2018 Clinical Practice GuidelinesIn-Hospital Management of Diabetes
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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Cited by (35)
Incretin-based therapy for glycemic control of hospitalized patients with type 2 diabetes: a systematic review
2022, Revista Clinica EspanolaSuggested Canadian Standards for Perioperative/Periprocedure Glycemic Management in Patients With Type 1 and Type 2 Diabetes
2022, Canadian Journal of DiabetesCitation Excerpt :Before round 2, a focused literature review was done to identify supporting evidence for each standard, then the literature and survey results were summarized and provided to the Delphi panel. An exhaustive systematic review was not conducted as this was done previously for the 2018 Diabetes Canada Guidelines on inpatient management (13). The Delphi consensus process was modified to exclude standards that received an average score of ≤2.
Are Surgical Site Infections an Anesthesiologist's Problem?
2021, Advances in AnesthesiaCitation Excerpt :Therefore, immediate preoperative glucose greater than 200 mg/dL should be treated with insulin irrespective of diabetic status [24,25]. Some common goals for intraoperative glucose management include targeted blood glucose levels less than 180 mg/dL, hourly blood glucose checks if using an insulin infusion, every 2 hours for subcutaneous treatment, and every 4 hours for monitoring without treatment [33–35]. Postoperatively, insulin therapy should be initiated for persistent hyperglycemia (>180 mg/dL) for a target glucose range 140 to 180 mg/dL in both critically ill and noncritically ill patients [33].
Variability of Clinical Practice Management of Type 1 and Type 2 Diabetes During Surgery Across Canada
2021, Canadian Journal of DiabetesCitation Excerpt :Appropriate glycemic management during the perioperative period has the potential to promote optimal surgical and patient outcomes (9). The 2018 Diabetes Canada clinical practice guidelines provide some recommendations for the perioperative management of patients undergoing coronary artery bypass grafting and for postoperative management (10); however, practical recommendations are lacking, in part due to an absence of high-quality evidence. Diabetes United Kingdom has published standards that are mostly consensus-based due to limited evidence to guide practice (11).
Management of diabetes and hyperglycaemia in the hospital
2021, The Lancet Diabetes and EndocrinologyCitation Excerpt :Recent reviews and consensus efforts have also suggested management strategies for patients with diabetes and COVID-19.21,22 Although the use of insulin therapy in the hospital is common in the USA and Canada,23,24 this is not a universal practice. The use of non-insulin agents such as metformin and sulfonylureas is relatively common in other countries (UK, India, Israel).25–28
The Canadian Diabetes Association is the registered owner of the name Diabetes Canada.
Conflict of interest statements can be found on page S121.