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Simplified regimen maintains blood glucose for hospitalized patients with diabetes

ORLANDO, Fla. — Patients with diabetes present a range of challenges in the hospital setting, with significantly elevated 30-day mortality and in-hospital complications compared with patients without diabetes, according to a presentation at Hospital Medicine 2018. Newer regimens are emerging that help achieve target blood glucose and are simpler to implement.

The inflammatory and oxidative stress associated with hyperglycemia is further exacerbated by the fact that patients in the hospital are likely not meeting their normal food intake, creating challenges in managing their blood glucose, Guillermo E. Umpierrez, MD, professor of medicine and director of the Clinical Research Diabetes & Metabolism Center at Emory University School of Medicine, said during his presentation.

Approximately one-third of patients admitted into hospitals have a blood glucose level of 180 mg/dL or higher, with almost one-quarter exceeding 200 mg/dL, he said. This poses significant risks in the medical as well as the surgical setting.

“Just having high blood sugar or a history of diabetes is associated with an increased risk of complications including pneumonia, wound infections and acute kidney injuries in patients undergoing surgery,” Umpierrez said.

The current recommendation in the noncritical setting is to keep blood glucose between 140 mg/dL and 180 mg/dL for most patients, with more critically ill patients lower than 180 mg/dL because of the risks associated with more aggressive lowering, he said. All patients should have their blood glucose checked at least three times daily in the hospital.

Current recommendations call for the discontinuation of oral medications and a regimen with insulin-naive patients receiving 0.3 to 0.5 units/kg, half as basal insulin and half as rapid-acting insulin before meals. For patients who were taking insulin prior to coming to the hospital, the insulin dose should be reduced by 20% to 25%, he said.

“Patients in the hospital don’t eat well,” Umpierrez said. “The average caloric intake in the hospital in Atlanta is 1,340 calories a day; so you have to lower the insulin 20% to 25%, if not the rate of hypoglycemia is about 30% to 40%.”

Some have advocated for sliding scale of insulin, but this has been associated with an increased rate of postoperative complications, including wound infection, pneumonia and renal failure, at a significant additional cost, Umpierrez said. Another option that has been studied has been the premixed insulin combination of 70% NPH insulin and 30% regular insulin, which achieved lower blood glucose, but at a significantly greater risk for hypoglycemic events.

Umpierrez discussed the simplified regimen that has been implemented at Emory University. Patients with blood glucose above 140 mg/dL receive a single dose of 0.25 units/kg — 0.15 units/kg for patients 70 years or older or with renal insufficiency — and adjustments with glulisine are made before meals. For both medical and surgical patients, this has maintained a consistent lowering of blood glucose with risk of hypoglycemia, he said.

“For every patient in our hospital who receives insulin, we give a single dose of basal, plus corrections,” Umpierrez said. “This is simple to use, and in my institution, 70% of surgical patients are treated with a single dose.”

Although the recommendations for hospital-based management of hyperglycemia has been not to use oral agents, evidence published last year suggests this may be an effective alternative, he said. A study of 280 patients showed that the DPP-IV inhibitor sitagliptin plus basal insulin was as effective as basal bolus in lowering blood glucose.

“The DPP-IV inhibitor works by addressing postprandial blood glucose, so the basal plus a tablet works as well as basal bolus, minimizing the number of injections,” Umpierrez said. “So it is a possibility that patient with a blood glucose less than 180 mg/dL should be treated with an oral agent and if you need to, add basal insulin.”

Oral agents should not be used when blood glucose exceeds 200 mg/dL, he added.

Reference:

Umpierrez G. Just “A Spoon of Sugar”: Update on inpatient management of surgical patients with T2D. Presented at: Hospital Medicine 2018; April 9-11; Orlando, Fla.

Disclosure: Umpierrez reports industry funding for research from Merck, Sanofi, Boehringer-Ingelheim and Astra Zeneca and serving as an advisory board member for Sanofi and Intarcia.