital stay, people are quickly seen in our clinic.” There, providers provide continuing care and follow patients and/or triage to primary care. The specialists within the UH Diabetes and Metabolic Care Center also connect people to leading diabetes technology and training, including continuous glucose monitors and insulin pumps.

“Outdated care models tended to be fragmented, leading to readmissions, patient frustration or duplication of workflow,” says Dr. Rafi. “Our inpatient and outpatient team members share information and collaborate so that everyone is prepared to meet our patients’ needs.”

For more information, contact the UH Diabetes and Metabolic Care Center at (440) 860-2353.

Contributing Expert:
Ebne Rafi, PharmD
University Hospitals Diabetes and Metabolic Care Center