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Version 4.0 VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus EVIDENCE TABLE Recommendation Sources LE QE SR 1 CSII for patients with poor glycemic Hirsch et al., 2005 I Fair to A control (including wide glucose Hoogma et al., 2006 Good excursions with hyperglycemia and Retnakaran et al., 2004 hypoglycemia and those not meeting HbA1c goal) Jeitler et al., 2008 Fatourechi et al., 2009 Pickup et al., 2008 2 CSII for patients with marked dawn Hirsch et al., 2005 I Fair B phenomenon (fasting AM hyperglycemia) 3 CSII for patients with recurrent Hirsch et al., 2005 I Fair B nocturnal hypoglycemia 4 CSII for patients with circumstances of employment, for example shift work, in which MDI regimens have been unable to maintain glycemic control Working Group Consensus III Poor I 5 Patients using CSII should have type 1 diabetes 6 Patients using CSII should have demonstrated willingness and ability to play an active role in diabetes selfmanagement to include frequent selfmonitoring of blood glucose (SMBG) 7 Patients using CSII should have completed a comprehensive diabetes education program 8 Patients using CSII should have demonstrated willingness and ability to have frequent contact with their healthcare team. 9 No evidence to support use of CSII over MDI regimens in most patients with type 2 diabetes Retnakaran et al., 2004 Hirsch et al., 2005 Hoogma et al., 2006 Barnard et al., 2007 Jeitler et al., 2008 Pickup et al., 2008 Fatourechi et al., 2009 I Good A Working Group Consensus III Poor I Working Group Consensus III Poor I Working Group Consensus III Poor I Raskin et al., 2003 Herman et al., 2005 Wainstein et al., 2005 Jeitler et al., 2008 Fatourechi et al., 2009 LE-Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (see Appendix A) I Good D Module G: Glycemic Control Page 67
Version 4.0 VA/DoD Clinical Practice Guideline for the Management of Diabetes Mellitus J-5. Glycemic Control for Hospitalized Patients BACKGROUND Hyperglycemia during hospitalization is associated with adverse outcomes independent of diabetes. Importantly, glucose lowering interventions have been shown to reduce morbidity and mortality in some critically ill populations. However, establishing evidence-based guidelines for inpatient glycemic control is challenging due to the fact that trials have produced discrepant findings and in many cases have had methodologic problems limiting the conclusions that can be made. Overall, the evidence supports the treatment of hyperglycemia during hospitalization, in both patients with and without a diagnosis of diabetes. Evidence to support “tight” glycemic control (80-110 mg/dl) remains insufficient. Although there are few studies examining the benefits of more moderate glucose lowering, the overall body of literature supports treating hyperglycemia to glucose levels < 180 mg/dl. Most of the controversies have centered on the ideal and exact glucose target for hospitalized patients, as well as which populations would derive benefit from glucose lowering interventions. However, a growing body of evidence from hospitals throughout the country indicates that more basic aspects of diabetes and glucose management during hospitalization are often not addressed. The following recommendations are intended for hospitalized patients with hyperglycemia and/or diabetes mellitus (DM) but are not intended for those with diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic nonketotic syndrome (HHNS) or pregnancy. RECOMMENDATIONS 1. In patients with known DM, it is reasonable to document the DM diagnosis in the medical record. Because of the potential harm from omission of insulin in patients with type 1 DM, it is suggested that the type of DM also be documented. [I] 2. In order to identify potentially harmful hyperglycemia and hypoglycemia, blood glucose monitoring may be ordered in hospitalized patients with diagnosed DM and/or hyperglycemia (BG > 180 mg/dl) on admission. There is no evidence to support a given frequency of monitoring. Therefore, the frequency of monitoring should be based upon clinical judgment taking into account the management of diabetes, the reason for admission, and the stability of the patient. [I] 3. Due to safety concerns related to potential adverse events with oral anti-hyperglycemic medications, it is prudent to thoughtfully review these agents in the majority of hospitalized patients. It may be reasonable to continue oral agents in patients who are medically stable and have good glycemic control on oral agents at home. [I] 4. For patients with DM and/or hyperglycemia who are not medically stable or who are poorly controlled with oral anti-hyperglycemic medications at home, initiating insulin therapy should be considered. It is appropriate to continue pre-hospitalization insulin regimens, but reasonable to reduce the dose in order to minimize the risk of hypoglycemia. In the ICU, continuous intravenous insulin infusion is recommended. Scheduled subcutaneous insulin is appropriate in the non-ICU setting and may include a long-acting basal insulin as well as a nutritional insulin for those eating discrete meals or receiving enteral nutrition. A supplementary correction (sliding) scale is also recommended but correction scale insulin regimens as sole therapy are discouraged. [B] 5. Insulin should be adjusted to maintain a BG < 180 mg/dl with the goal of achieving a mean glucose around 140 mg/dl. Evidence is lacking to support a lower limit of target blood glucose but based on a recent trial suggesting that blood glucose < 110 mg/dl may be harmful, we do not recommend blood glucose levels < 110 mg/dl. [A] 6. Insulin therapy should be guided by local protocols and preferably “dynamic” protocols that account for varied and changing insulin requirements. A nurse-driven protocol for the treatment of hypoglycemia is highly recommended to ensure prompt and effective correction of hypoglycemia. [I] 7. To minimize the risk of hypoglycemia and severe hyperglycemia after discharge it is reasonable to provide hospitalized patients who have DM and knowledge deficits, or patients with newly discovered hyperglycemia, basic education in “survival skills”. [I] 8. Patients who experienced hyperglycemia during hospitalization but who are not known to have DM should be re-evaluated for DM after recovery and discharge. [B] Module G: Glycemic Control Page 68
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