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Nine Things Hospitalists Need to Know about Treating Patients with Endocrine Disorders


 

Diabetes is as prevalent in hospitals today as lab coats and heart monitors. More than 8% of the population—almost 26 million people—and nearly 27% (11 million) of Americans 65 or older have diabetes, according to American Diabetes Association (ADA) statistics. That makes diabetes one of the most common conditions hospitalists face day in and day out.

Other endocrine disorders also pose a challenge to hospitalists because they may be relatively uncommon, endocrinologists say.

The Hospitalist spoke to several endocrinologists and veteran hospitalists, mining their backgrounds and observations for tips on caring for hospitalized patients with endocrine disorders. Here are nine things they think hospitalists need to know:

1. Realize the far-reaching impact of good care for diabetic patients.

Part of the reason this is important is the numbers of patients with the disease who will be hospitalized and come under the care of a hospitalist.

“They’re coming in for a host of medical conditions, not the least of which is that diabetes is a comorbid factor that goes along with it,” says John Anderson, MD, the ADA’s immediate past president of medicine and science and an internist and diabetician at The Frist Clinic in Nashville, Tenn. “For those who are critically ill—those having bypass, those having stroke—diabetes is overrepresented even more once they get inside the hospital and in the intensive care unit.”

Job No. 1, controlling blood sugar, can have broad implications, he says.

“We know that control of their glucose through the hospital stay actually makes a difference in long-term outcomes, particularly things like surgery, coronary bypass grafting, that type of thing,” he says, noting that the standard of care is to try to keep glucose under 200. “A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.1,2

“A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.1,2 However, if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

—John Anderson, MD, past president, American Diabetes Association, internist and diabetician, The Frist Clinic, Nashville, Tenn.

“However, the other part of this is…that if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

2. You probably shouldn’t be testing for thyroid-stimulating hormone (TSH) level by itself in an acutely ill inpatient.

Simply put, the results probably won’t be useful, says Tamara Wexler, MD, PhD, an endocrinologist attending at Massachusetts General Hospital in Boston.

“TSH alone, for some reason, seems to be often measured,” she says, but “it’s extremely rarely indicated during acute hospitalization.”

TSH is “notoriously spurious” in inpatients, she adds, because the stress of an illness can make the test difficult to interpret.

“Many endocrine hormone levels are affected by stress, for example, and thus are better measured in an outpatient setting than in an acute hospitalized illness because of the impact of the illness on interpreting the test results,” she says.

Euthyroid sick syndrome—or “sick euthyroid”—is a term used for abnormalities in thyroid tests in patients with systemic illnesses that are nonthyroidal.

Dr. Wexler

Dr. Wexler

In cases in which thyroid dysfunction is strongly suspected, TSH should be measured in conjunction with other levels, such as a free thyroxine (free T4) level, Dr. Wexler says.

3. Don’t forget to watch potassium in patients with diabetic ketoacidosis (DKA).

A patient with a normal level of potassium, or even a high one, at baseline can encounter a problem with plummeting levels, says Bruce Mitchell, MD, director of hospital medicine services at Emory Hospital Midtown and assistant professor of hospital medicine at Emory University in Atlanta.

“Once you start insulin and correcting the hyperosmolality, the potassium shifts,” says Dr. Mitchell, who has a particular interest in endocrinology, “so it can become abnormally low fairly quickly.

“You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding,” he says. “It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”

4. Be sure to wait long enough before rechecking TSH after a medication change.

It takes several weeks before thyroid medication dose changes start to show their effects, says Jeffrey Greenwald, MD, a hospitalist at Massachusetts General with expertise in endocrinology. Guidelines published in 2012 by the American Association of Clinical Endocrinologists and the American Thyroid Association recommend rechecking TSH within four to eight weeks.3

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH. That’s another reason why the TSH can be somewhat difficult to interpret. There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”—Jeffrey Greenwald, MD, hospitalist, Massachusetts General, Boston

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH,” he says. “That’s another reason why the TSH can be somewhat difficult to interpret.

“There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”

5. When administering insulin, factor in soon-to-arrive meals and give prandial insulin as needed.

If patients with diabetes are receiving insulin in the hospital, even if their glucose is in the normal range, they will need insulin if they’re about to have a carb-loaded breakfast, says Jose Florez, MD, PhD, an endocrinologist at Massachusetts General and associate professor of medicine at Harvard Medical School in Boston.

“A person with a glucose of 98 who is about to eat pancakes needs standing short-acting insulin regardless of the fingerstick,” Dr. Florez says. “A person with a glucose of 250 who is about to eat needs both the correction insulin and the amount needed to handle the impending carbohydrate load.”

“The person not only needs to correct what the glucose is at the moment, but they also need to account for the impending carbohydrate intake,” he says.

Dr. Anderson says he always cautions those caring for hospitalized diabetic patients against using the “sliding-scale philosophy”—marked by set amounts of long-acting insulin and set amounts of carbohydrate intake—because it’s overly formulaic for that setting.

“It leads to really variable glucoses,” he says, “and usually not good control.”

6. Giving isotonic fluids to someone who has fixed water retention or hypertonic urine can worsen the problem.

This can stem from an incomplete or incorrect evaluation of hyponatremia, which is a common problem in hospitalized patients. When hyponatremia is present, the first order of business should be to exclude pseudohyponatremia and confirm that it’s hypotonic hyponatremia.

After confirmation, the volume status should be assessed. One useful way to do this is to measure urine creatinine, urine sodium, and urine osmolality (osm), Dr. Florez says. If a patient has water retention or hypertonic urine from syndrome of inappropriate diuretic hormone secretion (SIADH), hypothyroidism, or glucocorticoid deficiency, the hospitalist needs to act accordingly.

“If the urine osm is high, higher than the serum osm, and is fixed at that level for some reason…giving that person isotonic fluids will lead to additional water retention and make the situation worse,” he says. “It’s very important to assess the volume status and establish the cause. And then, if you’re going to give fluids, be mindful of what the urine might look like. Do not give fluids that are hypotonic with respect to what the urine is making, unless you are completely convinced that the person is dry and therefore needs volume.”

“Once you start insulin and correcting the hyperosmolality, the potassium shifts, so it can become abnormally low fairly quickly. You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding. It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”—Bruce Mitchell, MD, director of hospital medicine services, Emory Hospital Midtown, assistant professor of hospital medicine, Emory University, Atlanta.

7. Encourage patients to check their own glucose and administer their own insulin while still in the hospital.

“We often deal with patients who start insulin treatment for diabetes during an admission or who seem not to be doing very well giving insulin at home,” Dr. Wexler says. “Many patients can benefit from supervised insulin injections and glucose testing.”

Going through the process while in the hospital with supervision can be a good refresher, she says.

“You don’t have to necessarily order specific diabetic teaching,” she adds, noting that not all hospitals have diabetic educators available at all times.

A patient might be waiting for diabetic teaching before discharge, but this might be one way to speed the process, Dr. Wexler says. She suggests teaching by example.

8. Patients on steroids every day are at risk for adrenal insufficiency.

Even if they aren’t on corticosteroids when they present, hospitalists should think of these patients as “at risk for adrenal insufficiency and potentially immunocompromised,” Dr. Greenwald says. “The bigger issue in most cases is the adrenal insufficiency.”

That means their bodies can’t mount an appropriate response to stress.

“And without that appropriate response of additional stress hormone the body would normally make, they may not be able, for example, to maintain their blood pressure,” he says. “This can be extremely dangerous.”

Inhaled steroids, and topical steroids if they are applied to broken skin, can have a kind of stealth effect.

“That’s something to keep in mind,” Dr. Wexler says, noting the connection between blood pressure management and endocrine conditions.

9. Thyroid hormone might not be as well absorbed under certain conditions.

With calcium or iron supplementation, thyroid hormones might present a problem, Dr. Wexler says. For patients at home taking thyroid hormone appropriately (an hour or two separated from calcium or iron supplementation), there “should be no issue,” she says. “But if they are administered at the same time at the hospital, patients may not absorb the full dose.”


Tom Collins is a freelance writer in South Florida.

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Misinterpreting Thyroid Function Tests Can Lead You Down the Wrong Path, Expert Warns

Thyroid function tests in hospitalized patients can sometimes be a case of a mistake begetting a mistake.4 Don’t fall into the trap, endocrinologists say.3

Consider a patient presenting with new atrial fibrillation. One of the triggers for the condition is hyperthyroidism, so it’s common to do a thyroid function test.

“Say the TSH [thyroid-stimulating hormone] is up because the patient is recovering from an acute illness,”

Dr. Florez

Dr. Florez

Dr. Florez says. “All of a sudden you were looking for hyperthyroidism, but now you have a high TSH, so that initiates a workup for hypothyroidism.” But that is not the proper course, because a high TSH is not uncommon in a person getting over an illness.

Once the TSH comes back high, you’ve ruled out hyperthyroidism as the reason for the atrial fibrillation.

The matter should be considered settled, he said. “No reason to get all excited about pursuing a hypothyroidism diagnosis,” Dr. Florez says. If thereis any concern, the thyroid function tests could be repeated in the outpatient setting when the patient is no longer acutely ill.

Misdirected concerns about hypothyroidism should also be avoided.

For example, a patient presents with altered mental status, which can be brought about by myxedema coma, or profound hypothyroidism.

If the TSH comes back low—eliminating hypothyroidism as a problem—a hospitalist should not embark on a hyperthyroidism diagnosis, Dr. Florez says. It’s probably just sick euthyroid causing the abnormal TSH level.

“What you need to do is work on the reasons for altered mental status,” he says. “You’ve already exonerated myxedema coma. Move on, and then have the thyroid test pursued as an outpatient to ensure it normalizes.”

—Thomas R. Collins

Slow Down

Because diabetes is such a common disease among hospitalized patients, it might be easy to gloss over, but it’s important to regard each inpatient as an individual and not go on auto-pilot, diabetes experts say.

“Not every type 2 or type 1 patient is alike. They all have different insulin requirements. Some patients are on oral meds with type 2 diabetes, some are on one insulin shot a day, [and] some are on several insulin injections a day,” Dr. Anderson says. “It’s managing that glucose in that individual and trying to optimize their therapy.”

Plenty of factors in the hospital might get in the way of that optimal care, he adds. Is a patient NPO (nothing by mouth) before a surgery? Feeling too nauseous to follow the appropriate eating schedule? Has a meal been delivered late by the meal service?

“The hospital introduces an incredible layer of complexity to the care of the patient with type 2 diabetes,” Dr. Anderson says. “That’s why it’s really important for everybody who takes care of people with diabetes in the hospital to be pretty savvy about this.”

Hospitalists shouldn’t be lulled into complacency just because diabetes is usually non-life-threatening. Often, patients with diabetes are admitted for a completely different condition.

“And by the time [providers] get to diabetes as an issue, they may just say ‘diabetes, sliding scale, check A1C as a reflex,’ and then not take the time to think about what is this person’s regimen,” Dr. Florez says.

All the details about that person’s eating status and insulin requirements should be tended to carefully.

“I don’t think diabetes is rocket science,” Dr. Florez says. “But it does require attention.

I think it’s not so much [hospitalists’] level of expertise as it is the time and the pressures and the stresses. They have to actually slow down and give the diabetes some thought.”

—Thomas R. Collins

References

  1. Omar AS, Salama A, Allam M, et al. Association of time in blood glucose range with outcomes following cardiac surgery. BMC Anesthesiol. 2015;15(1):14.
  2. Han HS, Kang SB. Relations between long-term glycemic control and postoperative wound and infectious complications after total knee arthroplasty in type 2 diabetics. Clin Orthop Surg. 2013;5(2):118–123.
  3. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18(6):988-1028.
  4. Supit EJ, Peiris AN. Interpretation of laboratory thyroid function tests for the primary care physician. South Med J. 2002;95(5):481-485.

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