In-HospitalManagementofDiabetesMellitus

NihalThomas,RahulRamnik8axi

INTRODUCTION

Astudy has shown that Indiahas spent a mind-boggling Rs.1.5trillionson diabetes care in 2010.Asignificantproportionofinpatients with hyperglycaemia have undiagnosed diabetesand stress hyperglycaemia.Hospitalisationshould be resortedto in diabetes patients only when absolutely necessary to cutdown on costs.

EVIDENCEOFHARMFROMIN-HOSPITALHYPERGLYCAEMIAANDBENEFITSOFGLUCOSELOWERING

Thereis compellingevidencethat poorly-controlledglucoselevels are associated with a higher in-hospital morbidityand mortality, prolonged length of stay, unfavourable post-dischargeoutcomes and significantincreaseinhealthcare costs.We have tried to stratify the impact of inpatient diabetesmanagement, relying on evidence-based norms.

WhichPatient Requires Hospitalisation?

Hospitalisation for a patient for reasons related to diabetes maybe indicated in specific situations.

1. Acute metabolic complications like diabetic ketoacidosis,

hyperglycaemic hyperosmolar state and hypoglycaemiawith neuroglycopaenia.

2. Newlydiagnosed diabetes in children and adolescents when

unstable or brittle, for the purpose of dose adjustment ormonitoring (when not possible on outpatient basis).

3. Chronic poor metabolic control that necessitates close

monitoring to determine the aetiology and modify therapyas in hypoglycaemia unawareness.

4. . Severe chronic complications requiring intensive treatment

or other conditions unrelated to diabetes that significantlyaffect its control, particularly wherein ambulation may bea problem.

5. Uncontrolled insulin-requiringdiabetes during pregnancyfor rapid control.

6. The institution of insulinpump therapy or other intensiveinsulin regimens.

Diabetes In-HospitalTeam

Thepatient

The patient forms the core of the team and is encouraged toparticipate in the formulation and conduct of their own care

plan while admitted in the hospital.

Consultantphysician/diabetologist/endocrinologist

The primary role of the consultant is as a leader of the multi-

:isdplinary team. They work closely to provide clinical support:::: ~rabetes specialist nurses and diabetes educators. The

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Diabetes educator or diabetes specialist nurses

They playa key role in patient and staff education andimplementation of glycaemic control strategies and are able

to facilitate a smooth patient pathway from hospital to home.The diabetes educator could also be the leader of the team.

Diabetes specialist dietician

They playa pivotal role in those with complex nutritional needs

-those unable to swallow, those with renal failure, pregnancy,

cystic fibrosis, and the elderly.

Targets to be Achieved

1. Initiate glucose monitoring in any patient not known to have

diabetes, but who receives therapy associated with high-risk

for hyperglycaemia, including high-dose glucocorticoid

therapy and initiation of enteral or parenteral nutrition. If

hyperglycaemia is documented and persistent, treatment

is necessary. Such patients should be treated to the same

glycaemic goals as patients with known diabetes.

2. A plan for treating hypoglycaemia should be established

for each patient. Episodes of hypoglycaemia in the hospitalshould be tracked.

3. Allpatients with diabetes admitted to the hospital should

have their glycosylated haemoglobin (HbA1c) obtained ifthe result oftesting in the previous 3 months is unavailable.

4. Patients with hyperglycaemia in the hospital should have

appropriate plans for follow-up testing and care documented

at discharge.

GOALSFORBLOODGLUCOSELEVELS

Critically-IIIPatients

Insulintherapy should be initiated for treatment of persistenthyperglycaemia starting at a threshold of 180 mg/dL (10mmol/L).Once insulin therapy is initiated, a glucose range of140 to 180 mg/dL (7.8to 10mmol/L)isrecommended for themajority of critically-illpatients.

Non-Critically-IIIPatients

Thereisnoclearevidenceforspecificbloodglucosegoals.Iftreatedwith insulin, the pre-meal blood glucose target should general~

be less than 140 mg/dL (7.8mmol/L) and random blood glucose

less than 180 mg/dL (10.0 mmol/L),provided these targets can be

safelyachieved.Morestringenttargetsmaybeappropriateinstablepatientswith previoustight glycaemiccontroland lessstringemtargetsin thosewith severeco-morbidities.

HospitalBarriersto GlucoseControl

Thismayseemto be a paradox.However,hospitalisationmalinfacthampertheeffortsto achieveglycaemiccontrolinsomesituations.Indeed, it may be more prudent to havegooceducationalfacilitiesonanout-patientbasisto enablepatien:self-emancipation.

-,1. Majority of diabetes patients are hospitalised for reasons

other than diabetes, e.g. vascular complications. The careof diabetes per se becomes subordinate to care for the

primary diagnosis.

2. Infection, fever, glucocorticoid therapy, surgical trauma and

general medical stress exacerbate hyperglycaemia due to

release of counter regulatory hormones.

3. Decreased physical activity (in previously active patients)

also exacerbates hyperglycaemia.

4. Strict diet and supervised compliance with drugs may result

in hypoglycaemia in patients who were not compliant earlier.

COMMONERRORSIN MANAGEMENT

Admission Ordersand lack ofTherapeuticAdjustment

Theout-patient treatment regimenis often continuedunchanged or withdrawn entirely upon admission. Althougheither of these choices may occasionally be indicated,patients more commonly will require some modification oftheir out-patient regimen. A patient may be treated withregular insulin alone during the entire hospital stay, whichwill deprive the treating physician of an opportunity toobserve the patient's response to regimens that can betransferred home.

Highglycaemic targets

Bloodglucose levels are commonly allowed to be more than200 mg/dL.In-patient care is sometimes taken for granted tobe superior; however, infrastructurallimitations and nursingstaff inadequately trained in diabetes could work contrary.

Overutilisation of' sliding scales'

There are opinions that sliding scales are illogical, as they aredesigned to correct the therapeutic inadequacies of theprevious 4- to 6-hour period rather than anticipating future

requirements. Sliding scale is used frequently as the only means

of insulin dosage, rather than concurrently with intermediate-

acting insulins, which may lead to fluctuations of insulin supplyand erratic glucose control. Sliding scale may be used in certainsituations outlined in Table 1.

Table 1:Situations in which Sliding Scales may be Useful

To adjust pre-prandial insulin based on the pre-meal capillaryglucose leveland the anticipated carbohydrate consumption

With basal insulinanalogues, such as insulinglargine

Toevaluate patient's initialresponse to insulin

In patients receiving parenteral nutrition, in whom each 6-hourperiod is similarto the last

Underutilisation of insulin infusions

Intravenous insulin is recommended for patients with

hyperglycaemic emergencies and also in the peri-operativesetting or when glucose control has deteriorated withconventional subcutaneous insulin. The intravenous route

providespredictable insulin delivery and enablesquick controlof glucose levels. Adequate nurse training, staffing andsupervision is required for their safe implementation.

BloodGlucoseMonitoring

In patients on enteral or parenteral nutrition, glucosemonitoring is optimally performed every 4 to 6 hours. Glucose

testing should be performed every 1 to 2 hours in patients onintravenous insulin infusions. In patients eating usual meals,glucose levelsshould be monitored asfasting and 2hours post-prandial after three major meals.The common error in 5MBCmonitoring have to be kept in mind and taken care (Table 2).

Table 2: Sources of Errors in Bedside Blood Glucose Results

Sources of analytical error

FalsehighLow haematocrit

Hyperbilirubin2emia

Severe lipaemiaFalse low

High haematoG;:

Either false high or "21SE'owHypoxia

Shock and dehydrat;c"

Drugs: acetamirop"e" c .'er-:ose,

dopamine, man!''':o 3.a':::.2:e

Sources of use error

Inadequate metre calibration

Inadequate quality-control

Poortechnique in finger prick

Poor technique of applyingblood drop on test strip

Test strip with unmatchedmeter code or that has

passed the expiration date

GLUCOSECONTROL

GeneralRecommendations

A keycomponentof prD'.~:;I";: :ffe::tive insulintherapyin the-hospital setting isto deter-' -: ,'''ether apatient hasthe abilityto produce endogenous :-5~ '- :- -::>t'Table 3). )

Table 3: Characteristics of Patients Yrittllnsulin Deficiency

Known type 1 diabetes

History of pancreatectomy or ~- ~a:"-: C'J-sfunction

History of wide fluctuations 'r')bo':>:: ~' .;.:ose ~s

History of diabetic ketoacidosis

History of insulin use for> 5 years 2-:0- c".abetesfor >10 years

Patients with type 1 diabetes ,',' -::-:1u:resome insulinat alltimes to preventketosis,eve- 'a',~e'" 'lot eating. The insulinregimen should be revisedh:~~-t"l c~sedon the valuesofglucose monitoring.lntermedia:e-2cj1g insulin added once ortwice daily,evenat smalldoses ' S't2:i;ise the control.Glucoselevels should be maintained as :: ose to the normal range aspossible in the post-operative. :;ost-"1'yocardialinfarction, and

intensivecaresettings.Cons~"v3f...e targetsshouldbe set inpatients prone to hypoglyccEl'1ia 'e.g. brittle diabetes,hypoglycaemia unawareness :" "'eryelderlyor in thosewithshort life expectancy due to cD-Morbid conditions and with

inadequate nursing or monitoring support.

Patient Specific Recommendations

Patient on oralagents and not consuming food

In patients on sulphonylurea or other secretagogues, thedrugs should bewithheld and ashort-acting insulin sliding scale

should be used temporarily. Addition of intermediate-actinginsulin should be considered,if insulin isneeded for more than

24 hours.Metformin may bewithheld owing to concernsabout

altered renal function in the acutely ill. Avoid a-glucosidaseinhibitors as these are effective only when taken with food.Thiazolidinediones are discontinued in patients with abnormalhepatic Qrcardiac function.

Patient on oral agents and consuming food

In patients on oral agents with controlled sugars,continue themedicationbut consideradosageadjustmentof 25%to 50%,due

to the likelihood of better dietary adherence.Metformin should

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::E ./::-CCC- :~perative patients (general anaesthesia), in

::-t:X .,,;:: s:cooard contraindications, or when dehydration is

s:..s:e:::-<: ~ antidpated and ifradio-contrast studies are planned.

;..;:w:~ inhibitors and thiazolidinediones may be continued."'&'="1should be started if sugars are uncontrolled.

Patient on insulin and not consuming food

Intravenous insulin infusion should be strongly considered intype 1 diabetes patients. Alternatively, half to two-thirds of the

patient's usual dose of intermediate-acting insulin may be givenalong with a short-acting insulin sliding scale.

Some patients with type 2 diabetes on insulin may haveimproved control with diet restriction and require only short-

acting insulin. A 5% dextrose solution intravenously at 75 to125 mL per hour should be provided.

Patient on insulin and consuming food

Continue insulin, although consider dosage reduction (10%to50%) in well-controlled patients because of the likelihood of

more rigid dietary adherence.

Patient Scheduled for Surgery

Peri-operative instructions

In general, patient's treatment programme is least affected if

surgeries are scheduled for early morning. Blood glucose levels

should be monitored every 1 to 2 hours before, during and afterthe procedure.

Type 1diabetes

Insulin infusion should be given at a maintenance rate (1 to 2

units per hour) with a 5% dextrose solution at 75 to 125 mL perhour, adjusted to maintain glucose levels between 100 and 150

mg/dL.Alternatively,give one-halfto two-thirds ofthe usual dose

of intermediate-acting insulin on the morning of procedure.

Type 2 diabetes

If the patient is taking an oral anti-diabetic agent, hold the

medication on the day of procedure and resume when toleratinga normal diet.

If. the patient is treated with insulin, give one-half ofintermediate-acting insulinon the morning of procedure. Donot giveshort-actinginsulinunlessthe bloodglucoselevelis>200mg/dL.Alternatively,an insulininfusioncanbeused.

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SPECIFICCLINICALSITUATIONS

Insulin Pumps

Patientswho use continuoussubcutaneousinsulin infusion

(CSII)therapyinan out-patientsettingcancontinueusingit inthe hospital,provided theyarementallyandphysicallyfit to doso.Theavailabilityof hospitalpersonnelwith expertiseandexperiencein C51!therapyisessential.

Enteral Nutrition

Forintermittent enteralfeedings,intermediate-actinginsulinwith asmalldoseof regularinsulinisadequate.Forcontinuousfeeding,onceor twice daily insulinglargine(or NPH)can beused.Startwith a smallbasaldose and use correction-dose

insulinasneededwhilethe glarginedoseisbeingincreased.

Parenteral Nutrition

The high glucose loads in standard parenteral nutritionfrequently results in hyperglycaemia. Insulin therapy is

recommendedwith glucosetargetsaccordingto severityofillness.

Glucocorticoid Therapy

The best predictorsof glucocorticoid-induceddiabetes arefamily historyof diabetes,increasingageand glucocorticoiddose and duration.Forpatients receivinghigh-dose intravenousglucocorticoids, an intravenous insulin infusion may beappropriate.Duringsteroidtapers,insulindosingshouldbeproactively adjusted to avoid hypoglycaemia.

Switching from Intravenous to Subcutaneous Insulin

It isimportant to administershort-actinginsulinsubcutaneously1to 2 hoursbeforediscontinuationof the intravenousinsulin

infusion.Intermediateor long-actinginsulinmustbe injected2to 3hoursbeforediscontinuingthe insulininfusion.

Prevention of Hypoglycaemia

Hypoglycaemiais the most important limiting factor in themanagementof diabetes,more so in patients on insulin.Institutionsaremorelikelyto haveprotocolsfor the treatmentof hypoglycaemia than for its prevention. Tracking suchepisodesand analysing their causesare important qualityimprovementactivities(Table4).

Table 4: Causes of Hypoglycaemia in Patients on Insulin

Suddenreductionin oral intakeor nil peroralstatus

Discontinuationof enteralfeedingfTPN/IVdextrose

Pre-mealinsulingivenandmealnot ingested

Unexpectedtransportfromnursingunit after rapidactinginsulingiven

Reduction/omissionof corticosteroiddose

Medical Nutrition Therapy in the Hospital

Current nutrition recommendations advise individualisation

based on treatment goals,physiologicparameters, medication

usage and other co-morbid conditions, such as obesity,dyslipidaemia, hypertension and renal failure. A registereddietician,skilledin diabetic MNT,should serve as an in-patientteam member.

DISCHARGEPLANNING

Patients (and their families) should be familiar with their

glucose targets and drug regimens after discharge fromhospital and should understand any changes made in theirtreatment (Table5).

Table 5: Issues to be Addressed Prior to Hospital Discharge

levelof understandingrelatedto the diagnosisof diabetes

Selfmonitoringof bloodglucoseandexplanationof homebloodglucosegoals

Recognition,treatment and preventionof hyperglycaemiaandhypoglycaemia

Identificationofhealthcareproviderwhowillprovidediabetescareafterdischarge

Informationon consistenteatingpatternsWhenandhowto takeoralmedicationsandinsulinadministra:i:s-

Sick-daymanagement

Properuseanddisposalof needles/lancets/syringes

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