DM Full Guideline (2010) - VA/DoD Clinical Practice Guidelines Home

Version 4.0
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
These studies also reveal that oral agents are often used rather than insulin, and when insulin is ordered, sliding scale
monotherapy is common. Lastly, insulin is infrequently adjusted after the initial order.
Hypoglycemia
Hypoglycemia is the most common complication associated with inpatient glycemic control, and is one of the
leading adverse outcomes limiting the quality of trials addressing the benefits of intensive glycemic control
(Brunkhorst et al., 2008; Gandhi et al., 2008; Finfer et al., 2009). In a recent meta-analysis by Griesdale et al.,
among the trials that reported hypoglycemia, the pooled relative risk with intensive insulin therapy was 6.0 (95% CI
4.5-8.0)(Griesdale et al., 2009). As such, the fear of hypoglycemia remains one of the most common barriers to the
implementation of inpatient diabetes care strategies. Studies of hypoglycemia during hospitalization have identified
factors that increase the risk for hypoglycemia; some of these include heart failure, renal or liver disease,
malignancy, infection, or sepsis. Additional precipitating factors which can further increase the likelihood of
inducing hypoglycemia include changing clinical condition, reduction of corticosteroid dose, reduction in the
amount of nutrition (e.g. interruption of enteral feeding or intravenous dextrose, NPO status), vomiting, and
inappropriate timing of short- or rapid-acting insulin in relation to meals (Smith et al., 2005; Krinsley et al., 2007;
Fischer et al., 1986). Therefore, in order to prevent and promptly manage hypoglycemia, standardized protocols to
treat hypoglycemia should be in place for nurses to implement immediately without an additional order from the
physician. As with other adverse events in the hospital, instances of severe hypoglycemia should be documented and
a root-cause analysis can be helpful. Monitoring such episodes and analyzing their cause can be used to eliminate
future occurrences of these episodes.
Some studies have demonstrated a relationship between hypoglycemia and increased mortality, however it is unclear
if hypoglycemia is a marker of severe illness that is frequently observed in individuals with serious comorbidities
such as sepsis, hepatic and renal failure, or if it is a direct cause of adverse outcomes. Several recent studies that
control for these comorbidities or segregate the analysis based on spontaneous versus iatrogenic hypoglycemia are
reassuring in that they have demonstrated no association between iatrogenic hypoglycemia and mortality (Kagansky
et al., 2003; Vriesendorp et al., 2006; Kosiborod et al., 2009). Nevertheless it remains unclear what the
consequences of hypoglycemia are during severe illness and how these sequelae may vary based on acute vs.
chronic complications or susceptibility in different disease states.
Oral anti-hyperglycemic agents
Various circumstances and conditions related to hospitalization increase the likelihood of adverse effects typically
associated with the use of oral agents. These include derangements in renal, cardiovascular, and hepatic function;
changes in hemodynamic and fluid status; frequent changes in nutritional status; a rapidly changing clinical
condition; and imaging studies requiring contrast. Because of the safety concerns, the use of oral agents should be
discouraged for most hospitalized patients. However, in some hospitalized patients who are medically stable and
have been controlled prior to admission with oral agents, the continuation of these medications may be of less risk
than the initiation of insulin.
Insulin
Insulin is encouraged as an anti-hyperglycemic agent for hospitalized patients because it is able to address both basal
and nutritional needs separately and is the only anti-hyperglycemic agent that allows intravenous infusion for
critically ill patients with poor subcutaneous absorption (e.g. edema, hypotension, vasopressors). Furthermore, the
rapidity of onset of action as well as flexibility in a variety of conditions makes insulin an ideal medication for
glycemic management in inpatient setting (Inzucchi, 2006).
When given subcutaneously, insulin should be prescribed with specifications for a basal, nutritional, and correction
dose. The basal insulin dose, which is meant to suppress hepatic gluconeogenesis in the non-fed state can be
calculated based on body weight for the insulin–naïve patient or based on previously known total daily dose of
insulin at home for patients who have been on insulin. A recent study suggests that decreasing the total daily insulin
dose of the patient’s home regimen by 20-25% is prudent given the observation that initiating the total home insulin
dose is associated with higher rates of hypoglycemia during hospitalization (Umpierrez et al., 2009). The nutritional
insulin, meant to correct glycemic excursions related to meals, should be tailored to the nutritional regimen, which
could be discrete meals, enteral or total parenteral nutrition. Basal insulin is an important component of an effective
insulin regimen. It should not be withheld in those individuals with “NPO” status, and is critical for an individual
with type 1 diabetes in whom withholding basal insulin can precipitate diabetic ketoacidosis (Clement et al., 2004;
Inzucchi 2006). The “sliding scale” method of insulin delivery is an algorithm for insulin orders to treat
Module G: Glycemic Control Page 72