take care of hospitalized patients with diabetes and hyperglycemia.
Boris Draznin, MD, PhD, Editor
The Celeste and Jack Grynberg Professor of Medicine
University of Colorado School of Medicine
The Management of Diabetes and Hyperglycemia in the Hospital Setting: A Practical Guide
As the number of patients with diabetes, both diagnosed and as yet undiagnosed, increases annually, it is not surprising that the number of patients with diabetes who are admitted to the hospital also increases. The prevalence of overt diabetes is estimated to exceed 30% among individuals who are 60 years of age and older. Because individuals in this age-group account for a large number of hospital admissions for a variety of medical and surgical conditions, even conservative estimates suggest that ~25 to 30% of all hospitalized patients on any given day in any given hospital in the U.S. have diabetes. The percentage of hospitalized patients outside the U.S. who have diabetes is likely to show the same trend.
Even though patients with diabetes may be admitted to the hospital with acute or chronic complications of diabetes, most frequently they are hospitalized for other medical and surgical problems and their diabetes becomes a significant comorbidity that may affect the outcome of their hospitalization. Moreover, patients with prediabetes or undiagnosed diabetes are frequently hyperglycemic either on admission to the hospital or in the course of their hospital stay, adding to the complexity of their medical or surgical problems. The treatment of diabetes and hyperglycemia in these situations requires the utmost attention and specialized knowledge.
Once in the hospital, patients with diabetes or hyperglycemia may be admitted to the intensive care unit, require urgent or elective surgery, enteral or parenteral nutrition, intravenous insulin infusion, and therapies that have a significant impact on glycemic control (e.g., steroids). Because many clinical outcomes are profoundly influenced by the degree of glycemic control, knowledge of the best practice in inpatient diabetes management assumes paramount importance.
In the twenty-first century, in most U.S. community hospitals, hospitalist physicians provide medical care to these patients. In some hospitals, particularly academic and other tertiary care hospitals, hospitalists share this task with endocrinologists. A small number of hospitals have established specialized glycemic (diabetes) management teams led by either a physician or a mid-level provider, such as a nurse practitioner or a physician assistant, to help control blood glucose levels in hospitalized patients. These teams prove to be of great importance not only for successful management of patients with diabetes, but also for diabetes education of patients, nursing staff, and house staff.
The field of inpatient management of diabetes and hyperglycemia has grown substantially in the last several years, accumulating and disseminating important clinical knowledge. This body of knowledge is summarized in this book, so it can reach the audience of hospitalists and endocrinologists, both in practice and in training—the very physicians who take care of hospitalized patients with diabetes and hyperglycemia.
Chapter 1
The Evolution of Glycemic Control in the Hospital Setting
Etie Moghissi, MD, FACE,1 and Silvio Inzucchi, MD2
1Associate Clinical Professor, Department of Medicine, University of California Los Angeles, Los Angeles, CA. 2Professor of Medicine Section of Endocrinology, Yale School of Medicine, New Haven, CT.
DOI: 10.2337/9781580406086.01
Introduction
Patients with diabetes are hospitalized three times more frequently than those without diabetes, and hyperglycemia in the hospital setting is associated with increased mortality, morbidity, longer hospital stays, and cost. Yet at the turn of the twenty-first century, few appreciated the risk of acute hyperglycemia among hospitalized patients. There were no clinical practice guidelines or recommended glycemic targets for inpatients, and every hospital relied on sliding-scale insulin therapy to manage hyperglycemia.
Early observational studies and the seminal 2001 randomized clinical trial of intensive insulin therapy in critically ill patients1 paved the way for diabetes organizations to issue calls for tight glycemic control in the critically ill patients.2–4 Investigations published after these initial recommendations, however, called into question the benefit of maintaining near-normal glycemic control in the critically ill and raised concerns regarding the prevalence of incremental hypoglycemia associated with such an approach.5–8 Notably, the Normoglycemia in Intensive Care Evaluation Using Glucose Algorithm Regulation (NICE-SUGAR) study actually showed that a 14% increased risk of death accompanied dramatically increased rates of severe hypoglycemia in patients whose glucose was controlled to the euglycemic range,9 the latter confirmed by meta-analysis of multiple studies involving the critically ill.8 These findings prompted the American Association of Clinical Endocrinologists (AACE)/American Diabetes Association (ADA) consensus group to evaluate all related published studies and update their recommendations for glycemic targets in hospitalized patients,10 with the goal of recommending reasonable, achievable, and safe glycemic targets. The consensus group chose a target of 140–180 mg/dL for critically ill patients based on the best available evidence. The group’s primary concern was maintaining patient safety, especially the avoidance of hypoglycemia. The panel recommended insulin as the treatment of choice for the majority of hospitalized patients. Continuous intravenous (IV) insulin infusion was recommended for those patients in the intensive care unit (ICU), and scheduled insulin in the form of basal, nutritional, and supplemental injections was preferred for the noncritically ill (Table 1.1). Echoing these recommendations, in 2012 The Endocrine Society issued an updated guidance focused on noncritically ill patients,11 with similar recommendations as the AACE/ADA consensus group. Both groups emphasize that clinical judgment, individualized regimens tailored to each patient, and ongoing assessment of clinical status must be incorporated into day-to-day decisions regarding the management of hyperglycemia.10,11
Table 1.1—Summary of ADA/AACE Recommendations for Management of Hyperglycemia among Hospitalized Patients
| Critically ill | Noncritically ill | |
| Blood glucose target | • 140 to 180 mg/dL(7.8 to 10.0 mmol/L) | • Premeal: <140 mg/dL (<7.8 mmol/L)* • Random: <180 mg/dL (<10.0 mmol/L)* |
| Preferred treatment regimen | • Intravenous insulin infusion of regular insulin • Use validated insulin infusion protocol • Frequently monitor blood glucose to minimize hypoglycemia | • Scheduled subcutaneous administration of insulin, with basal, nutritional, and correction components • Prolonged therapy with sliding-scale insulin as the sole regimen is discouraged • Noninsulin antihyperglycemic agents are not appropriate for most hospitalized patients who require therapy for hyperglycemia |
*Provided these targets can be safely achieved. More stringent targets may be appropriate in stable patients with previous tight glycemic control; less stringent targets may be appropriate in terminally ill patients or those with severe comorbidities.
Stress
