Clinical study
Inpatient management of diabetes mellitus

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Abstract

There is now widespread appreciation of the importance of maintaining glucose levels as close to the normal range as possible among outpatients with diabetes. However, the importance of tight glucose control in inpatients is less well established. During the past several years, it has become apparent that hyperglycemia in hospitalized patients, especially those in the postoperative setting, is associated with poorer outcomes. In addition, two randomized trials have shown improved outcomes with intensive glucose management in acutely ill patients. Based on these studies and our own experience, we propose guidelines and a framework for improving the glycemic control of hospitalized patients.

Section snippets

Hospital barriers to glucose control

Poor glycemic control is common among inpatients with diabetes, particularly in those treated with insulin (4), for many reasons. The majority of diabetic patients are hospitalized for reasons other than diabetes, such as vascular complications. Thus, care of diabetes per se becomes subordinate to care for the primary diagnosis requiring admission. Infection, fevers, glucocorticoid therapy, surgical trauma, and general medical stress exacerbate hyperglycemia due to the release of

Admission orders

The outpatient treatment regimen for diabetes is often continued unchanged or withdrawn entirely upon admission. Atlhough either of these choices may occasionally be indicated, patients more commonly will require some modification of their outpatient regimen to adapt to the effects of acute illness.

Overly high glycemic targets

Because of a general underappreciation of the importance of glycemic control in the hospital setting and concerns about hypoglycemia, blood glucose concentrations are commonly allowed to be >200

How important is inpatient glycemic control?

Several studies have demonstrated the benefits of glucose control during hospitalizations, particularly in the postoperative setting 14, 15, 16, 17. There is a clear association between poorly controlled diabetes and increased susceptibility to infection. Several aspects of immune function are altered in diabetes, including leukocyte function and immunoglobulin complement fixation, both of which are impaired in ambient glucose concentrations between 200 and 250 mg/dL 18, 19, 20, 21, 22, 23.

Intervention trials

Whether hyperglycemia is a cause or effect of complications in diabetic patients has been controversial for many years. A partial answer to this question was provided by the Diabetes Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study, albeit in a selected group of patients 14, 15. The DIGAMI investigators randomly assigned 620 diabetic patients with myocardial infarction to standard therapy or to standard therapy plus an insulin-glucose infusion for at least 24 hours. The

Hospital utilization

Diabetes increases hospital stay not only for diabetes-associated admissions but for seemingly unrelated conditions as well. In one report, the average stay was almost twice that among nondiabetic patients, and diabetes doubled the risk of requiring intensive care (36). Although the reasons for the longer hospitalization are not known, the additional hospital days likely resulted from complications of diabetes or from the time required to achieve glycemic control before procedures or discharge.

Recommendations

Based on the best available data, particularly in the postoperative setting, it seems rational for good glycemic control to be a goal in the management of inpatients with diabetes. Specific management protocols, treatment algorithms, and clinical pathways should be developed and implemented by each institution, coordinating the roles of physicians, nurses, nutritionists, pharmacists, and discharge planners. The following are guidelines we have developed based on our own experience and, when

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