Approach to the hospitalized patient with severe insulin resistance

Glucose control improves outcomes in the hospitalized patient, particularly patients on prolonged ventilator support, after acute myocardial infarction or after coronary artery bypass surgery. An iv insulin algorithm is the standard of care for initial treatment of significant hyperglycemia in the hospitalized patient, and it can be transitioned to periodic sc insulin once the patient is more stable. However, illness, medications, the endocrine and inflammatory response to stress, and pain can all contribute to insulin resistance and further aggravate preexisting insulin resistance caused by obesity. Glucose treatment goals have been established to guide the rapy, but achieving those goals can be more challenging in the presence of severe insulin resistance. When target glucose values are not achieved with established insulin algorithms, the practitioner should evaluate for potential causes of insulin resistance from technical factors that cause "pseudo-insulin resistance" as well as other modifiable factors, such as electrolyte disorders, parenteral and enteral nutrition, or other medications. Published glucose guidelines provide glucose "goals" to guide changes in the insulin algorithm, but these goals may be difficult to achieve in all individuals. We propose a stepwise approach to evaluate and treat severe insulin resistance in the hospitalized patient in order to achieve glucose goals in a timely fashion.