In-hospital Management of Diabetes

Abstract

Key Messages•Hyperglycemia is common in hospitalized patients, even in those without a previous history of diabetes, and is associated with increased in-hospital complications, length of hospital stay and mortality.•Insulin is the most appropriate agent for effectively controlling glycemia in-hospital. A proactive approach to management using scheduled basal, bolus and correction (supplemental) insulin is the preferred method. The use of sliding-scale insulin (SSI), which treats hyperglycemia after it has occurred, should be discouraged.•For the majority of noncritically ill patients treated with insulin, preprandial blood glucose (BG) targets should be 5.0 to 8.0 mmol/L, in conjunction with random BG values <10.0 mmol/L, as long as these targets can be safely achieved. For critically ill patients, BG levels should be maintained between 8.0 and 10.0 mmol/L. •Hyperglycemia is common in hospitalized patients, even in those without a previous history of diabetes, and is associated with increased in-hospital complications, length of hospital stay and mortality.•Insulin is the most appropriate agent for effectively controlling glycemia in-hospital. A proactive approach to management using scheduled basal, bolus and correction (supplemental) insulin is the preferred method. The use of sliding-scale insulin (SSI), which treats hyperglycemia after it has occurred, should be discouraged.•For the majority of noncritically ill patients treated with insulin, preprandial blood glucose (BG) targets should be 5.0 to 8.0 mmol/L, in conjunction with random BG values <10.0 mmol/L, as long as these targets can be safely achieved. For critically ill patients, BG levels should be maintained between 8.0 and 10.0 mmol/L. Diabetes increases the risk for disorders that predispose individuals to hospitalization, including cardiovascular disease, nephropathy, infection, cancer and lower-extremity amputations. In-hospital hyperglycemia is common. Umpierrez et al. (1Umpierrez G.E. Isaacs S.D. Bazargan N. et al.Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes.J Clin Endocrinol Metab. 2002; 87: 978-982Crossref PubMed Scopus (1187) Google Scholar) reviewed the medical records of over 2000 adult patients admitted to a community teaching hospital in the United States (>85% were non-intensive care unit [non-ICU] patients) and found that hyperglycemia was present in 38% of patients. Of these patients, 26% had a known history of diabetes, and 12% had no history of diabetes prior to admission (1Umpierrez G.E. Isaacs S.D. Bazargan N. et al.Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes.J Clin Endocrinol Metab. 2002; 87: 978-982Crossref PubMed Scopus (1187) Google Scholar). Diabetes has been reported to be the fourth most common comorbid condition listed on all hospital discharges (2Vasa F. Systematic strategies for improved outcomes for the hyperglycemic hospitalized patient with diabetes mellitus.Am J Cardiol. 2005; 96: 41E-46EAbstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar). Acute illness results in a number of physiological changes (e.g. increases in circulating concentrations of stress hormones) or therapeutic choices (e.g. glucocorticoid use) that can exacerbate hyperglycemia. Hyperglycemia, in turn, causes physiological changes that can exacerbate acute illness, such as decreased immune function and increased oxidative stress. This leads to a vicious cycle of worsening illness and poor glucose control (3Inzucchi S.E. Clinical practice. Management of hyperglycemia in the hospital setting.N Engl J Med. 2006; 355: 1903-1911Crossref PubMed Scopus (309) Google Scholar). Although a growing body of literature supports the need for targeted glycemic control in the hospital setting, blood glucose (BG) continues to be poorly controlled and is frequently overlooked in general medicine and surgery services. This is largely explained by the fact that the majority of hospitalizations for patients with diabetes are not directly related to the metabolic state, and diabetes management is rarely the primary focus of care. Therefore, glycemic control and other diabetes care issues are often not adequately addressed (4Roman S.H. Chassin M.R. Windows of opportunity to improve diabetes care when patients with diabetes are hospitalized for other conditions.Diabetes Care. 2001; 24: 1371-1376Crossref PubMed Scopus (53) Google Scholar). A history of diabetes should be elicited in all patients admitted to hospital and, if present, should be clearly identified on the medical record. In view of the high prevalence of inpatient hyperglycemia with associated poor outcomes, an admission BG measurement should be considered for all patients even in the absence of a prior diagnosis of diabetes (1Umpierrez G.E. Isaacs S.D. Bazargan N. et al.Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes.J Clin Endocrinol Metab. 2002; 87: 978-982Crossref PubMed Scopus (1187) Google Scholar). In-hospital hyperglycemia is defined as any glucose value >7.8 mmol/L (5Moghissi E.S. Korytkowski M.T. DiNardo M. et al.American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control.Endocr Pract. 2009; 15: 353-369Crossref PubMed Scopus (450) Google Scholar). A glycated hemoglobin (A1C) level should be drawn in all patients with known diabetes or with hyperglycemia if this has not been performed within 2 to 3 months of the admission. For patients with known diabetes, the A1C identifies patients who would benefit from efforts to improve glycemic control. For patients with newly recognized hyperglycemia, an elevated A1C may help differentiate patients with previously undiagnosed diabetes from those with stress-induced hyperglycemia (6Norhammar A. Tenerz A. Nilsson G. et al.Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study.Lancet. 2002; 359: 2140-2144Abstract Full Text Full Text PDF PubMed Scopus (929) Google Scholar). A number of studies have demonstrated that inpatient hyperglycemia is associated with increased morbidity and mortality in noncritically ill hospitalized patients (1Umpierrez G.E. Isaacs S.D. Bazargan N. et al.Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes.J Clin Endocrinol Metab. 2002; 87: 978-982Crossref PubMed Scopus (1187) Google Scholar, 7Baker E.H. Janaway C.H. Philips B.J. et al.Hyperglycaemia is associated with poor outcomes in patients admitted to hospital with acute exacerbations of chronic obstructive pulmonary disease.Thorax. 2006; 61: 284-289Crossref PubMed Scopus (285) Google Scholar, 8Cheung N.W. Napier B. Zaccaria C. et al.Hyperglycemia is associated with adverse outcomes in patients receiving total parenteral nutrition.Diabetes Care. 2005; 28: 2367-2371Crossref PubMed Scopus (168) Google Scholar, 9McAlister F.A. Majumdar S.R. Blitz S. et al.The relation between hyperglycemia and outcomes in 2,471 patients admitted to the hospital with community-acquired pneumonia.Diabetes Care. 2005; 28: 810-815Crossref PubMed Scopus (320) Google Scholar). However, due to a paucity of randomized controlled trials on the benefits and risks of “loose” vs. “tight” glycemic control in noncritically ill patients, it is difficult to define glycemic targets for this population. Current recommendations are based on clinical experience and judgement. Glycemic targets for hospitalized patients are modestly higher than those routinely advised for outpatients with diabetes given that the hospital setting presents unique challenges for the management of hyperglycemia, such as variations in patient nutritional status and the presence of acute illness. For the majority of noncritically ill patients treated with insulin, preprandial glucose targets should be 5.0 to 8.0 mmol/L, in conjunction with random BG values <10.0 mmol/L, as long as these targets can be safely achieved. Lower targets may be considered in clinically stable patients with a prior history of successful tight glycemic control in the outpatient setting, while higher targets may be acceptable in terminally ill patients or in those with severe comorbidities. If BG values are ≤3.9 mmol/L, the glucose-lowering therapy should be modified, unless the event is easily explained by other factors (e.g. a missed meal) (5Moghissi E.S. Korytkowski M.T. DiNardo M. et al.American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control.Endocr Pract. 2009; 15: 353-369Crossref PubMed Scopus (450) Google Scholar). Acute hyperglycemia in the intensive care setting is not unusual and results from a number of factors, including stress-induced counterregulatory hormone secretion and the effects of medications administered in the ICU (10Lewis K.S. Lane-Gill S.L. Bobek M.G. et al.Intensive insulin therapy for critically ill patients.Ann Pharmacother. 2004; 38: 1243-1251Crossref PubMed Scopus (86) Google Scholar). Appropriate glycemic targets for patients with preexisting diabetes who are critically ill (ICU setting) have not been firmly established. Some trials showed that achieving normoglycemia (4.4 to 6.1 mmol/L) in cardiac surgery patients or patients in postoperative surgical ICU settings may reduce mortality (11van den Berghe G. Wouters P. Weekers F. et al.Intensive insulin therapy in the critically ill patients.N Engl J Med. 2001; 345: 1359-1367Crossref PubMed Scopus (8161) Google Scholar). However, subsequent trials in mixed populations of critically ill patients did not show a benefit of targeting BG levels of 4.4 to 8.3 mmol/L. A meta-analysis of trials of intensive insulin therapy in the ICU setting suggested some benefit of intensive insulin therapy in surgical patients, but not in medical patients (12Griesdale D.E.G. deSouza R.J. vanDam R.M. et al.Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data.CMAJ. 2009; 180: 821-827Crossref PubMed Scopus (859) Google Scholar). However, this benefit in surgical ICU patients was not demonstrated in the Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study, the largest trial to date of intensive glucose control in critically ill patients (13Finfer S. Chittock D.R. Su S.Y. et al.NICE-SUGAR Study InvestigatorsIntensive versus conventional glucose control in critically ill patients.N Engl J Med. 2009; 360: 1283-1297Crossref PubMed Scopus (3738) Google Scholar). Furthermore, intensive insulin therapy has been associated with an increased risk of hypoglycemia in the ICU setting (12Griesdale D.E.G. deSouza R.J. vanDam R.M. et al.Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data.CMAJ. 2009; 180: 821-827Crossref PubMed Scopus (859) Google Scholar). Therefore, it is recommended to maintain BG levels between 8.0 and 10.0 mmol/L in critically ill patients; a lower BG target (but not <6.0 mmol/L) may be appropriate in select patients. Insulin infusion protocols with proven efficacy and safety are recommended to minimize the risk of hypoglycemia (5Moghissi E.S. Korytkowski M.T. DiNardo M. et al.American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control.Endocr Pract. 2009; 15: 353-369Crossref PubMed Scopus (450) Google Scholar). The management of individuals with diabetes at the time of surgery poses a number of challenges. Acute hyperglycemia is common secondary to the physiological stress associated with surgery. Preexisting diabetes-related complications and comorbidities may also influence clinical outcomes. Acute hyperglycemia has been shown to adversely affect immune function (14Kwoun M.O. Ling P.R. Lydon E. et al.Immunologic effects of acute hyperglycemia in nondiabetic rats.J Parenter Enteral Nutr. 1997; 21: 91-95Crossref PubMed Scopus (106) Google Scholar) and wound healing (15Verhofstad M.H. Hendriks T. Complete prevention of impaired anastomotic healing in diabetic rats requires preoperative blood glucose control.Br J Surg. 1996; 83: 1717-1721Crossref PubMed Scopus (45) Google Scholar) in animal models. Observational studies in humans have shown that hyperglycemia increases the risk of postoperative infections (16Golden S.H. Peart-Vigilance C. Kao W.H. et al.Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes.Diabetes Care. 1999; 22: 1408-1414Crossref PubMed Scopus (466) Google Scholar, 17Pomposelli J.J. Baxter 3rd, J.K. Babineau T.J. et al.Early postoperative glucose control predicts nosocomial infection rate in diabetic patients.J Parenter Enteral Nutr. 1998; 22: 77-81Crossref PubMed Scopus (556) Google Scholar, 18McAlister F.A. Man J. Bistritz L. et al.Diabetes and coronary artery bypass surgery: an examination of perioperative glycemic control and outcomes.Diabetes Care. 2003; 26: 1518-1524Crossref PubMed Scopus (200) Google Scholar) and renal allograft rejection (19Thomas M.C. Mathew T.H. Russ G.R. et al.Early peri-operative glycaemic control and allograft rejection in patients with diabetes mellitus: a pilot study.Transplantation. 2001; 72: 1321-1324Crossref PubMed Scopus (85) Google Scholar), and is associated with increased resource utilization (20Estrada C.A. Young J.A. Nifong L.W. et al.Outcomes and peri-operative hyperglycemia in patients with or without diabetes mellitus undergoing coronary artery bypass grafting.Ann Thorac Surg. 2003; 75: 1392-1399Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar). In patients undergoing coronary artery bypass grafting (CABG), a preexisting diagnosis of diabetes has been identified as a risk factor for postoperative sternal wound infections, delirium, renal dysfunction, respiratory insufficiency and prolonged hospital stays (21Brandt M. Harder K. Walluscheck K.P. et al.Coronary artery bypass surgery in diabetic patients.J Card Surg. 2004; 19: 36-40Crossref PubMed Scopus (16) Google Scholar, 22Bucerius J. Gummert J.F. Walther T. et al.Diabetes in patients undergoing coronary artery bypass grafting. Impact on perioperative outcome.Z Kardiol. 2005; 94: 575-582Crossref PubMed Scopus (20) Google Scholar, 23Bucerius J. Gummert J.F. Walther T. et al.Impact of diabetes mellitus on cardiac surgery outcome.Thorac Cardiovasc Surg. 2003; 51: 11-16Crossref PubMed Scopus (98) Google Scholar). Intraoperative hyperglycemia during cardiopulmonary bypass has been associated with increased morbidity and mortality rates in individuals with and without diabetes (24Doenst T. Wijeysundera D. Karkouti K. et al.Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery.J Thorac Cardiovasc Surg. 2005; 130: 1144Abstract Full Text Full Text PDF PubMed Scopus (302) Google Scholar, 25Gandhi G.Y. Nuttall G.A. Abel M.D. et al.Intraoperative hyperglycemia and perioperative outcomes in cardiac surgery patients.Mayo Clin Proc. 2005; 80: 862-866Abstract Full Text Full Text PDF PubMed Scopus (370) Google Scholar, 26Ouattara A. Lecomte P. Le Manach Y. et al.Poor intraoperative blood glucose control is associated with a worsened hospital outcome after cardiac surgery in diabetic patients.Anesthesiology. 2005; 103: 687-694Crossref PubMed Scopus (304) Google Scholar). The appropriate perioperative glycemic targets for minor or moderate surgeries are less clear. There are few intervention studies assessing the impact of tight glycemic control on morbidity or mortality in these settings; however, a number of small studies that compared different methods of achieving glycemic control during minor and moderate surgeries did not demonstrate any adverse effects of maintaining perioperative glycemic levels between 5.0 and 11.0 mmol/L (27Raucoules-Aimé M. Lugrin D. Boussofara M. et al.Intraoperative glycaemic control in non-insulin-dependent and insulin-dependent diabetes.Br J Anaesth. 1994; 73: 443-449Crossref PubMed Scopus (21) Google Scholar, 28Hemmerling T.M. Schmid M.C. Schmidt J. et al.Comparison of a continuous glucose-insulin-potassium infusion versus intermittent bolus application of insulin on perioperative glucose control and hormone status in insulin-treated type 2 diabetics.J Clin Anesth. 2001; 13: 293-300Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 29Christiansen C.L. Schurizek B.A. Malling B. et al.Insulin treatment of the insulin-dependent diabetic patient undergoing minor surgery. Continuous intravenous infusion compared with subcutaneous administration.Anaesthesia. 1988; 43: 533-537Crossref PubMed Scopus (54) Google Scholar). Rapid institution of perioperative control should be carefully considered in patients with poorly controlled type 2 diabetes undergoing monocular phacoemulsification cataract surgery with moderate to severe nonproliferative diabetic retinopathy because of the possible increased risk of postoperative progression of retinopathy and maculopathy (30Suto C. Hori S. Kato S. et al.Effect of perioperative glycemic control in progression of diabetic retinopathy and maculopathy.Arch Ophthalmol. 2006; 124: 38-45Crossref PubMed Scopus (48) Google Scholar). The outcome of vitrectomy does not appear to be influenced by perioperative control (31Kamio S. Kawasaki R. Yamashita H. Influence of systemic conditions and glycemic control on complications of vitrectomy for diabetic retinopathy [Japanese].Folia Ophthalmol Jpn. 2004; 55: 105-109Google Scholar). Given the data supporting tighter perioperative glycemic control during major surgeries and the compelling data showing the adverse effects of hyperglycemia, it is reasonable to target glycemic levels between 5.0 and 10.0 mmol/L for minor and moderate surgeries. However, the benefits of improved perioperative glycemic control must be weighed against the risk of perioperative hypoglycemia. Anesthetic agents and postoperative analgesia may alter the patient's level of consciousness and awareness of hypoglycemia. The risk of hypoglycemia can be reduced by frequent BG monitoring and carefully designed management protocols. In general, insulin is the preferred treatment for hyperglycemia in hospitalized patients with diabetes (5Moghissi E.S. Korytkowski M.T. DiNardo M. et al.American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control.Endocr Pract. 2009; 15: 353-369Crossref PubMed Scopus (450) Google Scholar). Patients with type 1 diabetes must be maintained on insulin therapy at all times to prevent diabetic ketoacidosis (DKA). Scheduled subcutaneous (SC) insulin administration that consists of basal, bolus (prandial) and correction (supplemental) insulin components is the preferred method for achieving and maintaining glucose control in noncritically ill patients with diabetes or stress hyperglycemia who are eating (5Moghissi E.S. Korytkowski M.T. DiNardo M. et al.American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control.Endocr Pract. 2009; 15: 353-369Crossref PubMed Scopus (450) Google Scholar). Bolus insulin can be withheld or reduced in patients who are not eating regularly; basal insulin should not be withheld. Stable patients can usually be maintained on their home insulin regimen with adjustments made to accommodate for differences in meals and activity levels, the effects of illness and the effects of other medications. In the hospital setting, rapid-acting insulin analogues are the preferred SC bolus insulins (32Meyer 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: 2496-2501Crossref PubMed Scopus (21) Google Scholar). Sliding-scale insulin (SSI) (defined as the administration of a preestablished amount of short-acting insulin in response to hyperglycemia) as the sole regimen for the management of hyperglycemia in the hospital setting is ineffective in the majority of patients and, therefore, is not recommended (5Moghissi E.S. Korytkowski M.T. DiNardo M. et al.American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control.Endocr Pract. 2009; 15: 353-369Crossref PubMed Scopus (450) Google Scholar, 33Becker T. Moldoveanu A. Cukierman T. et al.Clinical outcomes associated with the use of subcutaneous insulin-by-glucose sliding scales to manage hyperglycemia in hospitalized patients with pneumonia.Diabetes Res Clin Pract. 2007; 78: 392-397Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 34Umpierrez G. Maynard G. Glycemic chaos (not glycemic control) still the rule for inpatient care: how do we stop the insanity?.J Hosp Med. 2006; 1: 141-144Crossref PubMed Scopus (66) Google Scholar, 35Clement S. Braithwaite S.S. Magee M.F. et al.Management of diabetes and hyperglycemia in hospitals.Diabetes Care. 2004; 27: 553-591Crossref PubMed Scopus (968) Google Scholar, 36Umpierrez G.E. Palacio A. Smiley D. Sliding scale insulin use: myth or insanity?.Am J Med. 2007; 120: 563-567Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar). Insulin is often required temporarily in-hospital, even in patients with type 2 diabetes not previously treated with insulin. In these insulin-naïve patients, there is evidence demonstrating the superiority of basal-bolus-supplemental insulin regimens over SSI (37Umpierrez G.E. 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: 2181-2186Crossref PubMed Scopus (493) Google Scholar, 38Umpierrez G.E. 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: 256-261Crossref PubMed Scopus (463) Google Scholar). These studies have typically started patients on 0.4 to 0.5 units of insulin per kilogram of body weight per day, with 40% to 50% of the total daily dose (TDD) given as basal insulin (detemir, glargine, NPH) and the balance given as bolus (rapid or short-acting) insulin divided equally before each meal (i.e. breakfast, lunch, and dinner); supplemental doses of the bolus insulin are to be provided if BG values are above target. The patient's BG measurements should be reviewed daily and the insulin dose adjusted as required. To date, no large studies have investigated the use of oral antihyperglycemic drugs (OADs) on outcomes in hospitalized patients with diabetes. There are often short- and/or long-term contraindications to the use of OADs in the hospital setting, such as irregular eating, acute or chronic renal failure, and exposure to intravenous (IV) contrast dye (39Wesorick D. O'Malley C. Rushakoff R. et al.Management of diabetes and hyperglycemia in the hospital: a practical guide to subcutaneous insulin use in the non-critically ill, adult patient.J Hosp Med. 2008; 3: 17-28Crossref PubMed Scopus (27) Google Scholar). Stable patients without these contraindications can often have their home medications continued while in the hospital. However, if contraindications develop or if glycemic control is inadequate, these drugs should be discontinued and the patient should be started on a basal-bolus-supplemental insulin regimen. Medical nutrition therapy is an essential component of inpatient glycemic management programs and should include nutritional assessment and individualized meal planning. A consistent carbohydrate meal planning system may facilitate glycemic control in hospitalized patients and facilitate matching the prandial insulin dose to the amount of carbohydrate consumed (35Clement S. Braithwaite S.S. Magee M.F. et al.Management of diabetes and hyperglycemia in hospitals.Diabetes Care. 2004; 27: 553-591Crossref PubMed Scopus (968) Google Scholar, 40Curll M. Dinardo M. Noschese M. Korytkowski M.T. Menu selection, glycaemic control and satisfaction with standard and patient-controlled consistent carbohydrate meal plans in hospitalized patients with diabetes.Qual Saf Health Care. 2010; 19: 355-359Crossref PubMed Scopus (39) Google Scholar). In patients receiving parenteral nutrition (PN), insulin can be administered with the nutrition. An IV infusion of regular insulin is often used initially to estimate the TDD of insulin required. Approximately 80% of the TDD of insulin needed to maintain BG levels within the target range on IV insulin is added to the PN bags as regular insulin. SC correction (supplemental) insulin is often used in addition to the insulin mixed with PN for unusual hyperglycemia. The dose of insulin is adjusted based on BG monitoring results. To prevent ketoacidosis, patients with type 1 diabetes must be given subcutaneous insulin if the total parenteral nutrition (TPN) is interrupted. As an alternative to adding insulin to the PN, a separate IV insulin infusion may be used. Since nutrition is being provided continuously in patients receiving continuous enteral feeds, the TDD of insulin can be administered as a long-acting, nonpeaking basal insulin alone (once-daily glargine or twice daily detemir). Patients receiving bolus enteral feeds are typically treated like patients who are eating meals. Approximately 50% of the TDD is provided as basal insulin and 50% as bolus insulin, which is administered in divided doses to match feed times (39Wesorick D. O'Malley C. Rushakoff R. et al.Management of diabetes and hyperglycemia in the hospital: a practical guide to subcutaneous insulin use in the non-critically ill, adult patient.J Hosp Med. 2008; 3: 17-28Crossref PubMed Scopus (27) Google Scholar). Short-acting regular insulin is usually selected over rapid-acting insulin in this group of patients because of the longer duration of action. Supplemental insulin should be administered as needed with the bolus insulin. In the event that tube feeds are interrupted, IV dextrose may be required to prevent hypoglycemia. Hyperglycemia is a common complication of corticosteroid therapy, with prevalence between 20% and 50% among patients without a previous history of diabetes (41Donihi A.C. Raval D. Saul M. et al.Prevalence and predictors of corticosteroid-related hyperglycemia in hospitalized patients.Endocr Pract. 2006; 12: 358-362Crossref PubMed Google Scholar). Although the optimal management of hyperglycemia in patients receiving high-dose oral corticosteroids has not been clearly defined, glycemic monitoring for at least 48 hours is recommended for patients with or without a history of diabetes (5Moghissi E.S. Korytkowski M.T. DiNardo M. et al.American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control.Endocr Pract. 2009; 15: 353-369Crossref PubMed Scopus (450) Google Scholar). For management, insulin is generally preferred, with an emphasis on adjusting bolus insulin doses. Depending on the glucose monitoring results, gradual, persistent insulin adjustments should be made to prevent hyper- and hypoglycemia. During corticosteroid tapers, insulin dosing should be proactively adjusted to prevent hypoglycemia. Patients on insulin pump therapy do not necessarily need to discontinue this form of therapy while hospitalized. However, to promote a collaborative relationship between the hospital staff and the patient, and to ensure patient safety, hospitals must have clear policies and procedures in place to guide the continued use of insulin pump therapy in the inpatient setting (42Bailon R.M. Partlow B.J. Miller-Cage V. et al.Continuous subcutaneous insulin (insulin pump) therapy can be safely used in the hospital in select patients.Endocr Pract. 2009; 15: 25-29Crossref Scopus (48) Google Scholar). All patients admitted to hospital using insulin pumps must be assessed for their physical and mental competency to use their respective device. Patients should be asked to demonstrate or describe how to adjust their basal rate, administer a bolus dose, insert an infusion set, fill a reservoir, suspend their pump and correct a capillary BG result outside their target range. The patient should also have adequate insulin pump supplies. If the patient cannot competently demonstrate and/or describe the above-mentioned actions, insulin pump therapy should be discontinued and the patient placed on a SC insulin regimen or an IV insulin infusion. Most patients with type 1 or type 2 diabetes admitted to general medical wards can be treated with SC insulin. IV insulin may be appropriate for patients who are critically ill, patients who are not eating or those who require prompt improvement in their glycemic control. Staff education is a critical component of the implementation of an IV insulin infusion protocol. IV insulin protocols should take into account the patient's current and previous BG levels (and, therefore, the rate of change in BG), and the patient's usual insulin dose. Several published insulin infusion protocols appear to be both safe and effective, with low rates of hypoglycemia; however, most of these protocols have only been validated in the ICU setting, where the nurse-to-patient ratio is higher than on general medical and surgical wards (3Inzucchi S.E. Clinical practice. Management of hyperglycemia in the hospital setting.N Engl J Med. 2006; 355: 1903-1911Crossref PubMed Scopus (309) Google Scholar, 43Goldberg P.A. Siegel M.D. Sherwin R.S. et al.Implementation of a safe and effective insulin infusion protocol in a