2018 Clinical Practice Guidelines
In-Hospital Management of Diabetes

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Introduction

Diabetes increases the risk for hospitalization for several reasons, including: cardiovascular (CV) disease, nephropathy, infection, cancer and lower-extremity amputations. In-hospital hyperglycemia is common. A review of medical records of over 2,000 adult patients admitted to a community teaching hospital in the United States (>85% were nonintensive care unit patients) found that hyperglycemia was present in 38% of patients (1). Of these patients, 26% had a known history of diabetes, and 12% had no history of diabetes prior to admission. Diabetes has been reported to be the fourth most common comorbid condition listed on all hospital discharges (2).

Acute illness results in a number of physiological changes (e.g. increases in circulating concentrations of stress hormones) or therapeutic choices (e.g. glucocorticoid use) that can exacerbate hyperglycemia. Hyperglycemia, in turn, causes physiological changes that can exacerbate acute illness, such as decreased immune function and increased oxidative stress. These lead to a complex cycle of worsening illness and poor glucose control (3). Although a growing body of literature supports the need for targeted glycemic control in the hospital setting, blood glucose (BG) continues to be poorly controlled and is frequently overlooked in general medicine and surgery services. This is largely explained by the fact that the majority of hospitalizations for patients with diabetes are not directly related to their metabolic state, thus diabetes management is rarely the primary focus of care. Therefore, glycemic control and other diabetes care issues are often not specifically addressed (4).

Section snippets

Screening for and Diagnosis of Diabetes and Hyperglycemia in the Hospital Setting

A history of diabetes should be elicited in all patients admitted to hospital and, if present, should be clearly identified on the medical record. In view of the high prevalence of inpatient hyperglycemia with associated poor outcomes, an admission BG measurement of all patients would help identify people with diabetes, even in the absence of a prior diagnosis 1, 5. In-hospital hyperglycemia is defined as any glucose value >7.8 mmol/L. For hospitalized people with known diabetes, the glycated

Bedside blood glucose monitoring

Currently, there are no studies that have examined the effect of the frequency of bedside BG monitoring on the incidence of hyper- or hypoglycemia in the hospital setting. The frequency and timing of bedside BG monitoring can be individualized; however, monitoring is typically performed before meals and at bedtime in people who are eating; every 4 to 6 hours in people who are NPO (nothing by mouth) or receiving continuous enteral feeding; and every 1 to 2 hours for people on continuous

Glycemic Control in the Non-Critically Ill Patient

A number of studies have demonstrated that inpatient hyperglycemia is associated with increased morbidity and mortality in noncritically ill hospitalized people 1, 28, 29. However, due to a paucity of randomized controlled trials on the benefits and risks of “conventional” vs. “tight” glycemic control in noncritically ill hospitalized people, glycemic targets for this population remain undefined. Current recommendations are based mostly on retrospective studies, clinical experience and

Glycemic Control in the Critically Ill Patient

Acute hyperglycemia in the intensive care setting is not unusual and results from a number of factors, including stress-induced counter-regulatory hormone secretion and the effects of medications administered in the ICU (31). Glycemic targets for people with pre-existing diabetes who are in the critical care setting have not been firmly established. Early trials showed that achieving normoglycemia (4.4 to 6.1 mmol/L) in cardiac surgery patients or patients in postoperative surgical ICU settings

Role of Intravenous Insulin

There are few occasions when intravenous insulin is required, as most people with type 1 or type 2 diabetes admitted to general medical wards can be treated with subcutaneous insulin. Intravenous insulin, however, may be appropriate for people who are critically ill (with appropriate BG targets), people who are not eating and in those with hyperglycemia and metabolic decompensation (e.g. diabetic ketoacidosis [DKA] and hyperosmolar hyperglycemic state [HHS]) (see Hyperglycemic Emergencies in

Role of Subcutaneous Insulin

In general, insulin is the preferred treatment for hyperglycemia in hospitalized people with diabetes (35). People with type 1 diabetes must be maintained on insulin therapy at all times to prevent DKA. Scheduled subcutaneous insulin administration that consists of basal, bolus (prandial) and correction (supplemental) insulin components is the preferred method for achieving and maintaining glucose control in noncritically ill hospitalized people with diabetes or stress hyperglycemia who are

Role of Noninsulin Antihyperglycemic Agents

To date, no large studies have investigated the use of non-insulin antihyperglycemic agents on outcomes in hospitalized people with diabetes. There are often short- and/or long-term contraindications to the use of noninsulin antihyperglycemic agents in the hospital setting, such as irregular eating, acute or chronic renal failure, and exposure to intravenous contrast dye (75). Stable hospitalized people with diabetes without these contraindications can often have their home antihyperglycemic

Role of Medical Nutrition Therapy

Medical nutrition therapy including nutritional assessment and individualized meal planning is an essential component of inpatient glycemic management programs. A consistent carbohydrate meal planning system may facilitate glycemic control in hospitalized people and facilitate matching prandial insulin doses to the amount of carbohydrate consumed 61, 66, 75, 78, 79, 80.

Hospitalized people with diabetes receiving enteral or parenteral feedings

In hospitalized people with diabetes receiving parenteral nutrition, insulin can be administered in the following ways: as scheduled regular insulin dosing added directly to the parenteral solution; or as scheduled intermediate- or long-acting subcutaneous insulin doses (81). A separate intravenous infusion of regular insulin may be an alternative method to achieve glycemic control in critical care (82). For scheduled subcutaneous insulin dosing or regular insulin added directly to parenteral

Organization of Care

Institution-wide programs to improve glycemic control in the inpatient setting include the formation of a multidisciplinary steering committee, professional development programs focused on inpatient diabetes management 95, 96, policies to assess and monitor the quality of glycemic management, interprofessional team-based care (including comprehensive patient education and discharge planning) as well as standardized order sets, protocols and algorithms for diabetes care within the institution.

Hypoglycemia

Hypoglycemia remains a major barrier to achieving optimal glycemic control in hospitalized people with diabetes. Standardized treatment protocols that address mild, moderate and severe hypoglycemia may help mitigate this risk. Education of healthcare workers about factors that increase the risk of hypoglycemia, such as sudden reduction in oral intake, discontinuation of parenteral or enteral nutrition, unexpected transfer from the nursing unit after rapid-acting insulin administration or a

Other Relevant Guidelines

  • Glycemic Management in Adults With Type 1 Diabetes, p. S80

  • Pharmacologic Glycemic Management of Type 2 Diabetes in Adults, p. S88

  • Hyperglycemic Emergencies in Adults, p. S109

  • Management of Acute Coronary Syndromes, p. S190

  • Treatment of Diabetes in People With Heart Failure, p. S196

Literature Review Flow Diagram for Chapter 16: In-Hospital Management of Diabetes

*Excluded based on: population, intervention/exposure, comparator/control or study design.

From: Moher D, Liberati A,

Author Disclosures

Dr. Halperin reports personal fees from Dexcom, Novo Nordisk, and QHR technologies, outside the submitted work. Dr. Miller reports personal fees from Eli Lilly, Novo Nordisk, Sanofi, and AstraZeneca; and grants and personal fees from Boehringer Ingelheim, Janssen, Merck, outside the submitted work. Sarah Moore reports personal fees from Diabetes Care Alliance (Boehringer Ingelheim Eli Lilly Alliance), and Merck Canada, outside the submitted work. No other authors have anything to disclose.

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