Diabetes Care in the Hospital Setting
2016 ADA Guideline Recommendations |
Types of Diabetes Mellitus |
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2016 ADA Standard of Medical Care Guideline Recommendations |
Cardiovascular Disease and Risk Management |
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. [1] [2].[3][4].
- Key studies include:
- Basal-bolus versus a basal plus correction insulin[5]
- Basal-bolus versus sliding scale insulin[6]
- Basal-bolus versus basal Plus sliding scale versus sliding scale alone[5].
- Insulin analogues versus human insulin.[7]
- Key studies include:
- Basal-bolus insulin versus sliding scale insulin using the Glucommander eGlycemic Management System.[8]
- 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. [9]
- 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.[10][9]
- 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.[9]
- Based on a systematic review, universal usage of premixed insulin regimens is not trusted in hospitalized diabetic patients.[9]
- The following table is a summary of treatment in non-critically ill hospitalized patients with diabetes:[9]
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)
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)" |
References
- ↑ Christensen MB, Gotfredsen A, Nørgaard K (2017). "Efficacy of basal-bolus insulin regimens in the inpatient management of non-critically ill patients with type 2 diabetes: A systematic review and meta-analysis". Diabetes Metab Res Rev. 33 (5). doi:10.1002/dmrr.2885. PMID 28067472.
- ↑ Gómez Cuervo C, Sánchez Morla A, Pérez-Jacoiste Asín MA, Bisbal Pardo O, Pérez Ordoño L, Vila Santos J (2016). "Effective adverse event reduction with bolus-basal versus sliding scale insulin therapy in patients with diabetes during conventional hospitalization: Systematic review and meta-analysis". Endocrinol Nutr. 63 (4): 145–56. doi:10.1016/j.endonu.2015.11.008. PMID 26826772.
- ↑ American Diabetes Association (2018). "14. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2018". Diabetes Care. 41 (Suppl 1): S144–S151. doi:10.2337/dc18-S014. PMID 29222385.
- ↑ Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM; et al. (2012). "Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline". J Clin Endocrinol Metab. 97 (1): 16–38. doi:10.1210/jc.2011-2098. PMID 22223765.
- ↑ 5.0 5.1 Umpierrez GE, Smiley D, Hermayer K, Khan A, Olson DE, Newton C; et al. (2013). "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. 36 (8): 2169–74. doi:10.2337/dc12-1988. PMC 3714500. PMID 23435159.
- ↑ Zaman Huri H, Permalu V, Vethakkan SR (2014). "Sliding-scale versus basal-bolus insulin in the management of severe or acute hyperglycemia in type 2 diabetes patients: a retrospective study". PLoS One. 9 (9): e106505. doi:10.1371/journal.pone.0106505. PMC 4152280. PMID 25181406.
- ↑ Bueno E, Benitez A, Rufinelli JV, Figueredo R, Alsina S, Ojeda A; et al. (2015). "BASAL-BOLUS REGIMEN WITH INSULIN ANALOGUES VERSUS HUMAN INSULIN IN MEDICAL PATIENTS WITH TYPE 2 DIABETES: A RANDOMIZED CONTROLLED TRIAL IN LATIN AMERICA". Endocr Pract. 21 (7): 807–13. doi:10.4158/EP15675.OR. PMID 26121460.
- ↑ Newsom R, Patty C, Camarena E, Sawyer R, McFarland R, Gray T; et al. (2018). "Safely Converting an Entire Academic Medical Center From Sliding Scale to Basal Bolus Insulin via Implementation of the eGlycemic Management System". J Diabetes Sci Technol. 12 (1): 53–59. doi:10.1177/1932296817747619. PMC 5761993. PMID 29237289.
- ↑ 9.0 9.1 9.2 9.3 9.4 Pasquel FJ, Lansang MC, Dhatariya K, Umpierrez GE (2021). "Management of diabetes and hyperglycaemia in the hospital". Lancet Diabetes Endocrinol. 9 (3): 174–188. doi:10.1016/S2213-8587(20)30381-8. PMID 33515493 Check
|pmid=
value (help). - ↑ NICE-SUGAR Study Investigators. Finfer S, Chittock DR, Su SY, Blair D, Foster D; et al. (2009). "Intensive versus conventional glucose control in critically ill patients". N Engl J Med. 360 (13): 1283–97. doi:10.1056/NEJMoa0810625. PMID 19318384. Review in: J Fam Pract. 2009 Aug;58(8):424-6 Review in: Ann Intern Med. 2009 Aug 18;151(4):JC2-5