Glucose Management in Hospitalized Patients

 

Glucose management in hospitalized patients poses challenges to physicians, including identifying blood glucose targets, judicious use of oral diabetes mellitus medications, and implementing appropriate insulin regimens. Uncontrolled blood glucose levels can lead to deleterious effects on wound healing, increased risk of infection, and delays in surgical procedures or discharge from the hospital. Previously recommended strict blood glucose targets for hospitalized patients result in more cases of hypoglycemia without improvement in patient outcomes. The current target is 140 to 180 mg per dL. Use of oral diabetes medications, particularly metformin, in hospitalized patients is controversial. Multiple guidelines recommend stopping these medications at admission because of inpatient factors that can increase the risk of renal or hepatic failure. However, oral diabetes medications have important nonglycemic benefits and reduce the risk of widely fluctuating blood glucose levels. There is no proven risk of lactic acidosis from metformin in patients with normal kidney function, and it can be used safely in many hospitalized patients with diabetes. Insulin dosing depends on the patient's previous experience with insulin, baseline diabetes control, and renal function. Other considerations include the patient's current oral intake, comorbidities, and other medications. Many patients can be managed using only a basal insulin dose, whereas others benefit from additional short-acting premeal doses. Historically, sliding scale insulin regimens have been used, but they have no proven benefit, increase the risk of hypoglycemia and large fluctuations in blood glucose levels, and are not recommended. Discharge planning is an important opportunity to address diabetes control, medication adherence, and outpatient follow-up.

Patients with type 2 diabetes mellitus who are hospitalized experience changes in diet, medications, glucose metabolism, and schedule that can adversely affect blood glucose control. Patients may have hypoglycemia (defined as a blood glucose level less than 70 mg per dL [3.9 mmol per L]) because of missed meals (including “nothing by mouth” status) or hyperglycemia from medication effects or acute illness, or both may occur with widely fluctuating glucose levels. Hyperglycemia in hospitalized patients has a complex physiology and is partly due to relative insulin deficiency arising from the metabolic stress of acute illness that in turn triggers immune dysfunction, oxidative stress, and impaired wound healing.1 Historically, hospitalized patients with diabetes have been managed using a sliding scale insulin regimen; however, an increasing body of literature shows that this has more harms than benefits.

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Routine home diabetes mellitus medications should be continued during hospitalization unless there are specific contraindications.

C

12

The metformin dosage should be decreased in hospitalized patients with an estimated glomerular filtration rate of 30 to 45 mL per minute per 1.73 m2, and metformin should be discontinued if it is less than 30 mL per minute per 1.73 m2.

C

1517

To prevent wide glucose fluctuations, either a basal insulin approach or a basal-bolus correctional approach, using long-acting insulin plus adjusted premeal short-acting insulin, should be used.

C

24

Sliding scale insulin regimens have no benefit over continuation of routine home diabetes regimens and are not recommended.

B

2527


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Routine home diabetes mellitus medications should be continued during hospitalization unless there are specific contraindications.

C

12

The metformin dosage should be decreased in hospitalized patients with an estimated glomerular filtration rate of 30 to 45 mL per minute per 1.73 m2, and metformin should be discontinued if it is less than 30 mL per minute per 1.73 m2.

C

1517

To prevent wide glucose fluctuations, either a basal insulin approach or a basal-bolus correctional approach, using long-acting insulin plus adjusted premeal short-acting insulin, should be used.

C

24

Sliding scale insulin regimens have no benefit over continuation of routine home diabetes regimens and are not recommended.

B

2527


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating

The Authors

show all author info

CHARLES KODNER, MD, is an associate professor in the Department of Family and Geriatric Medicine at the University of Louisville (Ky.) School of Medicine....

LAURIE ANDERSON, MD, is a third-year resident in the Department of Family and Geriatric Medicine at the University of Louisville School of Medicine.

KATHERINE POHLGEERS, MD, is an assistant professor in the Department of Family and Geriatric Medicine at the University of Louisville School of Medicine.

Address correspondence to Charles Kodner, MD, University of Louisville School of Medicine, Med Center One Building, Louisville, KY 40292 (e-mail: charles.kodner@louisville.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Clement S, Braithwaite SS, Magee MF, et al.; American Diabetes Association Diabetes in Hospitals Writing Committee. Management of diabetes and hyperglycemia in hospitals [published correction appears in Diabetes Care. 2004;27(3):856,1255]. Diabetes Care. 2004;27(2):553–591....

2. Nau KC, Lorenzetti RC, Cucuzzella M, Devine T, Kline J. Glycemic control in hospitalized patients not in intensive care: beyond sliding-scale insulin. Am Fam Physician. 2010;81(9):1130–1135.

3. Guzman JZ, Iatridis JC, Skovrlj B, et al. Outcomes and complications of diabetes mellitus on patients undergoing degenerative lumbar spine surgery. Spine (Phila Pa 1976). 2014;39(19):1596–1604.

4. American Diabetes Association. Standards of medical care in diabetes—2017. DiabetesCare. 2017;40(suppl 1):S1–S135. http://care.diabetesjournals.org/content/40/Supplement_1. Accessed May 15, 2017.

5. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19):1359–1367.

6. Griesdale DE, de Souza RJ, van Dam RM, et al. Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ. 2009;180(8):821–827.

7. Kansagara D, Fu R, Freeman M, Wolf F, Helfand M. Intensive insulin therapy in hospitalized patients: a systematic review. Ann Intern Med. 2011;154(4):268–282.

8. Wesorick D, O'Malley C, Rushakoff R, Larsen K, Magee M. Management of diabetes and hyperglycemia in the hospital: a practical guide to subcutaneous insulin use in the non-critically ill, adult patient. J Hosp Med. 2008;3(5 suppl):17–28.

9. Maynard G, Lee J, Phillips G, Fink E, Renvall M. Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an insulin management algorithm. J Hosp Med. 2009;4(1):3–15.

10. Shetty S, Inzucchi SE, Goldberg PA, Cooper D, Siegel MD, Honiden S. Adapting to the new consensus guidelines for managing hyperglycemia during critical illness: the updated Yale insulin infusion protocol. Endocr Pract. 2012;18(3):363–370.

11. Wilson M, Weinreb J, Hoo GW. Intensive insulin therapy in critical care: a review of 12 protocols. Diabetes Care. 2007;30(4):1005–1011.

12. Umpierrez GE, Hellman R, Korytkowski MT, et al.; Endocrine Society. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97(1):16–38.

13. Finfer S, Chittock DR, Su SY, et al.; NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283–1297.

14. Salpeter S, Greyber E, Pasternak G, Salpeter E. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. Cochrane Database Syst Rev. 2010;(1):CD002967.

15. Lu WR, Defilippi J, Braun A. Unleash metformin: reconsideration of the contraindication in patients with renal impairment. Ann Pharmacother. 2013;47(11):1488–1497.

16. Stacul F, Adam A, Becker CR, et al.; CIN Consensus Working Panel. Strategies to reduce the risk of contrast-induced nephropathy. Am J Cardiol. 2006;98(6A):59K–77K.

17. Boucaud-Maitre D, Ropers J, Porokhov B, et al. Lactic acidosis: relationship between metformin levels, lactate concentration and mortality. Diabet Med. 2016;33(11):1536–1543.

18. Goergen SK, Rumbold G, Compton G, Harris C. Systematic review of current guidelines, and their evidence base, on risk of lactic acidosis after administration of contrast medium for patients receiving metformin. Radiology. 2010;254(1):261–269.

19. Scott KA, Martin JH, Inder WJ. Acidosis in the hospital setting: is metformin a common precipitant? Intern Med J. 2010;40(5):342–346.

20. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32(6):1119–1131.

21. Lepelley M, Giai J, Yahiaoui N, Chanoine S, Villier C. Lactic acidosis in diabetic population: is metformin implicated? Results of a matched case-control study performed on the type 2 diabetes population of Grenoble Hospital University [published ahead of print in 2016]. J Diabetes Res. https://www.hindawi.com/journals/jdr/2016/3545914/. Accessed May 15, 2017.

22. Deusenberry CM, Coley KC, Korytkowski MT, Donihi AC. Hypoglycemia in hospitalized patients treated with sulfonylureas. Pharmacotherapy. 2012;32(7):613–617.

23. Umpierrez GE, Gianchandani R, Smiley D, et al. Safety and efficacy of sitagliptin therapy for the inpatient management of general medicine and surgery patients with type 2 diabetes: a pilot, randomized, controlled study. Diabetes Care. 2013;36(11):3430–3435.

24. Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169–2174.

25. Lee YY, Lin YM, Leu WJ, et al. Sliding-scale insulin used for blood glucose control: a meta-analysis of randomized controlled trials. Metabolism. 2015;64(9):1183–1192.

26. Dickerson LM, Ye X, Sack JL, Hueston WJ. Glycemic control in medical inpatients with type 2 diabetes mellitus receiving sliding scale insulin regimens versus routine diabetes medications: a multicenter randomized controlled trial. Ann Fam Med. 2003;1(1):29–35.

27. Trotter B, Conaway MR, Burns SM. Relationship of glucose values to sliding scale insulin (correctional insulin) dose delivery and meal time in acute care patients with diabetes mellitus. Medsurg Nurs. 2013;22(2):99–104,135.

28. Umpierrez GE, Smiley D, Jacobs S, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care. 2011;34(2):256–261.

29. Roberts GW, Aguilar-Loza N, Esterman A, Burt MG, Stranks SN. Basal-bolus insulin versus sliding-scale insulin for inpatient glycaemic control: a clinical practice comparison. Med J Aust. 2012;196(4):266–269.

30. Porcellati F, Rossetti P, Busciantella NR, et al. Comparison of pharmacokinetics and dynamics of the long-acting insulin analogs glargine and detemir at steady state in type 1 diabetes: a double-blind, randomized, crossover study [published correction appears in Diabetes Care. 2008; 31(1):188]. Diabetes Care. 2007;30(10):2447–2452.

31. Freeland B, Penprase BB, Anthony M. Nursing practice patterns: timing of insulin administration and glucose monitoring in the hospital. Diabetes Educ. 2011;37(3):357–362.

32. Umpierrez GE, Reyes D, Smiley D, et al. Hospital discharge algorithm based on admission HbA1c for the management of patients with type 2 diabetes. Diabetes Care. 2014;37(11):2934–2939.

33. Griffith ML, Boord JB, Eden SK, Matheny ME. Clinical inertia of discharge planning among patients with poorly controlled diabetes mellitus. J Clin Endocrinol Metab. 2012;97(6):2019–2026.

34. Lilley SH, Levine GI. Management of hospitalized patients with type 2 diabetes mellitus. Am Fam Physician. 1998;57(5):1079–1088.

35. Sawin G, Shaughnessy AF. Glucose control in hospitalized patients. Am Fam Physician. 2010;81(9):1121–1124.

 

 

Copyright © 2017 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


MOST RECENT ISSUE


Dec 15, 2017

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article