Focus on Inpatient Diabetes Management: Overcoming Barriers to Glucose Control

CARLOS R. HAMILTON, JR., MD, FACE: Hello, I'm Dr. Carlos Hamilton and welcome to the AACE Clinical Conversations. In this program, we will focus on inpatient diabetes management; specifically, overcoming barriers to glucose control.

Joining me today is Dr. Andrew Ahmann, Medical Director of the Diabetes Center and associate professor of medicine in the Division of Endocrinology, Diabetes and Clinical Nutrition at Oregon Health and Science University. Also with us is Dr. Etie Moghissi, associate clinical professor of medicine at the University of California in Los Angeles and Co-Chair of the AACE Inpatient Glycemic Task Force. Thank you both for joining me today.

We all know that diabetes is a big factor in inpatient medical care in this country.

ETIE S. MOGHISSI, MD: Actually, the exact prevalence of diabetes and hyperglycemia in the patients -- in the hospital is not known. It is estimated that about 15 to 30% of patients who are in the hospital have hyperglycemia and these estimates are probably underestimates because many of these patients are admitted to the hospital for other reasons and, if diabetes is not mentioned in their medical record, those patients are not going to be accounted for.

So, in patients in the CCU, for example, two-thirds of the patients who are admitted to coronary care unit have either diabetes or prediabetes. Patients who undergo cardiac surgery, one out of three have diabetes. It is also very costly. Cost of inpatient diabetes care is about $40 billion. This is -- largest proportion of direct diabetes care actually goes to the hospital.

As you mentioned, it has been shown now that hyperglycemia in the hospital setting is a risk factor for poor clinical outcome. And controlling hyperglycemia can result not only in improvement in clinical outcome, decreasing mortality and morbidity, but also length of stay and cost.

CARLOS R. HAMILTON, JR., MD, FACE: So we know that the length of the hospital stay is longer in diabetic patients and the complications of their procedures or whatever may be greater. Infections are more common, delayed healing and all of these factors contribute to this, do they not?

What are some of the factors in the inpatient environment, Andrew, that contribute to the problems with diabetic patients?

ANDREW J. AHMANN, MD: Well, clearly, there's a number of barriers that are quite different that we need to think about in the hospital. The first of which is obvious, these are very ill patients and, when they're in the hospital, physiologic stress is high, that creates a great deal of insulin resistance and that, in itself is going to change greatly how we need to treat them and how they're going to respond to therapy.

Additionally, there's going to be issues of the medications that they're going to get in the hospital, things such as steroids that are going to affect how we treat them. There's going to be issues about how their illness is going to affect their food intake. They're gonna have anorexia, they may have nausea or vomiting. In addition, they may have procedures that are intervening that take them out of the place where they would eat, out of their room at the time that the meals would otherwise be delivered and this all has to be taken into account.

Additionally, there's multiple other things. I mean, we're really changing a whole lifestyle. I mean, you're taking somebody who was at home, active, probably doing physical activity on at least somewhat of a regular basis, at least through their job. Now they're confined to a bed.

Secondly, we have to realize that the timing of meals, the timing of their day is entirely different, once they get into the hospital. These are individuals who may typically have eaten their breakfast at 7 AM or before and may have typically eaten their dinner at 6 PM or after. Now, you find, in the hospital, you're going to be eating your breakfast more often at 8 o'clock and you're gonna be eating your dinner more often at 5 o'clock. And when we order things that we say are at bedtime, they're probably gonna be 8:30 that the nurses will deliver that medication, unless we're aware that we need to make changes.

CARLOS R. HAMILTON, JR., MD, FACE: Well, Andrew, I'm sure there's not a single physician that hasn't had the experience of having diabetic patients admitted to the hospital and being off of their usual schedules and having problems occur. What you mentioned about their medications is certainly true. I mean, many of the medications are held because they are not given anything to eat or drink in the morning or their medications may be discontinued altogether for certain imaging procedures, certain medications. These are all obviously factors involved in the problems managing these patients, right?

ANDREW J. AHMANN, MD: The insulin therapy that they may have had an outpatient, even if it were adequate amount of insulin, the timing might not be right for the inpatient setting. It may presuppose that they're going to each lunch, for instance, at noon. If they're not available for that lunch, they're in trouble.

And, accordingly, the physician who needs to think about this on a regular basis, the nursing staff needs to be educated. They need to realize these are problems they need to pick up on that they need to be alert to that they can circumvent problems if they think about all these differences that occur in the hospital as opposed to what the patient experienced at home.

CARLOS R. HAMILTON, JR., MD, FACE: And patients with -- that receive insulin or other medications that may cause a low blood sugar, hypoglycemia in the inpatient setting, can be oftentimes confused with some of the other symptoms that they might be having, I would think.

ANDREW J. AHMANN, MD: Exactly. The combination of the medications the patients are receiving, which can dull their senses, analgesics, for instance, will really cause people to not respond appropriately. You can see a patient in the bed who seems to be sleeping comfortably. In fact, that patient may be hypoglycemic and really needs attention.

CARLOS R. HAMILTON, JR., MD, FACE: Etie, what are some of the problems with oral agents that you've run into in terms of patients with diabetes coming into the hospital?

ETIE S. MOGHISSI, MD: Well, generally speaking, all hypoglycemic agents are not appropriate for majority of patients who are in the hospital. These patients are very ill. Their PO intake may be unpredictable. And -- for example, sulfonylureas, especially the longer-acting sulfonylureas, can cause hypoglycemia. So if the dose is given in the morning and the patient meal is delayed or kept NPO for procedure or surgery, for example, they can run into hypoglycemia.

Metformin is probably contraindicated in many of the critically ill patients because, as we know, elevated serum creatinine is a contraindication for using metformin, would prone the patient to lactic acidosis. And since these patients are very ill, their renal function may be unstable, metformin can cause problem.

Use of TZDs, probably, again, are not a good idea, because these agents can cause volume overload and many of these patients have cardiovascular problem and problem with congestive heart failure. Therefore, TZDs, for the most part, would not be appropriate.

CARLOS R. HAMILTON, JR., MD, FACE: So it almost seems as though the oral agents that are used to control many, if not almost all of our type 2 diabetics, seems like they all create problems in the inpatient setting that we need to be aware of and that the patients need to be aware of and their primary care doctor or their surgeon or whatever their specialist is that's looking after them needs to be aware of.

Obviously, insulin is -- is something that we would use more in the inpatient setting, perhaps than we would in the outpatient setting. Is that correct?

ETIE S. MOGHISSI, MD: Insulin is probably the most effective approach in management of patients in the hospital setting. It can easily control the blood glucose and it's more predictable and so many of these patients, in order to get them to correct target, need insulin. Now, the way we use insulin in the hospital setting would be either in the IV form in the insulin infusion, a variable-rate IV, mostly done in the intensive care unit, of course. And then subcutaneous insulin using appropriate use of subcutaneous insulin, of course, would be a scheduled dose of insulin using a basal insulin as well as a meal insulin and a correction dose.

CARLOS R. HAMILTON, JR., MD, FACE: Obviously, you don't feel very warmly towards the so-called sliding scale method of controlling blood sugars, do you?

ETIE S. MOGHISSI, MD: Sliding scale is a very ineffective way of managing hyperglycemia, because it is a reactive approach rather than a proactive approach. And the studies have shown that sliding scale can cause a lot of hyperglycemia, a lot of hypoglycemia in patients with type 1 diabetes, for example, can make the patient prone to diabetic ketoacidosis, if we provide a sliding scale without any basal insulin.

Use of a sliding scale is discouraged in majority of patients who are in the hospital. And now we are really shifting to more appropriate use of insulin, which is a scheduled dose of insulin and basically the component of a scheduled dose would be a basal dose. Usually 50% of the requirement is given to cover the basal needs, usually using long-acting analogs. And the other 50% is given, divided between meals, again, perhaps rapid-acting analogs would be more appropriate. And, in addition to the basal and meal insulin, we provide a correction dose or correction schedule to cover occasional hyperglycemia.

CARLOS R. HAMILTON, JR., MD, FACE: Andrew, I'm sure you've run into the experience in the inpatient setting where there was some reluctance to give insulin, even if it's a long-acting, basal-type insulin to a person who is going to be NPO or not taking in any nutrition over a period of time. Is that a problem or should we not hesitate to give basal insulin to such patients?

ANDREW J. AHMANN, MD: Yeah, that's one of the more basic problems we have with the sliding scale methods that people have used. The sliding scale methods really becomes partly terminology, if you call it supplemental, meaning supplemental to something else or you call it sliding scale, which, by tradition, we've done as an independent sort of post-event or sort of reactive approach to care. So it's really been shown that basal insulin not only is necessary or important to get good control, but, in fact, it's very safe, because, when we think about people, what basal insulin is defined as is that amount of insulin that you would need on a continuous basis throughout the day when you weren't eating, when you were in a basal state. Has nothing to do with the food, it has nothing to do with the stress amount. It has to do with the basal amount that everybody makes insulin every hour of the day throughout the 24 hours.

So basal insulin is very safe and it is a misconception that people have that we can't give this long-acting insulin, we're gonna cause hypoglycemia. But if you're thinking about the appropriate amounts, that just won't happen.

CARLOS R. HAMILTON, JR., MD, FACE: Well, I think this is just another example of where education of our colleagues and of the staff, the nursing staff and so forth is a critical part of what we and endocrinologists in general do.

Obviously, there are certain special situations that are likely to occur or may occur in the inpatient setting that change this paradigm. For example, ketoacidosis and perhaps others that you're aware of. What is your experience there?

ANDREW J. AHMANN, MD: Yeah. There are several special situations that are really kind of difficult to control and do take some special thought beyond that of the average patient in the hospital. Diabetic ketoacidosis is one example and there, we're, at least by tradition, still almost always would recommend a continuous insulin infusion.

Another one would be steroids, they cause a particular insulin resistance and a pattern of requirement for a greater deal of insulin during the daytime opposed to the nighttime. And it takes special thought and preparation for how you're going to do that in a special situation. Some cases in the ICU, you might actually give a continuous infusion of your steroid instead of a single bolus. But, for instance, in lots of the transplant patients, we find that it's still gonna be a single morning dose and we're gonna have to tailor the insulin for that.

And then, finally, whether you have parenteral or enteral hyperalimentation, that extra source of nutrition takes a lot of special customization of your regimen.

CARLOS R. HAMILTON, JR., MD, FACE: We've already discussed briefly the topic of education for the nursing staff and for the other consultants that are involved in inpatient care. You've had a lot of experience with that, Etie. Tell us a little bit about how you approach this giving advice and what sort of advice do you give to our colleagues?

ETIE S. MOGHISSI, MD: I think it is very important to educate all the clinical staff from nursing to physicians to dietary nutrition department to understand the basics of glycemic control, timing of meals and insulin administration, the time action profile of some of these insulins, when to hold insulin, what to do when, for example, a patient become NPO or enteral feeding is interrupted. So education is critical element of success and it needs to be actually provided to everyone across the board.

CARLOS R. HAMILTON, JR., MD, FACE: And since care of these patients really is a team sport, as it were, where the nurses and the surgeons and the anesthesiologists and the internist and whatever other specialists are involved, the endocrinologist has a really special place to play in this and I assume that you would recommend that they call the endocrinologist early rather than late in this program, don't you?

ETIE S. MOGHISSI, MD: Absolutely. I think that -- endocrinologists actually can have several roles. Obviously, they are the experts in diabetes care and they can be a consultant when there are difficult cases. But, also, to me, the more important role of the endocrinologist would be to champion the implementation of tight glycemic control by providing education, guidance when they are creating protocols and order sets, to make sure that this is done not only effectively but safely.

CARLOS R. HAMILTON, JR., MD, FACE: And I know you've had a great deal of success and involvement in that process. Well, thank you very much for joining us for this conversation today. I think this has been very helpful and I greatly appreciate Andrew and Etie, both of you, joining us. I'm Dr. Carlos Hamilton and I thank all of you for watching.