Selecting a Treatment Regimen
Hospitalized Patients
ÎÎFor most patients, a glucose concentration range of 140 to 180 mg/dL
(7.8 to 10 mmol/L) has been recommended, provided these targets can
be safely achieved.
ÎÎInsulin can rapidly control hyperglycemia and, therefore, is the drug of
choice for hospitalized patients with hyperglycemia (D-4).
>> Subcutaneous insulin orders should be specified as "basal," "prandial," or "correction" (D-4).
>> Insulin dosing should be synchronized with provision of enteral or parenteral nutrition (D-4).
>> Exclusive use of "sliding scale insulin" should be discouraged (D-4).
>> Oral antihyperglycemic agents have a limited role in acute care settings;
practitioners should consider discontinuing them in favor of insulin during acute
illness that might reasonably be expected to affect glucose levels and/or increase
the risk for medication-related adverse events (D-4).
>> Regular insulin is acceptable for intravenous administration, but insulin analogues
are preferred for subcutaneous administration.
>> Intravenous insulin is preferred for critically ill patients.
Glucose Monitoring
ÎÎHbA1c should be measured at least twice yearly in all patients with
DM and at least 4 times yearly in patients not at target (D-4).
ÎÎSMBG should be performed by all patients using insulin (minimum of
twice daily and ideally at least before any injection of insulin) (D-4).
>> More frequent SMBG after meals or in the middle of the night may be required
for insulin-taking patients with frequent hypoglycemia, patients not at HbA1c
targets, or those with symptoms (D-4).
>> Patients not requiring insulin therapy may benefit from SMBG, especially to
provide feedback about the effects of their lifestyle and pharmacologic therapy.
>> Testing frequency must be personalized (D-4).
>> Although still early in its development, continuous glucose monitoring can be useful
for many patients to improve HbA1c levels and reduce hypoglycemia (D-4).
Hypoglycemia
ÎÎHypoglycemia treatment requires oral administration of rapidly
absorbed glucose (D-4).
ÎÎIf the patient is unable to swallow, parenteral glucagon may be given
by a trained family member or by medical personnel (D-4).
ÎÎIn unresponsive patients, intravenous glucose should be given (D-4).
ÎÎPatients may need to be hospitalized for observation if an SU or a
very large dose of insulin is the cause of the hypoglycemia because
prolonged hypoglycemia can occur (D-4).
ÎÎIf the patient has hypoglycemic unawareness and hypoglycemiaassociated autonomic failure, several weeks of hypoglycemia
avoidance may reduce the risk or prevent the recurrence of severe
hypoglycemia (A-1).
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