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Demidowich AP, Stanback C, Zilbermint M. Inpatient diabetes management. Ann N Y Acad Sci 2024; 1538:5-20. [PMID: 39052915 DOI: 10.1111/nyas.15190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Diabetes mellitus is currently approaching epidemic proportions and disproportionately affects patients in the hospital setting. In the United States, individuals living with diabetes represent over 17 million emergency department visits and 8 million admissions annually. The management of these patients in the hospital setting is complex and differs considerably from the outpatient setting. All patients with hyperglycemia should be screened for diabetes, as in-hospital hyperglycemia portends a greater risk for morbidity, mortality, admission to an intensive care unit, and increased hospital length of stay. However, the definition of hyperglycemia, glycemic targets, and strategies to manage hyperglycemia in the inpatient setting can vary greatly depending on the population considered. Moreover, the presenting illness, changing nutritional status, and concurrent hospital medications often necessitate thoughtful consideration to adjustments of home diabetes regimens and/or the initiation of new insulin doses. This review article will examine core concepts and emerging new literature surrounding inpatient diabetes management, including glycemic targets, insulin dosing strategies, noninsulin medications, new diabetes technologies, inpatient diabetes management teams, and discharge planning strategies, to optimize patient safety and satisfaction, clinical outcomes, and even hospital financial health.
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Affiliation(s)
- Andrew P Demidowich
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Hospital Medicine, Johns Hopkins Community Physicians, Johns Hopkins Medicine, Baltimore, Maryland, USA
- Johns Hopkins Howard County Medical Center, Johns Hopkins Medicine, Columbia, Maryland, USA
| | - Camille Stanback
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Hospital Medicine, Johns Hopkins Community Physicians, Johns Hopkins Medicine, Baltimore, Maryland, USA
- Sibley Memorial Hospital, Johns Hopkins Medicine, Washington, District of Columbia, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Hospital Medicine, Johns Hopkins Community Physicians, Johns Hopkins Medicine, Baltimore, Maryland, USA
- Suburban Hospital, Johns Hopkins Medicine, Bethesda, Maryland, USA
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Ketaroonrut N, Kiertiburanakul S, Sriphrapradang C. Optimal initial insulin dosage for managing steroid-induced hyperglycemia in hospitalized COVID-19 patients: A retrospective single-center study. SAGE Open Med 2024; 12:20503121241238148. [PMID: 38516643 PMCID: PMC10956164 DOI: 10.1177/20503121241238148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 02/22/2024] [Indexed: 03/23/2024] Open
Abstract
Objectives To determine the optimal initial insulin dosage for controlling hyperglycemia in COVID-19 patients receiving steroids, an area with limited data. Methods We retrospectively analyzed 156 COVID-19 patients with steroid-induced hyperglycemia treated with insulin. Patients were categorized by their total daily dose of subcutaneous insulin therapy when starting dexamethasone ⩾6 mg/day or equivalent dose of glucocorticoid: Group A (⩽0.29 units/kg), Group B (0.3-0.49 units/kg), Group C (0.5-0.69 units/kg), and Group B (⩾0.7 units/kg). Treatment failure was defined as mean blood glucose level > 280 mg/dL for two consecutive days after initiating insulin or any blood glucose ⩾ 400 mg/dL. Results The mean age was 64 ± 14 years, with 50% male, and a mean body mass index of 26.9 ± 6.9 kg/m2. Most had preexisting type 2 diabetes (62%). Mean admission blood glucose and HbA1c were 233 ± 112 mg/dL and 7.8 ± 2.3%, respectively. Group A had the lowest HbA1c (6.7 ± 1.2%), while group D had the highest (9.8 ± 2.5%). Median daily dexamethasone dosage or equivalent was 36 (IQR 16.72) mg, with no significant differences in among groups. Group A had the lowest treatment failure rate. There were no significant differences in treatment failure rate between Groups B, C, and D. Additionally, there were no statistically significant differences in mean BG across the groups: Group A 232 ± 42 mg/dL, Group B 247 ± 57 mg/dL, Group C 247 ± 61 mg/dL, and Group D 227 ± 67 mg/dL (p = 0.2). Group D had a significantly higher rate of level 1 hypoglycemia (p = 0.008), while no differences in clinically significant hypoglycemia (level 2 or 3) were observed between groups. Conclusions Among patients requiring TDD ⩾ 0.3 units/kg/day, there was no significant difference in treatment failure rate between Groups B, C, and D. Group D had the highest rate of level 1 hypoglycemia. This initial insulin dosage for hospitalized COVID-19 patients on high-dose steroid therapy should be personalized.
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Affiliation(s)
- Nuttavadee Ketaroonrut
- Faculty of Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sasisopin Kiertiburanakul
- Faculty of Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chutintorn Sriphrapradang
- Faculty of Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Galindo RJ, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S295-S306. [PMID: 38078585 PMCID: PMC10725815 DOI: 10.2337/dc24-s016] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Tran NK, LaValley C, Bagley B, Rodrigo J. Point of care blood glucose devices in the hospital setting. Crit Rev Clin Lab Sci 2023; 60:290-299. [PMID: 36734399 DOI: 10.1080/10408363.2023.2170316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Dysglycemia is common among hospitalized patients. Accurate point-of-care (POC) glucose monitoring is necessary for the safe administration of insulin. Unfortunately, POC glucose meters are not all created equal. Interfering factors such as abnormal hematocrit, abnormal oxygen tension, and oxidizing/reducing substances can lead to inaccurate glucose measurements and result in inappropriate insulin dosing. The introduction of autocorrecting glucose meters has changed the POC testing landscape. Autocorrecting glucose meters provide more accurate measurements and have been associated with improved glycemic control in hospitalized patients. Continuous glucose monitoring has also created interest in using these platforms in at-risk inpatient populations. Future glucose monitoring technologies such as artificial intelligence/machine learning, wearable smart devices, and closed-loop insulin management systems are poised to transform glycemic management. The goal of this review is to provide an overview of glucose monitoring technology, summarize the clinical impact of glucose monitoring accuracy, and highlight emerging and future POC glucose monitoring technologies.
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Affiliation(s)
- Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California Davis, Sacramento, CA, USA
| | - Clayton LaValley
- Patient Care Services, University of California Davis, Sacramento, CA, USA
| | - Berit Bagley
- Patient Care Services, University of California Davis, Sacramento, CA, USA
| | - John Rodrigo
- Department of Pathology and Laboratory Medicine, University of California Davis, Sacramento, CA, USA
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S267-S278. [PMID: 36507644 PMCID: PMC9810470 DOI: 10.2337/dc23-s016] [Citation(s) in RCA: 68] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Bajaj MA, Zale AD, Morgenlander WR, Abusamaan MS, Mathioudakis N. Insulin Dosing and Glycemic Outcomes among Steroid-treated Hospitalized Patients. Endocr Pract 2022; 28:774-779. [PMID: 35550182 DOI: 10.1016/j.eprac.2022.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To determine the optimal insulin-to-steroid dose ratio for attainment of glycemic control in hospitalized patients. METHODS We retrospectively studied data collected from the electronic health record within an academic medical center from 18,599 patient-days where patients were treated concurrently with insulin and steroids. Multivariate logistic regression analyses, which included demographic and clinical variables, assessed the relationships between the exposures of total and basal insulin-to-steroid ratios and the outcomes of glycemic control (all blood glucose readings on the following patient-day >70 and ≤180 mg/dl) and hypoglycemia within three subgroups of steroid dosing: low (≤10 mg prednisone equivalent dose [PED]), medium (>10 to ≤40 mg PED), and high (>40 mg PED). RESULTS Increased insulin-to-steroid ratio was associated with increased odds of both glycemic control and hypoglycemia. The optimal total insulin-to-steroid ratio for attaining glycemic control was 0.294 units/kg/10 mg PED in the low-dose subgroup, 0.257 units/kg/10 mg PED in the medium-dose subgroup, and 0.085 units/kg/10 mg PED in the high-dose subgroup. The optimal basal insulin-to-steroid ratio was 0.215 units/kg/10 mg PED in the low-dose subgroup, 0.126 units/kg/10 mg PED in the medium-dose subgroup, and 0.036 units/kg/10 mg PED in the high-dose subgroup. CONCLUSIONS Increasing insulin-to-steroid ratios are positively associated with glycemic control and hypoglycemia. Our study suggests that ∼0.3 units/kg/10 mg PED is an optimal dose for low and medium dose steroids, while ∼0.1 units/kg/10 mg PED is optimal for high dose steroids. Further prospective studies are needed to identify insulin regimens that will optimize glycemic control in steroid treated patients while minimizing hypoglycemia risk.
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Affiliation(s)
- Mira A Bajaj
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew D Zale
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - William R Morgenlander
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mohammed S Abusamaan
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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