Management of diabetes mellitus in hospitalized patients
- David K McCulloch, MD
David K McCulloch, MD
- Clinical Professor of Medicine
- University of Washington
- 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 hemoglobin A1C (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.
Much of what was formerly done in hospital, including many surgical procedures, complex diagnostic testing, or treatment of community-acquired infections, is now done in a clinic or at home. However, the presence of diabetes might precipitate admission of a patient who would otherwise be treated as an outpatient . Whether in hospital or not, glycemic control is likely to become unstable in these patients because of the stress of the illness or procedure, the concomitant changes in dietary intake and physical activity, and the frequent interruption of the patient's usual antihyperglycemic regimen.
Once in the hospital, the length of stay and cost are greater for patients with diabetes than for those without it [1,4]. Efficient treatment of diabetes in hospital may be an important factor in limiting the costs of care. However, as mentioned below, firm data on optimal in-hospital treatment are sparse.
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 an untoward result, and return the patient to a stable glycemic balance as quickly as possible. 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.
- Ahmann A. Comprehensive management of the hospitalized patient with diabetes. Endocrinologist 1998; 8:250.
- Moss SE, Klein R, Klein BE. Risk factors for hospitalization in people with diabetes. Arch Intern Med 1999; 159:2053.
- American Diabetes Association. Hospital admission guidelines for diabetes. Diabetes Care 2004; 27 Suppl 1:S103.
- Hirsch IB, Paauw DS, Brunzell J. Inpatient management of adults with diabetes. Diabetes Care 1995; 18:870.
- Turchin A, Matheny ME, Shubina M, et al. Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care 2009; 32:1153.
- Chaney MA, Nikolov MP, Blakeman BP, Bakhos M. Attempting to maintain normoglycemia during cardiopulmonary bypass with insulin may initiate postoperative hypoglycemia. Anesth Analg 1999; 89:1091.
- Nasraway SA Jr. Sitting on the horns of a dilemma: avoiding severe hypoglycemia while practicing tight glycemic control. Crit Care Med 2007; 35:2435.
- Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care 2004; 27:553.
- Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 2002; 87:978.
- Pomposelli JJ, Baxter JK 3rd, Babineau TJ, et al. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. JPEN J Parenter Enteral Nutr 1998; 22:77.
- Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009; 32:1119.
- Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2012; 97:16.
- American Diabetes Association. Standards of medical care in diabetes--2013. Diabetes Care 2013; 36 Suppl 1:S11.
- Van den Berghe G, Wilmer A, Milants I, et al. Intensive insulin therapy in mixed medical/surgical intensive care units: benefit versus harm. Diabetes 2006; 55:3151.
- Jacober SJ, Sowers JR. An update on perioperative management of diabetes. Arch Intern Med 1999; 159:2405.
- Inzucchi SE. Clinical practice. Management of hyperglycemia in the hospital setting. N Engl J Med 2006; 355:1903.
- Queale WS, Seidler AJ, Brancati FL. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Intern Med 1997; 157:545.
- Goldberg PA, Siegel MD, Sherwin RS, et al. Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care 2004; 27:461.
- Umpierrez GE, Gianchandani R, Smiley D, et al. Safety and efficacy of sitagliptin therapy for the inpatient management of general medicine and surgery patients with type 2 diabetes: a pilot, randomized, controlled study. Diabetes Care 2013; 36:3430.
- Ballani P, Tran MT, Navar MD, Davidson MB. Clinical experience with U-500 regular insulin in obese, markedly insulin-resistant type 2 diabetic patients. Diabetes Care 2006; 29:2504.
- Umpierrez GE, Hor T, Smiley D, et al. Comparison of inpatient insulin regimens with detemir plus aspart versus neutral protamine hagedorn plus regular in medical patients with type 2 diabetes. J Clin Endocrinol Metab 2009; 94:564.
- Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care 2007; 30:2181.
- Schoeffler JM, Rice DA, Gresham DG. 70/30 insulin algorithm versus sliding scale insulin. Ann Pharmacother 2005; 39:1606.
- Umpierrez GE, Smiley D, Jacobs S, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care 2011; 34:256.
- Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a Basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care 2013; 36:2169.
- Wesorick D, O'Malley C, Rushakoff R, et al. Management of diabetes and hyperglycemia in the hospital: a practical guide to subcutaneous insulin use in the non-critically ill, adult patient. J Hosp Med 2008; 3:17.
- Korytkowski MT, Salata RJ, Koerbel GL, et al. Insulin therapy and glycemic control in hospitalized patients with diabetes during enteral nutrition therapy: a randomized controlled clinical trial. Diabetes Care 2009; 32:594.
- Levetan CS, Salas JR, Wilets IF, Zumoff B. Impact of endocrine and diabetes team consultation on hospital length of stay for patients with diabetes. Am J Med 1995; 99:22.
- Koproski J, Pretto Z, Poretsky L. Effects of an intervention by a diabetes team in hospitalized patients with diabetes. Diabetes Care 1997; 20:1553.
- Smith SA, Poland GA. Use of influenza and pneumococcal vaccines in people with diabetes. Diabetes Care 2000; 23:95.
- GOALS IN THE HOSPITAL SETTING
- Avoidance of hypoglycemia
- Avoidance of hyperglycemia
- Glycemic targets
- - Non-critically ill
- - Critically ill
- - Acute MI
- PREVENTION AND TREATMENT OF HYPERGLYCEMIA
- Types of insulin
- - 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
- SUMMARY AND RECOMMENDATIONS
- Glycemic goals
- Type 2 diabetes
- Type 1 diabetes