This presentation will discuss management of inpatient hyperglycaemia in two controversial areas: 1.) Critically ill patients and 2.) Patients prescribed glucocorticoids.

Hyperglycaemia is associated with increased mortality in critically ill patients in the Intensive Care Unit (ICU). The increased risk associated with hyperglycaemia is intuitively secondary to diabetes. However, there is a paradoxical relationship between diabetes and mortality in ICU. In contrast to new hyperglycaemia, which is associated with increased mortality, hyperglycaemia in ICU patients with diabetes is not.

The optimal management of hyperglycaemia in ICU is controversial. Early single centre studies reported that intensive insulin therapy reduced mortality in surgical ICU patients and renal failure and ventilation duration in medical ICU patients. In contrast, a large multi-centre randomized-controlled trial reported the opposite with increased mortality in ICU patients receiving intensive insulin therapy. Current therapeutic guidelines recommend targeting a moderate glucose concentration between 7.8 and 10.0 mmol/L in most ICU patients. As the effect of intensive insulin therapy may differ in patients with and without diabetes, some authors recommend different glycaemic targets in ICU patients with and without diabetes.

Glucocorticoid therapy is a common cause of hyperglycaemia in hospitalized patients. The most common glucocorticoid prednisolone causes a distinctive circadian pattern of hyperglycaemia, with glucose elevations predominantly between midday and midnight. This suggests that insulin therapy should be predominantly directed at this time period. However, there is a paucity of good clinical studies of treatment of glucocorticoid-induced hyperglycaemia.