Management of diabetes and hyperglycemia in the hospital: A practical guide to subcutaneous insulin use in the non-critically ill, adult patient

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Abstract

5 MedStar Diabetes Institute, Washington, DC. R ecently, there has been a heightened interest in improving the quality and safety of the management of diabetes and hyperglycemia in the hospital. While observational data strongly suggests an association of hyperglycemia with morbidity and mortality in adults on general medicine and surgery units, clinical research has not yet defined the best practices for managing hyperglycemia in the hospital outside the intensive care unit (ICU). As a result, many physicians do not have a well-formulated approach to managing hyperglycemia in the noncritically ill hospital patient, and the use of insulin therapy to attain targeted blood glucose (BG) control is often subject to practice variability, leading to suboptimal glycemic outcomes. Practical ‘‘guidelines’’ for the management of this common clinical problem have been formulated by experts in the field, based on understanding of the physiology of glucose and insulin dynamics, the characteristics of currently available insulin preparations, and clinical experience. In 2004, in Clement et al., the American Diabetes Association published a technical review promoting the use of physiologic (‘‘basal-nutritional-correction dose’’) insulin regimens in the hospital to achieve targeted glycemic outcomes. This approach has been disseminated via review articles, and more recently, a randomized, controlled trial demonstrated that hospitalized type 2 diabetes patients experienced better glycemic control when treated with a physiologic insulin regimen than when treated with sliding-scale insulin alone. The Society of Hospital Medicine has assembled a Glycemic Control Task Force, which is charged with providing physicians and hospitals with practical tools to improve the safety and efficacy of diabetes management in the hospital. One product of this work is an educational module that serves as a tutorial on the best practice for the management of diabetes and hyperglycemia in the noncritically ill hospital patient. This article is based on that module, and provides a practical summary of the key concepts that will allow clinicians to confidently employ physiologic insulin regimens when caring for their hospital patients. Case: Ms. X is a 56-year-old obese woman with type 2 diabetes mellitus who is admitted for treatment of an infected diabetes-related foot ulcer. The patient will be allowed to eat dinner in a couple of hours, but the surgeons have requested that she be kept ‘‘nothing by mouth’’ (NPO) after midnight for surgical debridement in the morning. Her current weight is 100 kg, and her No honoraria were paid to any authors for time and expertise spent on the writing of this article.

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