Evidence-based review: scheduled insulin best for inpatient hyperglycemia.(Clinical Rounds)

SAN FRANCISCO -- Programmed and scheduled administration of insulin improves glucose control in hospitalized patients with hyperglycemia, compared with sliding-scale orders alone, Dr. Stephen C. Clement said at a meeting sponsored by the American Diabetes Association.

This is contrary to much current hospital practice, which relies on sliding-scale insulin orders, said Dr. Clement of Georgetown University Hospital, Washington. Sliding-scale therapy is a reactive approach that treats hyperglycemia after it has already occurred and can result in rapid changes in blood glucose levels, exacerbating both hyperglycemia and hypoglycemia.

Dr. Clement suggested that hospitals develop a preprinted insulin order form that would prompt the physician to address basal, prandial, and correction doses of insulin. He acknowledged that hospital bureaucracy can make it challenging to get such a form approved, noting that the effort took a year at his institution.

The recommendation for programmed and scheduled insulin is one of several recommendations on the hospital management of hyperglycemia based on a recently published, evidence-based review of the literature undertaken by a committee of the American Diabetes Association (Diabetes Care 27[2]:553-97, 2004). The online version of the article includes a sample preprinted insulin order form in an appendix (http://care.diabetesjournals.org/cgi/reprint/27/2/553.pdf).

These are the major recommendations from the review:

* Good metabolic control is associated with improved hospital outcomes. Target plasma glucose levels are less than 110 mg/dL preprandial, and less than 180 mg/dL peak postprandial.

* Intensive insulin therapy with intravenous insulin, with the goal of maintaining blood glucose at 80-110 mg/dL, ...