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Hospitalization serves as opportunity to diagnose diabetes

NEW ORLEANS — Although diabetes is rarely the focus of an inpatient visit, the inpatient setting can be an opportunity for physicians to diagnose diabetes and improve the outcomes of patients with hyperglycemia, according to a presentation at the ACP Internal Medicine Meeting.

Hyperglycemia is a common problem in the hospital whether or not the patient has diabetes, Vivian A. Fonseca, MD, assistant dean for clinical research at Tulane University School of Medicine, said during his presentation.

“This is an opportunity for diagnosis in the inpatient setting for patients or making plans for improving their care long term,” he said.

“We want to try to improve the outcomes in our patients with diabetes who come into the hospital and make a good long-term treatment plan for them,” he added.

“Despite cost savings associated with glycemic control, we are still stuck with a lot of people not getting good care,” Fonseca said.

“There are a number of studies showing that hyperglycemia is linked to mortality regardless of diabetes status,” according to Fonseca.

Blood glucose may rise in the hospital for several reasons in addition to the presence of diabetes, such as stress, withholding antihyperglycemic medications and administration of hyperglycemia-provoking agents, he said. The most serious adverse event associated with hyperglycemia in the hospital is the increased risk for infection, he said. Other adverse events may include delayed wound healing, prolonged hospital stay and increased risk of renal complications, cardiac arrhythmias and mortality, according to Fonseca.

“In some, but not all, critically ill patients, tight glycemic control can help,” he said. “Hospitalization is an opportunity to assess glycemic control and outpatient therapy and make a diagnosis of diabetes,” he added.

Fonseca recommended that physicians measure HbA1c to diagnose diabetes.

There is no clear evidence of specific glycemic targets in hospitalized patients, but generally a target around 140 mg/dL in critically ill patients and a less aggressive target in noncritically ill patients are safe, according to Fonseca.

Barriers to good glycemic control in the hospital include reliance on sliding-scale insulin regimens, fear of hypoglycemia, inadequate understanding of diabetes, lack of integrated information systems to track glucose data and trends and unpredictable changes in diet, he said.

“Very often diabetes is not the reason for admission or the focus,” Fonseca said.

Transition from inpatient to outpatient is important but sometimes gets neglected, he said.

Better communication during patient transfers is necessary, he said.

Factors related to carbohydrate intake, inadequate glucose monitoring, medication changes, liver or renal dysfunction, advanced age and interruption of IV dextrose, total parenteral nutrition, enteral feedings or continuous renal replacement therapy can increase the risk of hyperglycemia in the inpatient setting, according to Fonseca.

An IV insulin infusion is the best method to manage hyperglycemia, he said. Basal-bolus therapy also effectively manages hyperglycemia, he said.

Occasionally, oral hypoglycemic agents can be used to manage patients with diabetes in the hospital, he said.

As physicians make the transition to outpatient care, they should plan what the patient needs and how to achieve their needs, he said.

Metrics for evaluation is a very important component in successfully implementing strategies to control hyperglycemia, he said.

HbA1c therapy on admission helps with discharge planning, Fonseca noted. Appropriate diabetes education and follow-up is also important to consider when planning for discharge, he said.

“We are far from perfect... I think one of the problems has been that the monitoring of blood glucose has not been good,” Fonseca said.

“It would be really nice if the technology on continuous glucose monitoring which we are using with type 1 diabetes in outpatient could be adapted to using it for inpatient,” he added. “Unfortunately, we are not there yet because it measures interstitial fluid glucose as opposed to blood glucose... Once we have that, we would be able to make adjustments in a more rational way. I am optimistic that someday — just like we have systems for type 1 diabetes as outpatients — we will get this for inpatients with hyperglycemia and keep people under better control.” – by Alaina Tedesco

Reference:

Fonseca VA. Diabetes management in the hospitalized patient. Presented at: ACP Internal Medicine Annual Meeting; April 19-21, 2018; New Orleans.

Disclosure: Fonseca reports receiving research grants from Asahi and Bayer, as well as Honoria from Takeda, Novo Nordisk, Sanofi Aventis, Eli Lilly, AstraZeneca and Janssen.