Diabetes Care in the Hospital Setting
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2016 ADA Guideline Recommendations |
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Types of Diabetes Mellitus |
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2016 ADA Standard of Medical Care Guideline Recommendations |
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Cardiovascular Disease and Risk Management |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]; Shivani Chaparala M.B.B.S [3]; Tarek Nafee, M.D. [4]
- There are numerous considerations regarding hyperglycemia management in diabetic patients who are hospitalized. Formerly guidelines advocated to stop all oral antidiabetic agents in the hospital settings, nevertheless new clinical trials support the effectiveness of oral antidiabetic drugs, solitary or in combination to insulin therapy.
- The following table is a summary of treatment in non-critically ill hospitalized patients with diabetes:[1][2]
| Patient status | Mild hyperglycaemia | Moderate hyperglycaemia | Severe hyperglycaemia |
|---|---|---|---|
| Definition | Blood glucose < 200 Patients who are taking less than 2 anti-diabetic drugs (such as oral anti-diabetic drug or GLP-1 receptor agonists) |
201 < Blood glucose <300 Patients who are taking multiple anti-diabetic drug (such as oral anti-diabetic drug or GLP-1 receptor agonists) Patients who are taking less than 0·6 U/kg insulin per day |
Blood glucose > 301 Patients who are taking multiple anti-diabetic drug (such as oral anti-diabetic drug or GLP-1 receptor agonists) Patients who are taking more than 0·6 U/kg insulin per day |
| Approach | Low dose basal insulin OR oral anti-diabetic drug†, if there are no contraindications. Further blood glucose correction can be applied by rapid-acting insulin (before meals or every 6 hours) |
Basal insulin OR oral anti-diabetic drug†, if there are no contraindications. Initial insulin dose: 0·2–0·3 U/kg per day (start from 0·15 U/kg per day (if using basal insulin alone) or 0·3 U/kg per day (if using basal–bolus) for patients with high risk of hypoglycemia). Further blood glucose correction can be applied by rapid-acting insulin (before meals or every 6 hours) |
Basal–bolus insulin regimen Initial insulin dose: Reduce patient's home insulin regimen by 20% OR 0·3 U/kg per day (half basal and half bolus) If patient has poor intake, hold the prandial insulin. |
†One of the options which has been studied in randomized controlled trials is dipeptidyl peptidase-4 inhibitor. Although metformin use is common, use it with caution due to high risk of lactic acidosis, especially in high risk patients (such as sepsis, hypoxia, renal insufficiency, shock and hepatic failure)
- The following table is a summary of treatment in critically ill hospitalized patients with diabetes:[1][2][3]
| Patient status | Patients with surgical or other medical conditions‡ | Mild to moderate DKA | Severe DKA or HHS |
|---|---|---|---|
| Approach | Continuous insulin infusion § | Continuous insulin infusion OR subcutaneous insulin (consider DKA protocol) | Continuous insulin infusion |
‡Continuous insulin infusion specially could be beneficial in hypoglycemia due to steroid use or in solid organ transplant patients.
§Prompt treatment is recommended in patients with myocardial infarction or ischemic stroke due to possible further harm due to hyperglycemia. ALthough intensive treatment is not recommended due to higher chance of hypoglycemia.
2016 ADA Standards of Medical Care in Diabetes Guidelines
| "1. Consider performing an A1C on all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the previous 3 months. (Level of Evidence: C)" |
| "2. Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients(Level of Evidence: A)and noncritically ill patients (Level of Evidence: C)" |
| "3. More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) may be ap- propriate for selected critically ill patients, as long as this can be achieved without significant hypoglycemia (Level of Evidence: C)" |
| "4. Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. (Level of Evidence: E)" |
| "5. A basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for patients with good nutritional intake. (Level of Evidence: A)" |
| "6. The sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged (Level of Evidence: A)" |
| "7. A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. (Level of Evidence: E)" |
| "8. The treatment regimen should be reviewed and changed if necessary to prevent further hypoglycemia when a blood glucose value is <70 mg/dL (3.9 mmol/L). (Level of Evidence: C)" |
| "9. There should be a structured discharge plan tailored to the individual patient. (Level of Evidence: B)" |
Insulin Treatment
- There are some available clinical practice guidelines and systematic reviews that suggest basal-bolus insulin may lower blood sugar more efficient, nevertheless it is more likely to cause hypoglycemia with no change in clinical outcomes. [4][5][6][7].
- Key studies include:
- Basal-bolus versus a basal plus correction insulin[8]
- Basal-bolus versus sliding scale insulin[9]
- Basal-bolus versus basal Plus sliding scale versus sliding scale alone[8].
- Insulin analogues versus human insulin.[10]
- Basal-bolus insulin versus sliding scale insulin using the Glucommander eGlycemic Management System.[11]
- Key studies include:
- A landmark trial done in 2009 demonstrated an increased mortality risk with intensive insulin treatment, specifically in critically ill patients. Chance of hypoglycemia rises with intensive insulin therapy and can further complicate the situation.[12][1]
- Continuous insulin infusion is recommended for critically ill diabetic patients (such as ICU patients), which should be replaced by subcutaneous insulin when patient is stable.[1][13]
- The following factors should be considered when transition from continuous insulin infusion to subcutaneous insulin is planned:
- Patients should have a steady glucose concentration, at least for last 4–6 hours
- Normal anion gap must be achieved (if patient have been presented with DKA, acidosis should have been resolved before transition).
- Patients should be hemodynamically stable with out vasopressors
- Patients should be on a stable diet
- Patients should be on a steady intravenous infusion rate
- The following factors should be considered when transition from continuous insulin infusion to subcutaneous insulin is planned:
- Based on a systematic review published in 2021, numerous subcutanoeus insulin regimen have been studied on non-critically ill diabetic patients. The following table is a summary of the afformentioned studies: [1][14][7][15][16][10][17][18]
| Umpierrez et al (2007) | Glargine–glulisine (basal-bolus) Vs sliding-scale insulin Study has been done on 130 patients with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·4 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration in basal-bolus group has been 166 mg/dL (SD: 1.8) Vs average glucose concentration of 193 mg/dL in sliding-scale insulin group (P value < 0·001). Non of the patients developed hypoglycemia (glucose concentrations less than 40 mg/dl). |
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| Umpierrez et al (2009) | Human insulin (NPH and regular) † Vs detemir–aspart (basal-bolus) Study has been done on 130 patients with diabetes type 2 who were on various type of treatments, with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed no difference. 4·5% of patients in detemir–aspart group developed hypoglycemia (glucose concentrations less than 40 mg/dl Vs 1·6% of patients in human insulin. |
| Umpierrez et al (2011) | Glargine–glulisine (basal-bolus) Vs sliding-scale insulin Study has been done on 211 surgical patients with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·4 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed better glycemic control in basal-bolus group (P value = 0·003 ). Patients in basal-bolus group showed lower rate of general complications₪, nevertheless rates of hypoglycemia were higher (4% in basal-bolus group Vs 0% in sliding-scale insulin group). |
| Schroeder et al (2012) | NPH and regular‡ Vs sliding-scale insulin Study has been done on 141 orthopaedic surgery patients with diabetes type 2 or history of frequent hyperglycemia (>180 mg/dL). Reported average glucose concentration in NPH and regular group has been 161·2 mg/dL Vs average glucose concentration of 175·8 mg/dL in sliding-scale insulin group (P value < 0·0005). Two episodes of severe hypoglycemia have been reported in NPH and regular group. |
| Umpierrez et al (2013) | Basal-plus (glargine–glulisine) Vs basal-bolus (glargine–glulisine) Vs sliding-scale insulin Study has been done on 375 patients with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·4 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentrations were akin in both basal-plus and basal-bolus groups. Treatment failure was higher in sliding-scale insulin group (19%), compared to basal-bolus (0%) or basal-plus (2%) groups. |
| Mader et al (2014) | Glargine–aspart (basal-bolus) Vs standard treatment (such as oral antidiabetic agents), insulin or combination of both Study has been done on 74 patients with diabetes type 2 who were on various type of treatments, with glucose concentrations higher than 140 mg/dL. Reported average glucose concentration in basal-bolus group (33%) was higher compared to standard treatment group (23%) (P value 0·001) ¶ |
| Bueno et al (2015) | Glargine–glulisine (basal-bolus) Vs NPH and regular₳ Study has been done on 134 patients with diabetes type 2 who were not a surgical case. Reported average glucose concentrations were akin in both NPH and regular and basal-bolus groups. Hypoglycemic events were reported as 35% in basal-bolus group, compared to 38% in NPH and regular group. |
| Bellido et al (2015) | Glargine–glulisine (basal-bolus) Vs premixed NPH and regular (70/30)¥ Study has been done on 72 patients with diabetes type 2 who were either medical or surgical cases, who were on oral antidiabetic agents, insulin or a combination of both.§ Reported average glucose concentration showed no difference. Objectionably high rate of hypoglycemia have been reported in premixed NPH and regular group. |
| Vellanki et al (2015) | Glargine–aspart (basal-bolus) without bedtime addition Vs Glargine–aspart (basal-bolus) with bedtime addition Study has been done on 206 patients with diabetes type 2 who were medical or surgical cases with glucose concentrations of 140–400 mg/dL. Patients were on oral antidiabetic agents, insulin or a combination of both. Reported average glucose concentration showed no difference. Non of the patients developed hypoglycemia (glucose concentrations less than 40 mg/dl). |
| Gracia-Ramos et al (2016) | Glargine–lispro (basal-plus) Vs premixed insulin analog (lispro 25/75) ¤ Study has been done on 54 patients with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·4 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentrations showed no difference. Rate of hypoglycemia was simillar in both groups (16%). |
| Pasquel et al (2020) | Basal-bolus (glargine U300–glulisine) Vs basal-bolus (glargine U100–glulisine) Study has been done on 176 patients with diabetes type 2 who were on various type of treatments, with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed no difference. Significant lower rate of hypoglycemic events in glargine U300 group. (P value = 0·023) |
†Two-thirds before breakfast and one-third before dinner
₪Patients in basal-bolus group showed lower rate of general complications such as postoperative wound infection, bacteremia, pneumonia, renal insufficiency and respiratory failure.
‡Three times a day
¶Related article didn't provide the absolute numbers
₳NPH insulin has been used twise a day. Regular insulin has been used before meals
¥60% before breakfast and 40% before dinner
§Study terminated after interim analysis.
¤Two-thirds with breakfast and one-third with dinner
- There are numerous data rejecting use of subcutaneous sliding scale insulin in management of inpatient diabetes. However it usage could be accepted in management of stress hyperglycaemia in nondiabetics.[1]
- If home insulin regimen of a patient has been higher than ≥0·6 U/kg each day, 20% reduction in general insulin dose should be considered at the time of admission. This effort is recommended to lower the chance of hypoglycemia in poor oral intake.[1]
- Basal-bolus approach has been reported as an effective treatment for hyperglycemia, nevertheless it's usage in patients with mild hyperglycemia (<200 mg/dl) has been warned due to high risk of iatrogenic hypoglycaemia (with rate of 12–30% in some studies).[15]
- Another approach of insulin therapy such as basal-plus has been recommended for patients with mild hyperglycemia, surgical patients and low oral intake. The mentioned approach is consisted of a basal dose of insulin (0·1–0·25 U/kg/day) and corrective insulin doses if hyperglycemia developed (Monitor glucose concentration every 6 hours in NPO patients, and before every meal in others). This approach has been associated with lower risk of hypoglycemia and is recommended in patients with low oral intake or surgical cases.[1][19]
- Based on a systematic review, universal usage of premixed insulin regimens is not trusted in hospitalized diabetic patients.[1]
- High rate of iatrogenic hypoglycaemia in premixed insulin therapy turned this approach into an untrsuted hyperglycemia treatment in hospitalized diabetic patients. However using premixed insulin therapy in patients taking enteral nutrition have been recommended (there are not enough supporting data). [20]
Non-Insulin Treatments
- Formerly guidelines advocated to stop all oral antidiabetic agents in the hospital settings of diabetes management, nevertheless some clinical trials support the effectiveness of oral antidiabetic drugs, solitary or in combination to insulin therapy, in some hospitalized individuals. Countries such as England, Israel and India practice the usage of oral antidiabetic agents such as, metformin and sulfonylureas for inpatient diabetic patients. [1] [21][22][23]
Dipeptidyl Peptidase-4 Inhibitor Medications
- Dipeptidyl peptidase-4 inhibitor medications are effective for glycemic control in mild to moderate hyperglycemia. Moreover dipeptidyl peptidase-4 inhibitors are tolerated very well and there has been low rate of hypoglycemia. It's usage has been recommended alone or in combination with basal insulin in patients with blood glucoselower than 180 mg/dl. [1]
- There are some evidences about possible effectiveness of sitagliptin in survival of diabetic patients who are infected with COVID-19. Nevertheless due to limitted data more study is required. [1][24][25][26][27]
Glucagon-Like Peptide-1 Analogs
- Studies have shown effectiveness of glucagon-like peptide-1 analogs (such as liraglutide and exenatide) in hospitalized diabetic patients. Based on systematic reviews gastrointestinal side effects have been reported in patients who received glucagon-like peptide-1 analogs.[1][28]
- Studies show that GLP-1 agonists reduced glycated haemoglobin A1c levels to a greater extent than SGLT-2 inhibitors.[29]
- The following table is summary of various randomized controlled trial and observational studies regards dipeptidyl peptidase-4 inhibitor and glucagon-like peptide-1 analogs use in hospital setting:[30][31][22][32][33][34][35][26][36][23][37][1][27]
| Umpierrez et al (2013) | Sitagliptin + sliding-scale insulin or sitagliptin + glargine Vs basal-bolus insulin (glargine–lispro) Study has been done on 90 patients (medical or surgical cases) with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·4 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed no difference. Sole sitagliptin treatment has not been effective in patients who had blood glucose higher than 180 mg/dL. |
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| Pasquel et al (2017) | Sitagliptin + glargine Vs basal-bolus insulin (glargine–lispro or glargine–aspart) Study has been done on 278 patients (medical or surgical cases) with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·6 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed no difference. |
| Garg et al (2017) | Saxagliptin Vs basal-bolus insulin (glargine–aspart) Study has been done on 66 patients (medical or surgical cases) with diabetes type 2 who were on maximum 1 non-insulin antidiabetic agents or 2 non-insulin antidiabetic agents with HbA1c measure less than 7·5% and 7·0%, respectively. Reported average glucose concentration showed no difference. Patients who received saxagliptin showed less blood glucose variation. |
| Vellanki et al (2019) | Linagliptin + sliding-scale insulin Vs basal-bolus insulin (glargine–lispro or glargine–aspart) Study has been done on 250 surgical patients with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·5 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed no difference. Less chance of hypoglycemia has been reported in linagliptin group. Sole linagliptin use has not been effective in patients with blood glucose more than 200 mg/dl |
| Abuannadi et al (2013) | Exenatide infusion Vs intensive glycemic control (90–119 mg/dL) or moderate glycemic control (100–140 mg/dL) Study has been done on 40 non-diabetic ICU patients with coronary heart disease and type 2 diabetic patients who were on non-insulin antidiabetic agents, with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed good control in exenatide group. (Same result as moderate glycemic control) The main limitation has been the non-randomized study with historical controls. |
| Kohl et al (2014) | Native GLP-1 Vs placebo Study has been done on 77 cardiac surgery patients with or without diabetes Reported average glucose concentration showed lower measure in GLP-1 group. |
| Besch et al (2017) | Exenatide infusion Vs insulin infusion Study has been done on 104 CABG patients with or without diabetes (on non-insulin treatment) Reported average glucose concentration showed no statistically valuable differences. Study discontinued after futility analysis. |
| Polderman et al (2018) | Liraglutide † Vs glucose + insulin + potassium ‡ Study has been done on 150 surgical patients with diabetes type 2 who where on diet, oral antidiabetic agents or insulin doses less than 1 U/kg. Reported average glucose concentration measures 1 hour after surgery showed lower levels in liraglutide group. Nausea has been reported in patients of liraglutide. |
| Lipš et al (2017) | Continuous exenatide infusion + insulin treatment Vs 0·9% saline + insulin treatment Study has been done on 40 CABG patients with or without diabetes. Reported average glucose concentration showed lower measures in exenatide group. Decreased demand for temporary pacing after surgery was the only benefit in cardiac function of the exenatide group. |
| Fayfman et al (2019) | Exenatide ¶ Vs exenatide + basal insulin (glargine or levemir) Vs basal insulin (glargine or levemir + aspart or lispro) Study has been done on 150 surgical or medical patients with diabetes type 2 who were on diet, oral antidiabetic agents or low dose insulin (less than 0·5 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed lower measures in exenatide plus basal insulin group, compared to exenatide alone. ALthough reported average glucose concentration showed no differences between exenatide plus basal insulin and basal insulin groups. Exenatide plus basal insulin group was more succesful in keeping the blood glucose within the target goal, compared to the other two groups. (P value = 0·023) |
| Kaneko et al (2018) | Liraglutide Vs insulin Study has been done on 92 surgical patients (elective surgery) with diabetes type 2 Reported average glucose concentration showed lower measures in liraglutide group. |
| Hulst et al (2020) | Liraglutide ₳ Vs placebo Study has been done on 278 cardiac surgery patients with (16%) or without (84%) diabetes type 2 Reported average glucose concentration showed lower demand for insulin use in liraglutide group. Hypoglycemia has not been reported in non of the groups. |
†Liraglutide has been used subcutaneously with dosage of 0·6 mg before surgery and 1.2 mg after anesthesia induction.
‡Infusion of glucose, insulin and potassium was 30 mintunes before surgery and continued until 4 hours after surgery.
¶Exenatide has been used with dose of 5 mg twice a day.
₳Liraglutide has been used subcutaneously with dosage of 0·6 mg on the evening before surgery and 1.2 mg after anesthesia induction.
SGLT2 Inhibitors
- SGLT2 inhibitors are the current treatment of choice among other oral antidiabetic drugs especially for diabetes type 2 patients with concurrent heart failure or diabetic nephropathy. It's use has been related to lower rate of readmission, death within 60 days and heart failure. Nevertheless it's routine use in hospital setting is not recommended.[1][38][39]
- Frequent euglycaemic diabetic ketoacidosis, mostly in patients with poor oral intake and genitourinary infections have been made worry regards SGLT2 inhibitors use for diabetic inpatients. Fungal infections are the common responsible microorganisms for genitourinary infections of these patients.[1]
- Based on a meta-analysis by Palmer et al., SGLT-2 inhibitors and GLP-1 receptor agonists, together for the treatment of DM type 2, reduce mortality, non-fatal myocardial infarction, and serious hyperglycemia, and renal failure.[29]
- Based on a systematic review empagliflozin use has not shown any improvement compared to the placebo groups, in the following Characteristics:[40]
- Dyspnea
- Brain natriuretic peptide level
- Hospitalization period
- Response to diuretics
Metformin
- Use metformin with caution in hospitalized patients especially if renal or hepatic failure, sepsis and shock is present due to high chance of lactic acidosis. To prevent such an adverse effect, patients with GFR in range of 30–45 mL/min per 1·73 m² should recieve lower doses of metformin. Furthermore metformin must be discontinued in patients with GFR lower than 30 ml/min per 1·73 m².[41]
- Metformin should be discontinued prior to iodinated contrast imaging if eGFR <60 mL/min per 1·73 m², history of hepatic disease, acute heart failure, alcoholism or received intra-arterial contrast medium.[42]
- Compared to other oral antidiabetic agents, metformin showed higher rate of gastrointestinal adverse effects in the hospitalized patients.[43]
Sulfonylureas
- Frequent hypoglycemic events have been reported in sulfonylureas usage in the hospital setting, hence experts don't recommend it for treatment of diabetic inpatients. Facrors such as old age, renal insufficiency and concurrent insulin use have been related to higher risk of hypoglycemia. Although UK recommendations proposed it's effectiveness in mangement of hyperglycemia due to glucocorticoid use.[44][45]
Thiazolidinediones
- Late onset of action and risk of heart failure (due to water retention) turned thiazolidinediones into an ineffective treatment in hospital settings.[43][46]
Specific Circumstances
The following are some management considerations that are recommended in hospitalized diabetic patients with specific circumstances.
Medical Nutrition Therapy
- Use low glucose content formulas in diabetic patients who are receiving nutritional therapy to avoid hyperglycemia. [1]
- There are some studies that demonstrate the effectiveness of adding short acting insulins into the parenteral bag, compared to usage of solitary subcutaneous insulin. [47][48]
- If laboratory evaluations show constant hyperglycemia in diabetic or non-diabetic patients usage of basal-bolus insulin is recommended.
- UK guidelines advocate use of 70/30 mixed insulin in diabetic patients in hospital who are receiving nutrition therapy.[1] [20]
- When medical nutritional therapy paused infusion of 10% dextrose at rate of 50 ml/hr is recommended.[20]
- Closed loop insulin therapy has been proposed by a randomised trial done in 2019 as a possible treatment in hospitalized diabetic patients on nutrition therapy. [49][49]
Concurrent Glucocorticoid Use
- Frequent hyperglycemia has been reported in hospitalized patients who are taking glucocorticoids.[50]
- Management of glucocorticoid induced hyperglycemia, in order to achieve the glycemic goal, is much harder in diabetic patients who were receiving home insulin.[51]
- Based on an observational study done on patients who were recieving high dose dexamethasone with 2 glucose concentration higher than 250 mg/dL, multiple dose insulin therapy was an effective treatment. Insulin therapy in the aforementioned study initiated at 1–1·2 U/kg per day with 1/4 basal and 3/4 prandial distribution. In the case of hyperglycemic patients without diabetes who are taking glucocorticoids, isophane insulin in the morning could be a possible treatment. [44][52]
- Based on a systematic review done in 2020, usage of insulin twice a day with a total dose of 0·3 u/kg/day has been recommended. Recommendations divided this dose to 2/3 in the morning and 1/3 in the evening.[1]
- It is recommended to adjust insulin dose based on the glucocorticoid dosage and oral intake. [51][1]
- Dexamethasone discontinuation can be followed by a rapid decrease in insulin requirement, hence insulin dose reduction is necessary.
- Sulfonylurea is not an effective treatment in diabetic patients who are on glucorticoids.
Preoperative State
- Appropriate glycemic control is critical in surgical patients since high glucose concentration is related to higher rates of complications. [53]
- Basal-bolus insulin treatment has been effective in patients with diabetes type 2 in the preoperative period. [15]
- Simillarly basal plus insulin treatment approach is effective in patients with diabetes type 2 in the preoperative period, hence it could be an alternative for basal-bolus insulin treatment.[8]
- Reports of some studies support the effectiveness of glucagon-like peptide 1 receptor agonists for glycemic control of diabetic patients in peroperative state. [26][27]
- SGLT2 inhibitors is recommended by The US Food and Drug Administration (FDA) to be discontinued 3-4 days before surgery in order to reduce the risk of euglycaemic diabetic ketoacidosis in patients. [1]
- Dipeptidyl peptidase-4 inhibitor is not an effective treatment in diabetic patients in preoperative period. [54]
Hospital Technologies
Continuous Glucose Monitoring
- More than just checking glucose continuously, this devices give us trends and patterns in order to better study hyperglycemia and hypoglycemia events.[55]
- 2 approved systemes by Food and Drug Administration (FDA) are GlucoScout and OptiScanner 5000, which intemittently collect venous blood samples (central or peripheral veins). [1]
- The Abbott Freestyle Libre flash glucose is another system in continuous glucose monitoring which collects blood samples intermitently and alarm when high glucose concentration is detected.
- Real time continuous glucose monitoring is used in Dexcom and Medtronic devices which are recommended as an effective approach for management of diabetic patients in hospital.[56][57]
- Senseonics Eversense is an implanted device which could be used for 5-6 months.
- Apart from all the benefits of continuous glucose monitoring there are some concerns regarding the accuracy of glucose measures due to physiologic changes (such as vasoconstriction, severe dehydration, hypoxemia and rapid changes in blood glucose levels due to diabetic ketoacidosis) or interaction by some agents. Agents that can possibly interact with glucose reading are salicylic acid, paracetamol (doses higher than 4 grams per day) and ascorbic acid.[58][59]
Continuous Subcutaneous Insulin Pumps
- Rate of hyperglycemia and hypoglycemia is reduced with use of continuous subcutaneous insulin infusion pumps such as standalone insulin pumps.[1][60]
- The following are some of the contraindications of continuous subcutaneous insulin pumps:[61][62]
- Hyperglycemia crisis
- Absence of trained medical provider
- Low level of consciousness (excluding short-term anaesthesia)
- Incapability of patients to maintain an appropriate pump setting
- Incapability of patients to manage their diabetes
- Absence of required supplies
- Pumps should be removed during some investigations such as MRI. [63]
Closed Loop Insulin Delivery System
- Closed loop system is a combination of continuous glucose monitoring and subcutaneous insulin pumps, which is also known as artificial pancreas system.[1]
- Medtronic 670G, Diabeloop and Tandem Control-IQ are 3 currently commercially available systems that are commonly used by patients with diabetes type 1.[1]
- A trial evaluated the effect of closed loop system on patients with diabetes type 2 reported better glycemic control, compared with the control group (p<0∙0011). [64]
- Another study investigated the effectiveness of this method on diabetic patients with end stage renal disease which demonstrated better glycemic control. [65]
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 Pasquel FJ, Lansang MC, Dhatariya K, Umpierrez GE (2021). "Management of diabetes and hyperglycaemia in the hospital". Lancet Diabetes Endocrinol. 9 (3): 174–188. doi:10.1016/S2213-8587(20)30381-8. PMID 33515493 Check
|pmid=value (help). - ↑ 2.0 2.1 Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN (2009). "Hyperglycemic crises in adult patients with diabetes". Diabetes Care. 32 (7): 1335–43. doi:10.2337/dc09-9032. PMC 2699725. PMID 19564476.
- ↑ Johnston KC, Bruno A, Pauls Q, Hall CE, Barrett KM, Barsan W; et al. (2019). "Intensive vs Standard Treatment of Hyperglycemia and Functional Outcome in Patients With Acute Ischemic Stroke: The SHINE Randomized Clinical Trial". JAMA. 322 (4): 326–335. doi:10.1001/jama.2019.9346. PMC 6652154 Check
|pmc=value (help). PMID 31334795. Review in: Ann Intern Med. 2019 Dec 17;171(12):JC67 - ↑ Christensen MB, Gotfredsen A, Nørgaard K (2017). "Efficacy of basal-bolus insulin regimens in the inpatient management of non-critically ill patients with type 2 diabetes: A systematic review and meta-analysis". Diabetes Metab Res Rev. 33 (5). doi:10.1002/dmrr.2885. PMID 28067472.
- ↑ Gómez Cuervo C, Sánchez Morla A, Pérez-Jacoiste Asín MA, Bisbal Pardo O, Pérez Ordoño L, Vila Santos J (2016). "Effective adverse event reduction with bolus-basal versus sliding scale insulin therapy in patients with diabetes during conventional hospitalization: Systematic review and meta-analysis". Endocrinol Nutr. 63 (4): 145–56. doi:10.1016/j.endonu.2015.11.008. PMID 26826772.
- ↑ American Diabetes Association (2018). "14. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2018". Diabetes Care. 41 (Suppl 1): S144–S151. doi:10.2337/dc18-S014. PMID 29222385.
- ↑ 7.0 7.1 Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM; et al. (2012). "Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline". J Clin Endocrinol Metab. 97 (1): 16–38. doi:10.1210/jc.2011-2098. PMID 22223765.
- ↑ 8.0 8.1 8.2 Umpierrez GE, Smiley D, Hermayer K, Khan A, Olson DE, Newton C; et al. (2013). "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. 36 (8): 2169–74. doi:10.2337/dc12-1988. PMC 3714500. PMID 23435159.
- ↑ Zaman Huri H, Permalu V, Vethakkan SR (2014). "Sliding-scale versus basal-bolus insulin in the management of severe or acute hyperglycemia in type 2 diabetes patients: a retrospective study". PLoS One. 9 (9): e106505. doi:10.1371/journal.pone.0106505. PMC 4152280. PMID 25181406.
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- ↑ Pasquel FJ, Lansang MC, Khowaja A, Urrutia MA, Cardona S, Albury B; et al. (2020). "A Randomized Controlled Trial Comparing Glargine U300 and Glargine U100 for the Inpatient Management of Medicine and Surgery Patients With Type 2 Diabetes: Glargine U300 Hospital Trial". Diabetes Care. 43 (6): 1242–1248. doi:10.2337/dc19-1940. PMC 7411278 Check
|pmc=value (help). PMID 32273271 Check|pmid=value (help). - ↑ Umpierrez GE, Pasquel FJ (2017). "Management of Inpatient Hyperglycemia and Diabetes in Older Adults". Diabetes Care. 40 (4): 509–517. doi:10.2337/dc16-0989. PMC 5864102. PMID 28325798.
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|pmc=value (help). PMID 30679302. - ↑ Nauck MA, Meier JJ (2020). "Reduced COVID-19 Mortality With Sitagliptin Treatment? Weighing the Dissemination of Potentially Lifesaving Findings Against the Assurance of High Scientific Standards". Diabetes Care. 43 (12): 2906–2909. doi:10.2337/dci20-0062. PMID 33033068 Check
|pmid=value (help). - ↑ Sokos GG, Bolukoglu H, German J, Hentosz T, Magovern GJ, Maher TD; et al. (2007). "Effect of glucagon-like peptide-1 (GLP-1) on glycemic control and left ventricular function in patients undergoing coronary artery bypass grafting". Am J Cardiol. 100 (5): 824–9. doi:10.1016/j.amjcard.2007.05.022. PMID 17719327.
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|pmc=value (help). PMID 31749275. - ↑ Nyström T, Gutniak MK, Zhang Q, Zhang F, Holst JJ, Ahrén B; et al. (2004). "Effects of glucagon-like peptide-1 on endothelial function in type 2 diabetes patients with stable coronary artery disease". Am J Physiol Endocrinol Metab. 287 (6): E1209–15. doi:10.1152/ajpendo.00237.2004. PMID 15353407.
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|pmc=value (help). PMID 30456796. - ↑ Abuannadi M, Kosiborod M, Riggs L, House JA, Hamburg MS, Kennedy KF; et al. (2013). "Management of hyperglycemia with the administration of intravenous exenatide to patients in the cardiac intensive care unit". Endocr Pract. 19 (1): 81–90. doi:10.4158/EP12196.OR. PMID 23186969.
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- ↑ Kaneko S, Ueda Y, Tahara Y (2018). "GLP1 Receptor Agonist Liraglutide Is an Effective Therapeutic Option for Perioperative Glycemic Control in Type 2 Diabetes within Enhanced Recovery After Surgery (ERAS) Protocols". Eur Surg Res. 59 (5–6): 349–360. doi:10.1159/000494768. PMID 30537714.
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|pmid=value (help). - ↑ Thiruvenkatarajan V, Meyer EJ, Nanjappa N, Van Wijk RM, Jesudason D (2019). "Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review". Br J Anaesth. 123 (1): 27–36. doi:10.1016/j.bja.2019.03.028. PMID 31060732.
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|pmc=value (help). PMID 31980123. - ↑ Singh LG, Satyarengga M, Marcano I, Scott WH, Pinault LF, Feng Z; et al. (2020). "Reducing Inpatient Hypoglycemia in the General Wards Using Real-time Continuous Glucose Monitoring: The Glucose Telemetry System, a Randomized Clinical Trial". Diabetes Care. 43 (11): 2736–2743. doi:10.2337/dc20-0840. PMC 7576426 Check
|pmc=value (help). PMID 32759361 Check|pmid=value (help). - ↑ Fortmann AL, Spierling Bagsic SR, Talavera L, Garcia IM, Sandoval H, Hottinger A; et al. (2020). "Glucose as the Fifth Vital Sign: A Randomized Controlled Trial of Continuous Glucose Monitoring in a Non-ICU Hospital Setting". Diabetes Care. 43 (11): 2873–2877. doi:10.2337/dc20-1016. PMC 7576427 Check
|pmc=value (help). PMID 32855160 Check|pmid=value (help). - ↑ Galindo RJ, Aleppo G, Klonoff DC, Spanakis EK, Agarwal S, Vellanki P; et al. (2020). "Implementation of Continuous Glucose Monitoring in the Hospital: Emergent Considerations for Remote Glucose Monitoring During the COVID-19 Pandemic". J Diabetes Sci Technol. 14 (4): 822–832. doi:10.1177/1932296820932903. PMC 7673156 Check
|pmc=value (help). PMID 32536205 Check|pmid=value (help). - ↑ Montero AR, Dubin JS, Sack P, Magee MF (2019). "Future technology-enabled care for diabetes and hyperglycemia in the hospital setting". World J Diabetes. 10 (9): 473–480. doi:10.4239/wjd.v10.i9.473. PMC 6748879 Check
|pmc=value (help). PMID 31558981. - ↑ Kannan S, Satra A, Calogeras E, Lock P, Lansang MC (2014). "Insulin pump patient characteristics and glucose control in the hospitalized setting". J Diabetes Sci Technol. 8 (3): 473–8. doi:10.1177/1932296814522809. PMC 4455446. PMID 24876608.
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