2008 Clinical Practice Guidelines - Canadian Diabetes Association

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
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MANAGEMENT