Diabetes Care In Specific Settings

A. Diabetes care in the hospital

Recommendations

* All patients with diabetes admitted to the hospital should be identified in the medical record as having diabetes. (E)

* All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team. (E)

* Goals for blood glucose levels:
Critically ill patients: blood glucose levels should be kept as close to 110 mg/dl (6.1 mmol/l) as possible and generally <180 mg/dl (10 mmol/l). These patients will usually require intravenous insulin. (B)

Non??“critically ill patients: premeal blood glucose levels should be kept as close to 90??“130 mg/dl (5.0??“7.2 mmol/l; midpoint of range 110 mg/dl) as possible given the clinical situation and postprandial blood glucose levels <180 mg/dl. Insulin should be used as necessary. (E)

Text continued below

*

Due to concerns regarding the risk of hypoglycemia, some institutions may consider these blood glucose levels to be overly aggressive for initial targets. Through quality improvement, glycemic goals should systematically be reduced to the recommended levels. (E)

* Scheduled prandial insulin doses should be given in relation to meals and should be adjusted according to point of care glucose levels. The traditional sliding-scale insulin regimens are ineffective and are not recommended. (C)

* A plan for treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be tracked. (E)

* All patients with diabetes admitted to the hospital should have an A1C obtained for discharge planning if the result of testing in the previous 2??“3 months is not available. (E)

* A diabetes education plan including “survival skills education” and follow-up should be developed for each patient. (E)

* Patients with hyperglycemia in the hospital who do not have a diagnosis of diabetes should have appropriate plans for follow-up testing and care documented at discharge. (E)

The management of diabetes in the hospital is extensively reviewed in an ADA technical review by Clement et al.. This review forms the basis for these guidelines. In addition, the American Association of Clinical Endocrinologists held a conference on this topic, and the recommendations from this meeting were also carefully reviewed and discussed in the formulation of the guidelines that follow. The management of diabetes in the hospital is generally considered secondary in importance compared with the condition that prompted admission.

Patients with hyperglycemia fall into three categories:

* Medical history of diabetes: diabetes has been previously diagnosed and acknowledged by the patient??™s treating physician.
* Unrecognized diabetes: hyperglycemia (fasting blood glucose 126 mg/dl or random blood glucose 200 mg/dl) occurring during hospitalization and confirmed as diabetes after hospitalization by standard diagnostic criteria but unrecognized as diabetes by the treating physician during hospitalization.
* Hospital-related hyperglycemia: hyperglycemia (fasting blood glucose 126 mg/dl or random blood glucose 200 mg/dl) occurring during the hospitalization that reverts to normal after hospital discharge.

The prevalence of diabetes in hospitalized adult patients is not precisely known. In the year 2000, 12.4% of hospital discharges in the U.S. listed diabetes as a diagnosis. The prevalence of diabetes in hospitalized adults is conservatively estimated at 12??“25%, depending on the thoroughness used in identifying patients. Patients presenting to hospitals may have diabetes, unrecognized diabetes, or hospital-related hyperglycemia. Using the A1C test may be a valuable case-finding tool for identifying diabetes in hospitalized patients.

A rapidly growing body of literature supports targeted glucose control in the hospital setting with potential for improved mortality, morbidity, and health care economic outcomes. Hyperglycemia in the hospital may result from stress, decompensation of type 1 diabetes, type 2 diabetes, or other forms of diabetes and/or may be iatrogenic due to administration or withholding of pharmacologic agents, including glucocorticoids, vasopressors, etc. Distinction between decompensated diabetes and stress hyperglycemia is often not made.

1. Blood glucose targets

a. General medicine and surgery.

Observational studies suggest an association between hyperglycemia and increased mortality. General medical and surgical patients with a blood glucose value(s) >220 mg/dl (12.2 mmol/l) have higher infection rates.

When admissions on general medicine and surgery units were studied, patients with new hyperglycemia had significantly increased inhospital mortality, as did patients with known diabetes. In addition, length of stay was higher for the new hyperglycemic group, and both the patients with new hyperglycemia and those with known diabetes were more likely to require intensive care unit (ICU) care and transitional or nursing home care. Better outcomes were demonstrated in patients with fasting and admission blood glucose <126 mg/dl (7 mmol/l) and all random blood glucose levels <200 mg/dl (11.1 mmol/l).

b. CVD and critical care.

The relationship of blood glucose levels and mortality in the setting of acute myocatdial infarction (AMI) has been reported. A meta-analysis of 15 previously published studies compared in-hospital mortality and CHF in both hyper- and normoglycemic patients with and without diabetes. In subjects without known diabetes whose admission blood glucose was 109.8 mg/dl (6.1 mmol/l), the relative risk for in-hospital mortality was increased significantly. When diabetes was present and admission glucose 180 mg/dl (10 mmol/l), risk of death was moderately increased compared with patients who had diabetes but no hyperglycemia on admission. In another study, admission blood glucose values were analyzed in consecutive patients with AMI. Analysis revealed an independent association of admission blood glucose and mortality. The 1-year mortality rate was significantly lower in subjects with admission plasma glucose <100.8 mg/dl (5.6 mmol/l) than in those with plasma glucose 199.8 mg/dl (11 mmol/l).

Finally, in the first Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study, insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with AMI was examined. Intensive subcutaneous insulin therapy for 3 months improved long-term survival. Mean blood glucose in the intensive insulin intervention arm was 172.8 mg/dl (9.6 mmol/l) (compared with 210.6 mg/dl [11.7 mmol/l] in the "conventional" group). The broad range of blood glucose levels within each arm limits the ability to define specific blood glucose target thresholds.

c. Cardiac surgery.

Attainment of targeted glucose control in the setting of cardiac surgery is associated with reduced mortality and risk of deep sternal wound infections in cardiac surgery patients with diabetes and supports the concept that perioperative hyperglycemia is an independent predictor of infection in patients with diabetes , with the lowest mortality in patients with blood glucose <150 mg/dl (8.3 mmol/l).

d. Critical care.

A mixed group of patients with and without diabetes admitted to a surgical ICU were randomized to receive intensive insulin therapy (target blood glucose 80??“110 mg/dl [4.4??“6.1 mmol/l]). The mean blood glucose of 103 mg/dl (5.7 mmol/l) had reduced mortality during the ICU stay and decreased overall in-hospital mortality. Subsequent analysis demonstrated that for each 20 mg/dl (1.1 mmol/l) glucose was elevated above 100 mg/dl (5.5 mmol/l), the risk of ICU death increased. Hospital and ICU survival were linearly associated with ICU glucose levels, with the highest survival rates occurring in patients achieving an average blood glucose <110 mg/dl (6.1 mmol/l).

e. Acute neurological disorders.

Hyperglycemia is associated with worsened outcomes in patients with acute stroke and Head injury, as evidenced by the large number of observational studies in the literature. A meta-analysis identified an admission blood glucose >110 mg/dl (6.1 mmol/l) for increased mortality for acute stroke.

---
AMERICAN DIABETES ASSOCIATION
DIABETES CARE, VOLUME 27, SUPPLEMENT 1, JANUARY 2004

References
1.  Bode BW (Ed.): Medical Management of Type 1 Diabetes. 4th ed. Alexandria, VA, American Diabetes Association, 2004
2.  Zimmerman BR (Ed.): Medical Management of Type 2 Diabetes. 4th ed. Alexandria, VA, American Diabetes Association, 1998
3.  Kilingensmith G (Ed.): Intensive Diabetes Management.  3rd ed.  Alexandria, VA, American Diabetes Association, 2003
4.  The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 20:1183-1197, 1997
4a.World Health Organization:  Diabetes Mellitus: Report of a WHO Study Group. Geneva, World Health Org., 1985 (Tech. Rep. Ser., no. 727)
5.  The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus: Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 26:3160 - 3167, 2003
6.  Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, Keinanen-Kiukaaniemi S, Laakso M, Louheranta A, Rastas M, Salminen V, Uusitupa M: Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 344:1343-1350, 2001
7.  Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, Hu ZX, Lin J, Xiao JZ, Cao HB, Liu PA, Jiang XG, Jiang YY, Wang JP, Zheng H, Zhang H, Bennett PH, Howard BV: Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the DaQing IGT and Diabetes Study. Diabetes Care 20:537- 544, 1997
8.  The Diabetes Prevention Program Research Group:  Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346:393- 403, 2002
9.  Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M: Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomized trial. Lancet 359:2072-2077, 2002
10.  Sjostrom L, et al: XENDOS ( Xenical in the prevention of diabetes in obese subjects):  a landmark study.  Poster presented at the International Congress on Obesity (ICO), San Paulo, Brazil, 2002
11.  Buchanan TA, Xiang AH, Peters RK, Kjos SL, Marroquin A, Goico J, Ochoa C, Tan S, Berkowitz, Hodis HN, Azen SP: Preservation of pancreatic β-cell function and prevention of type 2 diabetes by pharmacological trewatment of insulin resistance in high-risk hispanic women. Diabetes 51:2796 -2803, 2002
12.  Engelgau ME, Narayan KMV, Herman WH:  Screening for type 2 diabetes (Technical Review).  Diabetes Care 23:1563-1580, 2000 [erratum appears in Diabetes Care 23:1868 -1869, 2000]
13.  American Diabetes Association: Type 2 diabetes in children and adolescents (Consensus Statement).  Diabetes Care 23:381-389, 2000
14.  American Diabetes Association: Gestational diabetes mellitus (Position Statement). Diabetes Care 27 (Suppl. 1):S88 - S90, 2004
15.  The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of longterm complications in insulin-dependent diabetes mellitus. N Engl J Med 329: 977-986, 1993
16.  The UK Prospective Diabetes Study Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352: 837- 853, 1998
17.  The UK Prospective Diabetes Study Group: Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). Lancet 352:854 -865, 1998

May 27, 10 • Diabetes mellitus