Diabetes is a persistent presence in the hospital, and hospitalists must remain up to date on the latest in disease management.
An endocrinologist will walk the audience through four major points on caring for diabetes patients in a talk to be given Thursday at HM17. The session, “Inpatient Diabetes Management for the Hospitalist,” will begin at 7:40 a.m.
Guillermo Umpierrez, MD, CDE, FACP, FACE, professor of medicine, director of the clinical research center and section of diabetes and metabolism at Emory University, Atlanta, and section head of diabetes and endocrinology at Grady Health System, also in Atlanta, said that, “in most patients, diabetes is a comorbidity that has a serious impact on the outcome of patients with cardiovascular disease or malignancies or surgery.
“Hyperglycemia in patients with or without diabetes can be 30%-40%,” he said. “There are somewhere around 8 to 10 million hospital discharges with diabetes every year in the United States.”
Dr. Umpierrez intends to discuss the following topics in his presentation:
• Intensive insulin therapy. “There is no evidence that intensive insulin therapy aiming to normalize blood glucose [leads to] improvement in outcome and could even [worsen] outcome because of the risk of hypoglycemia. This is true for patients in intensive care and the regular floor.”
• Treatment other than insulin. Guidelines say that using insulin is the only way to manage diabetic patients in the hospital, but evidence is growing that this might not be ideal in some cases, he said.
“Recent evidence in the past 5 years has shown that maybe a one-size-fits-all approach is wrong because using insulin, especially the basal-bolus insulin regimen” – with long-lasting insulin between meals and bolus insulin at mealtime – “can be an overtreatment for some patients with multiple complications and patients with mild hyperglycemia.” In many patients, the administration of a single basal insulin dose (glargine or detemir) is sufficient to achieve reasonable glucose control. In addition, patients with blood glucose less than 180 to 200 mg/dL could benefit from the use of incretin therapy with or without insulin to “at least minimize the risk of hypoglycemia.”
• Limitations for sliding-scale insulin therapy. This approach, in which mealtime bolus insulin is based on blood-sugar level before meals and which has dominated diabetes management over the past 80 years, can bring problems, according to the latest literature, Dr. Umpierrez said.
“Now we have excessive evidence, both in the ICU and non-ICU, that the use of sliding-scale insulin therapy … is associated with higher blood glucose levels [and a] higher rate of complications compared to the use of basal insulin. So, I think that physicians are becoming more aware that sliding scale is not the only way to manage patients in the hospital.”
• Insulin at discharge. The belief that all patients need to go home with insulin might be misguided, he said. “This could be an overtreatment associated with increased risk of hypoglycemia with no benefit in outcome.”
• The use of computer-guided algorithms on insulin therapy. “Are they better than the standard insulin drip protocols that we have? Not clear,” he said. Many commercial versions and institution-generated versions have been developed, but there is uncertainty about their value, he added.
“They may reduce the risk of hypoglycemia,” Dr. Umpierrez said. “We don’t have any evidence that they are better in reducing complications in the hospital. And they can be costly. So the physician has to be aware of the cost. But, it’s an option for some institutions that have very little support from hospitalists or intensivists in their hospital to adjust insulin therapy in the rapidly changing environment in critically ill patients in the ICU.”
Inpatient Diabetes Management for the Hospitalist
Thursday, 7:40–8:15 a.m.