Achieve better glucose control for your hospitalized patients

,

Applied Evidence

Achieve better glucose control for your hospitalized patients

J Fam Pract. 2008 December;57(12):782-787

By

Donald R. Woolever, MD

Forget sliding-scale insulin. A basal/bolus regimen yields better results with no additional risk

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References

1. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591.

2. Pomposelli JJ, Baxter JK, III, Babineau TJ, et al. Early postoperative glucose control predict nosocomial infection rate in diabetic patients. J Parenter Enteral Nutr. 1998;22:77-81.

3. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:978-982.

4. Deedwania P, Kosiborod M, Barrett E, et al. Hyperglycemia and acute coronary syndrome: a scientific statement from the American Heart Association Diabetes Committee of the Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2008;117:1610-1619.

5. Garber AJ, Moghissi ES, Bransome ED, Jr, et al. American College of Endocrinology Task Force on Inpatient Diabetes Metabolic Control. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract. 2004;10 (suppl 2):S4-S9.

6. American Diabetes Association: Standards of Medical Care in Diabetes—2008. Diabetes Care. 2008;31(suppl 1):S12-S54.

7. Umpierrez GE, Smiley D, Zisman A, et al. Randmonized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes. Diabetes Care. 2007;30:2181-2186.

8. Browning LA, Dumo P. Sliding scale insulin: an antiquated approach to glycemic control in hospitalized patients. Am J Health Syst Pharm. 2004;61:1611-1614.

9. Robbins L. Let’s get the sliding scale out of medicine. Med Rec Ann. 1963;56:201.-

10. Inzucchi SE. Management of hyperglycemia in the hospital setting. N Engl J Med. 2006;355:1903-1911.

11. Abourizk N, Vora CK, Verna PK. Inpatient diabetology: the new frontier. J Gen Intern Med. 2004;19 (5 pt 1):479-480.

12. Polonsky KS, Given BD, van Cauter E. Twenty-four-hour profiles and pulsatile patterns of insulin secretion in normal and obese subjects. J Clin Invest. 1988;81:442-448.

13. Leahy JL. Insulin management of diabetic patients on general medicine and surgical floors. Endocr Pract. 2006;12(suppl 3):S86-S90.

14. Hirsch IB. Insulin analogues. N Engl J Med. 2005;352:174-183.

15. Donner TW, Flammer KM. Diabetes management in the hospital. Med Clin North Am. 2008;92:407-425.

16. Walsh J, Roberts R, Bailey T, Varma CB. Using Insulin: Everything You Need to Know for Success With Insulin. San Diego, Calif: Torrey Pines Press; 2003.

17. Lien LF, Angelyn Bethel M, Feinglos M. In-hospital management of type 2 diabetes mellitus. Med Clin North Am. 2004;88:1085-1105.

18. Funary AP, Wu Y. Effect of hyperglycemia and continuous intravenous insulin infusions on outcome of cardiac surgical procedures: the Portland Diabetic Project. Endocr Pract. 2004;10(suppl 2):S21-S33.

19. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patient. N Engl J Med. 2001;345:1359-1367.

20. Malmberg K. for the DIGAMI group. Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ. 1997;314:1512-1515.

21. Lien LF, Spratt SE, Woods Z, Osborne KK, Feinglos MN. Optimizing hospital use of intravenous insulin therapy: improved management of hyperglycemia and error reduction with a new nomogram. Endocr Pract. 2005;11:240-253.

22. Davies M, Dixon S, Currie CI, Davis RE, Peters JP. Evaluation of a hospital diabetes specialist nursing service: a randomized controlled trial. Diabet Med. 2001;18:301-307.

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24. Glucophage [package insert]. Princeton, NJ: Bristol-Myers-Squibb; 1998.

25. Salpeter S, Greyber E, Pasternak GA, Salpeter EE. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. Cochrane Database Syst Rev. 2003(2);CD002967.-

26. Brady P, Terzic A. The sulfonylurea controversy: more questions from the heart. J Am Coll Cardiol. 1998;31:950-956.

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Practice recommendations

Use the basal/bolus insulin regimen for inpatients with diabetes. It follows normal physiological insulin rhythm and is associated with significantly better glycemic control than the sliding-scale regimen. (B)
If a patient on a basal/bolus regimen consistently requires supplemental insulin, reevaluate baseline dosing and make adjustments as needed. (B)
Whenever possible, switch hospitalized patients to their outpatient diabetes control regimen ≥24 hours prior to discharge. (C)

Strength of recommendation (SOR)

Good-quality patient-oriented evidence
Inconsistent or limited-quality patient-oriented evidence
Consensus, usual practice, opinion, disease-oriented evidence, case series

Mr. H, a 62-year-old with type 2 diabetes, hypertension, and hypercholesterolemia, arrives at the emergency department complaining of acute onset chest pain. An EKG shows no ischemic changes and his initial cardiac enzymes are normal, but Mr. H is admitted to telemetry for further monitoring and to rule out myocardial infarction. Mr. H normally takes metformin and glipizide to manage his diabetes; his most recent glycosylated hemoglobin (HbA1c) was 8.2. After admission, he is placed on a diabetic diet and switched to insulin.

As primary care physicians, we all care for patients like Mr. H, who are hospitalized because of cardiovascular or other symptoms and have diabetes—a comorbidity that affects an estimated 12% to 25% of inpatients.¹ We are also well aware of the elevated risks such patients face—for bacterial infection, impaired wound healing, and reduced tissue and organ perfusion,² among others. In one study, a single blood glucose reading >220 mg/dL was associated with a nearly 6-fold increase in nosocomial infection.² A number of recent studies have also found hyperglycemia to be an independent marker of overall inpatient mortality.^1,3-5

American Diabetes Association goals. In 2008, the ADA issued new glycemic control goals for inpatients with diabetes. For critically ill patients, the association recommends that blood glucose levels be maintained at <140 mg/dL—and as close to 110 mg/dL as possible. For patients who are hospitalized but are not critically ill, the ADA recommends fasting blood glucose levels of 90 to 130 mg/dL and postprandial levels <180 mg/dL.⁶

As the ADA recommendations make clear, it is imperative that we do everything possible to lower the blood glucose levels of our hospitalized patients. Ironically, though, fear of hypoglycemia has prevented many physicians from putting patients with diabetes on a basal/bolus insulin protocol¹—a dosing regimen that, according to at least one recent report, is more effective than the traditional sliding-scale insulin regimen.⁷ (See “No heightened hypoglycemia risk with basal/bolus regimen”) To help you achieve glycemic targets safely and confidently using the basal/bolus regimen, we’ve assembled this review of the latest evidence, complete with strategies for success.

Oral agents are no match for the hospital routine

The hospital environment interferes with the patterns and schedules that people with diabetes rely on to manage their condition. Thus, it is not unusual even for patients whose glucose levels were very well-controlled at home to have poor glycemic control as inpatients. Dietary change is one of the primary reasons.

FAST TRACK

No need to worry that the basal/bolus insulin regimen heightens the risk of hypoglycemia. A recent study found that it does not

Mealtimes typically deviate from the patient’s at-home schedule. In addition, patients are often put on a calorie-restricted, carefully enforced diabetic diet, which is quite different from their usual eating pattern. NPO orders are also common in preparation for diagnostic testing or other procedures. And some medications—particularly high doses of steroids—affect glucose levels. It is difficult to adjust oral hypoglycemic agents to accommodate such variations.

A look at Mr. H’s regimen. Mr. H’s physician knew that continuation of his oral medications—particularly glipizide—in combination with the hospital’s strict diabetic diet could result in hypoglycemia. Continuing to take metformin was also a concern, given that Mr. H was at risk for new cardiac symptoms—a contraindication to metformin use. So his physician switched him over to insulin, a safer alternative.

Finding the right insulin regimen

For years, a sliding-scale regimen was the most common approach to glycemic management of inpatients with diabetes. This concept, developed in 1934, originally used urine glucose testing to determine dosing, and its convenience and ease of treatment initiation led to widespread use. Although many variations have been introduced over the years, traditional sliding-scale regimens use short-acting analog or regular insulin in predetermined doses based on blood glucose readings at mealtimes and bedtime.

Despite the popularity of this method, however, there is little evidence to support it. Sliding-scale insulin as monotherapy has not been associated with effective glycemic control or improved outcomes.^8,9 By design, this traditional regimen makes hyperglycemia the threshold for action, rather than taking action to prevent it. The result: wide fluctuations in blood sugar levels and the potential for prolonged periods of hyperglycemia.