Management of diabetes mellitus in hospitalized patients
- David K McCulloch, MD
David K McCulloch, MD
- Washington Permanente Medical Group
- Silvio E Inzucchi, MD
Silvio E Inzucchi, MD
- Professor of Medicine
- Yale University School of Medicine
Patients with type 1 or type 2 diabetes mellitus are frequently admitted to a hospital, usually for treatment of conditions other than the diabetes [1,2]. In one study, 25 percent of patients with type 1 diabetes and 30 percent with type 2 diabetes had a hospital admission during one year; patients with higher values for glycated hemoglobin (A1C) were at highest risk for admission . The prevalence of diabetes rises with increasing age, as does the prevalence of other diseases; both factors increase the likelihood that an older person admitted to a hospital will have diabetes.
The treatment of patients with diabetes who are admitted to the general medical wards of the hospital for a procedure or intercurrent illness is reviewed here. The treatment of hyperglycemia in critically ill patients, the perioperative management of diabetes, and the treatment of complications of the diabetes itself, such as diabetic ketoacidosis, are discussed separately. (See "Glycemic control and intensive insulin therapy in critical illness" and "Perioperative management of blood glucose in adults with diabetes mellitus" and "Diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults: Treatment" and "Management of hypoglycemia during treatment of diabetes mellitus".)
GOALS IN THE HOSPITAL SETTING
The main goals in patients with diabetes needing hospitalization are to minimize disruption of the metabolic state, prevent adverse glycemic events (especially hypoglycemia), return the patient to a stable glycemic balance as quickly as possible, and ensure a smooth transition to outpatient care. These goals are not always easy to achieve. On the one hand, the stress of the acute illness tends to raise blood glucose concentrations. On the other hand, the anorexia that often accompanies illness or the need for fasting before a procedure tends to do the opposite. Because the net effect of these countervailing forces is not easily predictable in a given patient, the target blood glucose concentration is usually higher than when the patient is stable.
Uncertainty regarding goal blood glucose concentration is compounded by the paucity of controlled trials on the benefits and risks of "loose" or "tight" glycemic control in hospitalized patients, with the exception of patients who are critically ill or have had an acute myocardial infarction (MI). (See "Glycemic control and intensive insulin therapy in critical illness" and "Glycemic control for acute myocardial infarction in patients with and without diabetes mellitus".)
In general, the goals are to:
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- GOALS IN THE HOSPITAL SETTING
- Avoidance of hypoglycemia
- Avoidance of hyperglycemia
- Glycemic targets
- - Noncritically ill
- - Critically ill
- - Acute MI
- PREVENTION AND TREATMENT OF HYPERGLYCEMIA
- Blood glucose monitoring
- Insulin delivery
- - Basal-bolus regimen
- - Sliding-scale insulin
- - Correction insulin
- - Insulin infusion
- Patients with type 2 diabetes
- - Diet-treated patients
- - Patients treated with oral agents
- - Patients treated with insulin
- Patients with type 1 diabetes
- Patients receiving enteral or parenteral feedings
- - TPN
- - Enteral feedings
- Evaluation of overall care
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS
- Glycemic goals
- Type 2 diabetes
- Type 1 diabetes