2008 Clinical Practice Guidelines - Canadian Diabetes Association

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2008 CLINICAL PRACTICE GUIDELINES S70 40. Umpierrez GE, Kelly JP, Navarrete JE, et al. Hyperglycemic crises in urban blacks. Arch Intern Med. 1997;157;669-675. 41. Musey VC, Lee JK, Crawford R, et al. Diabetes in urban African-Americans. I. Cessation of insulin therapy is the major precipitating cause of diabetic ketoacidosis. Diabetes Care. 1995;18:483-489. 42. Wachtel TJ, Silliman RA, Lamberton P. Predisposing factors for the diabetic hyperosmolar state. Arch Intern Med. 1987;147: 499-501.
In-hospital Management of Diabetes Canadian Diabetes Association Clinical Practice Guidelines Expert Committee The initial draft of this chapter was prepared by Alun Edwards MB MRCP (UK) FRCPC, Alice Y.Y. Cheng MD FRCPC, Maureen Clement MD CCFP, Amir Hanna MB BCh FRCPC, Robyn Houlden MD FRCPC and Jacqueline James MD MEd FRCPC KEY MESSAGES • Diabetes increases the risk for disorders that predispose individuals to hospitalization, including cardiovascular diseases, nephropathy, infection and lower-extremity amputations. • Use of “sliding scale” insulin therapy, although common, treats hyperglycemia after it has occurred.A proactive approach to management with the use of basal, bolus and correction insulin is preferred. • Hypoglycemia remains a major impediment to achieving optimal glycemic control in hospitalized patients. Healthcare institutions should have standardized treatment protocols that address mild, moderate and severe hypoglycemia. INTRODUCTION Diabetes increases the risk for disorders that predispose individuals to hospitalization, including cardiovascular disease (CVD), nephropathy, infection and lower-extremity amputations. The majority of hospitalizations for patients with diabetes are not directly related to the metabolic state, and diabetes management is rarely the primary focus of care. Therefore, glycemic control and other diabetes care issues are often not adequately addressed (1). A rapidly growing body of literature supports targeted glycemic control in the hospital setting, with potential for improved mortality, morbidity and healthcare economic outcomes (2). The precise prevalence of diabetes in hospitalized adult patients is not known. One study reported a prevalence of 26% of known diabetes in hospitalized patients in a community teaching hospital (3). An additional 12% of patients had unrecognized diabetes or hospital-related hyperglycemia that reverted to normoglycemia after discharge. Diabetes has been reported to be the fourth most common comorbid condition listed on all hospital discharges (4). ROLE OF ORAL ANTIHYPERGLYCEMIC AGENTS No large studies have investigated the potential roles of various oral antihyperglycemic agents (OHAs) on outcomes in hospitalized patients with diabetes. However, OHAs may have a role in stable patients who had good glycemic control on OHAs prior to admission (unless newly developed condi- tions, such as renal, hepatic or cardiac disturbances, represent contraindications to their use). ROLE OF SUBCUTANEOUS INSULIN Patients with type 1 diabetes must be maintained on insulin therapy during hospitalization to prevent diabetic ketoacidosis. Stable patients who are able to eat should typically receive the same dose of subcutaneous basal insulin (NPH, glargine, detemir) they were taking at home. Bolus (prandial) insulin (regular, lispro, aspart) may require adjustment depending on the patient’s intercurrent illness and ability to consume meals. Correction-dose (supplemental) insulin is useful to treat unanticipated hyperglycemia in hospitalized patients (2,5). This involves the adjustment of the patient’s usual scheduled or programmed insulin to compensate for unanticipated hyperglycemia. If correction doses are frequently required, the scheduled insulin doses should be increased. If patients are not able to eat their usual meals, prandial insulin doses might also need to be adjusted to avoid hypoglycemia. Stable patients with type 2 diabetes using insulin at home should also continue their pre-admission insulin regimen, with adjustment as needed. The use of “sliding scale” insulin therapy for inpatient management of diabetes is a common practice. Sliding scale insulin therapy treats hyperglycemia after it has occurred. Studies have shown that this reactive approach is associated with higher rates of hyper- and hypoglycemia (6). ROLE OF INTRAVENOUS INSULIN INFUSION Intravenous (IV) insulin infusion therapy should be considered during critical illness, or other illness requiring prompt glycemic control, or prolonged fasting (NPO status) (7). IV insulin infusion therapy should be administered only where frequent blood glucose (BG) monitoring and close nursing supervision are possible. Staff education is a critical component of the implementation of an IV insulin infusion protocol. IV insulin protocols should take into account the current and previous BG levels (and, therefore, the rate of change), and the patient’s usual insulin dose. BG determinations should be performed every 1 to 2 hours until BG stability has been demonstrated. For NPO patients not receiving enteral or parenteral S71 MANAGEMENT
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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