Inpatient management of diabetes and hyperglycemia

Illness, particularly when severe, leads to increased concentrations of counter-regulatory factors which induce insulin resistance and predispose patients to stress hyperglycemia. Elevated glucose concentrations are common in hospitalized patients, both those with as well as without recognized diabetes. Substantial data has emerged over the past decade that quality glucose management in these individuals actually improves clinical outcomes. Controlling glucose in this setting is challenging, given the phenotypic variability amongst patients, with fluctuating courses of acute illnesses and unpredictable nutritional schedules. We review the evidence basis that has informed national standards and glucose targets in both critically and non-critically ill patients. In the intensive care setting, insulin infusions are now widely endorsed to quickly achieve and maintain glucose control. On the hospital wards, physiological subcutaneous insulin therapy, incorporating both basal and nutritional components, is emerging as the optimal treatment strategy. The transition to outpatient care is another important aspect of any hospital glycemic management program.