Focus on Inpatient Diabetes Management: Overcoming Barriers to Glucose Control

According to estimates, at least 15% to 30% of hospitalized patients have hyperglycemia or diabetes. A full 2/3 of critical care patients fall into this category, as do 1/3 of cardiac surgery patients. Hyperglycemia is associated with poor outcomes in the inpatient setting, including a higher rate of infection, delayed healing, and more procedure-related complications. Controlling hyperglycemia improves clinical outcomes, resulting in decreased morbidity and mortality, as well as decreased length of hospitalization and lower overall costs.

Barriers to care for patients with hyperglycemia or diabetes arise with hospital admission. Being an inpatient affects patients’ control over eating, physical exercise, and the ability to adhere to an established medication regimen. Also, it is often necessary to withhold medications prior to a medical or diagnostic procedure. In addition, the physiologic stress that occurs when a patient is hospitalized and the stresses of illness, trauma and surgery can lead to increased insulin resistance. In general, hypoglycemic agents are contraindicated in hyperglycemic patients. Longer-acting sulfonylureas can cause hypoglycemia; metformin could lead to lactic acidosis in critically ill patients with elevated serum creatinine; and thiazolidinones may cause volume overload. Therefore, insulin is considered the most effective approach to management of hyperglycemia/diabetes in the inpatient setting, with a preference for a subcutaneous basal/bolus regimen or continuous insulin infusion in critically ill patients. Traditional sliding-scale insulin has now been replaced for inpatient management by infusion and basal/bolus insulin delivery. Ongoing education of the medical treatment staff is still needed, with the main goal being reinforcing the need for tight glycemic control.

In this conversation, two diabetes experts, Dr. Andrew Ahmann and Dr. Etie Moghissi, join Dr. Carlos Hamilton to discuss overcoming barriers to glucose control in the inpatient setting.

Related References/Reading:

1. Thompson CL, Dunn KC, Menon MC, et al. Hyperglycemia in the hospital. Diabetes Spect. 2005;18:20-27.
2. Cook CB, Boyle ME, Cisar NS, et al. Use of continuous subcutaneous insulin infusion (insulin pump) therapy in the hospital setting. The Diabetes Educator. 2005;31:84-57.