Diabetes Care in the Hospital Setting

2016 ADA Guideline Recommendations
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Diabetes Care in the Hospital Setting

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]; Shivani Chaparala M.B.B.S [3]; Tarek Nafee, M.D. [4]

• There are some available clinical practice guidelines and systematic reviews that suggest basal-bolus insulin may lower blood sugar more efficient, nevertheless it is more likely to cause hypoglycemia with no change in clinical outcomes. .
  • Key studies include:
    • Basal-bolus versus a basal plus correction insulin
    • Basal-bolus versus sliding scale insulin
    • Basal-bolus versus basal Plus sliding scale versus sliding scale alone.
    • Insulin analogues versus human insulin.
    • Basal-bolus insulin versus sliding scale insulin using the Glucommander eGlycemic Management System.
• Formerly guidelines advocated to stop all oral antidiabetic agents in the hospital settings of diabetes management, nevertheless some clinical trials support the effectiveness of oral antidiabetic drugs, solitary or in combination to insulin therapy, in some hospitalized individuals. Countries such as England, Israel and India practice the usage of oral antidiabetic agents such as, metformin and sulfonylureas for inpatient diabetic patients.
• A landmark trial done in 2009 demonstrated an increased mortality risk with intensive insulin treatment, specifically in critically ill patients. Chance of hypoglycemia rises with intensive insulin therapy and can further complicate the situation.
• Continuous insulin infusion is recommended for critically ill diabetic patients (such as ICU patients), which should be replaced by subcutaneous insulin when patient is stable.
  • The following factors should be considered when transition from continuous insulin infusion to subcutaneous insulin is planned:
    • Patients should have a steady glucose concentration, at least for last 4–6 hours
    • Normal anion gap must be achieved (if patient have been presented with DKA, acidosis should have been resolved before transition).
    • Patients should be hemodynamically stable with out vasopressors
    • Patients should be on a stable diet
    • Patients should be on a steady intravenous infusion rate
• Based on a systematic review, universal usage of premixed insulin regimens is not trusted in hospitalized diabetic patients.
• The following table is a summary of treatment in non-critically ill hospitalized patients with diabetes:

Patient status	Mild hyperglycaemia	Moderate hyperglycaemia	Severe hyperglycaemia
Definition	Blood glucose < 200 Patients who are taking less than 2 anti-diabetic drugs (such as oral anti-diabetic drug or GLP-1 receptor agonists)	201 < Blood glucose <300 Patients who are taking multiple anti-diabetic drug (such as oral anti-diabetic drug or GLP-1 receptor agonists) Patients who are taking less than 0·6 U/kg insulin per day	Blood glucose > 301 Patients who are taking multiple anti-diabetic drug (such as oral anti-diabetic drug or GLP-1 receptor agonists) Patients who are taking more than 0·6 U/kg insulin per day
Approach	Low dose basal insulin OR oral anti-diabetic drug†, if there are no contraindications. Further blood glucose correction can be applied by rapid-acting insulin (before meals or every 6 hours)	Basal insulin OR oral anti-diabetic drug†, if there are no contraindications. Initial insulin dose: 0·2–0·3 U/kg per day (start from 0·15 U/kg per day (if using basal insulin alone) or 0·3 U/kg per day (if using basal–bolus) for patients with high risk of hypoglycemia). Further blood glucose correction can be applied by rapid-acting insulin (before meals or every 6 hours)	Basal–bolus insulin regimen Initial insulin dose: Reduce patient's home insulin regimen by 20% OR 0·3 U/kg per day (half basal and half bolus) If patient has poor intake, hold the prandial insulin.

_{†One of the options which has been studied in randomized controlled trials is dipeptidyl peptidase-4 inhibitor. Although metformin use is common, use it with caution due to high risk of lactic acidosis, especially in high risk patients (such as sepsis, renal insufficiency, shock and hepatic failure)}

• The following table is a summary of treatment in critically ill hospitalized patients with diabetes:

Patient status	Patients with surgical or other medical conditions‡	Mild to moderate DKA	Severe DKA or HHS
Approach	Continuous insulin infusion §	Continuous insulin infusion OR subcutaneous insulin (consider DKA protocol)	Continuous insulin infusion

_{‡Continuous insulin infusion specially could be beneficial in hypoglycemia due to steroid use or in solid organ transplant patients. §Prompt treatment is recommended in patients with myocardial infarction or ischemic stroke due to possible further harm due to hyperglycemia. ALthough intensive treatment is not recommended due to higher chance of hypoglycemia.}

• Based on a systematic review published in 2021, numerous subcutanoeus insulin regimen have been studied on non-critically ill diabetic patients. The following table is a summary of the afformentioned studies:

2016 ADA Standards of Medical Care in Diabetes Guidelines

"1. Consider performing an A1C on all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the previous 3 months. (Level of Evidence: C)"

"2. Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients(Level of Evidence: A)and noncritically ill patients (Level of Evidence: C)"

"3. More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) may be ap- propriate for selected critically ill patients, as long as this can be achieved without significant hypoglycemia (Level of Evidence: C)"

"4. Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. (Level of Evidence: E)"

"5. A basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for patients with good nutritional intake. (Level of Evidence: A)"

"6. The sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged (Level of Evidence: A)"

"7. A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. (Level of Evidence: E)"

"8. The treatment regimen should be reviewed and changed if necessary to prevent further hypoglycemia when a blood glucose value is <70 mg/dL (3.9 mmol/L). (Level of Evidence: C)"

"9. There should be a structured discharge plan tailored to the individual patient. (Level of Evidence: B)"