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Kleinhans M, Albrecht LJ, Benson S, Fuhrer D, Dissemond J, Tan S. Continuous Glucose Monitoring of Steroid-Induced Hyperglycemia in Patients With Dermatologic Diseases. J Diabetes Sci Technol 2024; 18:904-910. [PMID: 36602041 PMCID: PMC11307234 DOI: 10.1177/19322968221147937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Systemic administration of glucocorticoids is a mainstay therapy for various inflammatory diseases and may lead to hyperglycemia, which carries the risk of worsening preexisting diabetes and triggering steroid-induced diabetes. Therefore, we aimed to identify patients at risk and to quantify severity of steroid-induced hyperglycemia (SIH) by continuous glucose monitoring (CGM) in hospitalized patients needing systemic glucocorticoid treatment. PATIENTS AND METHODS This prospective study included 51 steroid-naive, dermatological patients requiring systemic high-dose glucocorticoid treatment at the Department of Dermatology of the University Hospital Essen. After careful diabetes-specific assessment at admission, glucose monitoring was performed using a CGM system and glucose profile was analyzed in patients with and without SIH. RESULTS SIH occurred in 47.1% of all treated patients, and a relevant part of patients with initial normoglycemia developed SIH (2/10 patients). Doubling of SIH incidence was observed with each severity grade of dysglycemia (4/10 in prediabetes; 9/10 in diabetes). Patients with SIH spend nearly 6 hours daily above targeted glucose range, and severe hyperglycemia was observed for 1.2 hours/day. CONCLUSIONS Our study underlines the need for dedicated glucose monitoring in dermatologic patients on systemic glucocorticoid therapy by demonstrating its impact on glucose metabolism.
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Affiliation(s)
- Monika Kleinhans
- Department of Dermatology, Allergology and Venerology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Lea Jessica Albrecht
- Department of Dermatology, Allergology and Venerology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sven Benson
- Institute of Medical Psychology and Behavioral Immunobiology & Institute for Medical Education, Center for Translational Neuro- and Behavioral Sciences, Medical Faculty, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Dagmar Fuhrer
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Joachim Dissemond
- Department of Dermatology, Allergology and Venerology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Susanne Tan
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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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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4
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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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5
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Handattu K, Sharma LK, Vijayasekharan K, Bhat K V, Aroor S, Sudhanshu S. Drug Induced Diabetes Mellitus in Pediatric Acute Lymphoblastic Leukemia: Approach to Diagnosis and Management. J Pediatr Hematol Oncol 2022; 44:273-279. [PMID: 35700365 DOI: 10.1097/mph.0000000000002494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/08/2022] [Indexed: 11/26/2022]
Abstract
Corticosteroids and l -asparaginase used in the treatment of pediatric acute lymphoblastic leukemia (ALL) can cause drug-induced diabetes mellitus (DIDM). DIDM can lead to dyselectrolytemia, a higher risk of infections including cellulitis, bacteremia, fungemia, and a higher incidence of febrile neutropenia and may have an impact on the outcome of ALL. Literature on the management of DIDM among children with ALL is sparse and the diagnostic criteria for pediatric diabetes should be carefully applied considering the acute and transient nature of DIDM during ALL therapy. Insulin remains the standard of care for DIDM management and the choice of Insulin regimen (stand-alone Neutral Protamine Hagedorn or basal bolus) should be based on the type and dose of steroids used for ALL and the pattern of hyperglycemia. A modest glycemic control (postmeal 140 to 180 mg/dL, premeal <140 mg/dL) to prevent complications of hyperglycemia, as well as hypoglycemia, would be the general approach. This review is intended to suggest evidence-based practical guidance in the diagnosis and management of DIDM during pediatric ALL therapy.
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Affiliation(s)
| | - Lokesh K Sharma
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
| | | | - Vasudeva Bhat K
- Division of Pediatric Hematology and Oncology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka
| | | | - Siddhnath Sudhanshu
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh
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Abstract
Hintergrund Eine Hyperglykämie bei Menschen mit und ohne Diabetes, die ins Krankenhaus eingeliefert werden, ist mit einem erheblichen Anstieg von Morbidität, Mortalität und Gesundheitskosten verbunden. Während eines Krankenhausaufenthaltes treten Stoffwechseldekompensationen häufig als Folge unterschiedlicher Ereignisse oder Zusatztherapien auf. Aufgrund des erhöhten Risikos für eine Zunahme der Morbidität, verbunden mit längerem Krankenhausaufenthalt sowie höheren Kosten und Mortalität, erscheint eine genaue Betrachtung der Bedeutung von Glukosewerten und der Therapieformen im Krankenhaus sinnvoll und angebracht. Material und Methode Aktuelle Befunde, Übersichtsarbeiten und Grundlagendaten wurden analysiert und in einer kurzen Übersicht zusammengefasst und diskutiert. Fazit Eine persistierende Hyperglykämie im Krankenhaus ist häufig und oft mit unzureichenden Ergebnissen des Krankenhausaufenthaltes verbunden. Die kontinuierliche Insulininfusion bleibt die Therapie der Wahl während hyperglykämischer Krisen und kritischen Erkrankungen. Auch bei nicht kritisch kranken Menschen mit ausgeprägter Hyperglykämie, schon ambulant bekannten hohen Insulindosen, mit Typ-1-Diabetes oder mit steroidinduzierter Hyperglykämie bleibt Insulin das Mittel der Wahl.
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Affiliation(s)
- Michael Jecht
- Diabetesschwerpunktpraxis, Rodensteinstr. 32, 13593 Berlin, Deutschland
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Abstract
The American Diabetes Association (ADA) "Standards of Medical 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 (https://doi.org/10.2337/dc22-SPPC), 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, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Abstract
The American Diabetes Association (ADA) "Standards of Medical 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 (https://doi.org/10.2337/dc21-SPPC), 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, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Marić A, Miličević T, Vučak Lončar J, Galušić D, Radman M. Patterns of Glucose Fluctuation are Challenging in Patients Treated for Non-Hodgkin's Lymphoma. Int J Gen Med 2020; 13:131-140. [PMID: 32346306 PMCID: PMC7167272 DOI: 10.2147/ijgm.s245779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/25/2020] [Indexed: 12/13/2022] Open
Abstract
Purpose This cohort study aimed to determine patterns of glycemic fluctuation and changes in metabolic parameters during and after corticosteroid administration in newly diagnosed diffuse large B-cell lymphoma (DLBCL) patients treated with R-CHOP chemotherapy. Patients and Methods The study was performed in 20 patients of whom 11 had diabetes and 9 were nondiabetics. Anthropometric parameters were collected, and blood samples were taken four times during the study to analyze metabolic parameters. Capillary glucose was measured seven times a day (fasting, before mean meals, postprandial, and before bedtime) to evaluate the glycemic profile. Results In all 20 patients, acute glucocorticoid administration resulted in the elevation of average glucose levels, dominantly postprandial in the afternoon which correlates with corticosteroid peak action. In 7 out of 11 diabetics, prandial insulin was started during corticosteroid administration and discontinued afterward. Although none of our nondiabetic patients met diabetes criteria, evident is the elevation in average glycemia levels six weeks after corticosteroid administration. Potentially, even transient corticosteroid administration reduces insulin sensitivity and contributes to later glycemic disturbances. HbA1c levels were higher at the end of the study while fructosamine levels were higher during the study. Conclusion Patients and health-care professionals need to be aware of corticosteroid-induced hyperglycemia. We recommend identifying risk factors, measuring glycemia before, during, and after corticosteroid administration, and starting the adequate therapy as soon as possible.
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Affiliation(s)
- Andreja Marić
- Department of Internal Medicine, County Hospital Čakovec, Čakovec 40000, Croatia
| | - Tanja Miličević
- Department of Internal Medicine, University Hospital Center Split, Split 21000, Croatia
| | - Jelena Vučak Lončar
- Department of Internal Medicine, County Hospital Zadar, Zadar 23000, Croatia
| | - Davor Galušić
- Department of Internal Medicine, University Hospital Center Split, Split 21000, Croatia
| | - Maja Radman
- Department of Internal Medicine, University Hospital Center Split, Split 21000, Croatia
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Abstract
The American Diabetes Association (ADA) "Standards of Medical 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 (https://doi.org/10.2337/dc20-SPPC), 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, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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11
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Clark L, Weeda E, Griffin ML, Jones LA, Haney J. Outcomes Associated With the Adjunctive Use of Dipeptidyl Peptidase-4 Inhibitors With Insulin Versus Other Antihyperglycemic Medications in Patients With Prediabetes or Diabetes After Cardiac Surgery. J Pharm Pract 2019; 34:259-264. [PMID: 31409190 DOI: 10.1177/0897190019867850] [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: 11/16/2022]
Abstract
BACKGROUND Dipeptidyl peptidase-4 inhibitors (DPP-4i) plus basal insulin is noninferior to insulin monotherapy for glycemic control in medical-surgical patients, but data in postoperative cardiac surgery patients are sparse. OBJECTIVE To compare glucose control in postoperative cardiac surgery patients with prediabetes or diabetes receiving a DPP-4i plus insulin versus other antihyperglycemic regimens. METHODS We retrospectively identified patients with prediabetes or diabetes who underwent cardiac surgery at our hospital between May 2016 and June 2017. Included patients were stratified into cohorts: (1) DPP-4i plus insulin and (2) other antihyperglycemic regimens. Blood glucose levels were collected on postoperative days 2 to 7. Uncontrolled glucose (≥2 measurements <80 or >180 mg/dL in 1 day), hyperglycemia (>2 measurements ≥180 mg/dL in 1 day), and hypoglycemia (any measurement <70 mg/dL) were compared between cohorts using logistic regression adjusted for home antihyperglycemics. RESULTS We included 135 cardiac surgery patients, of which 65 received DPP-4i plus insulin. Eighty-two patients received antihyperglycemics at home. Uncontrolled glucose occurred in 61 (45.2%) patients; while hyperglycemia and hypoglycemia occurred in 50 (37.0%) and 24 (17.8%) patients, respectively. There was no difference in the adjusted odds of uncontrolled glucose (odds ratio [OR] = 1.43; 95% confidence interval [CI] = 0.65-3.11), hyperglycemia (OR = 1.20; 95% CI = 0.52-2.78), or hypoglycemia (OR = 0.69; 95% CI = 0.27-1.75) for those receiving DPP-4i plus insulin versus other regimens. CONCLUSION Glucose control was no different among postoperative cardiac surgery patients receiving a DPP-4i plus insulin versus other regimens. DPP-4i use was not associated with hypoglycemia.
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Affiliation(s)
- Lisa Clark
- 15472South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Erin Weeda
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA. Clark is now with the Department of Pharmacy at Tampa General Hospital, Tampa, FL, USA. Griffin is now with the Department of Pharmacy at the University of Virginia Health System, Charlottesville, VA, USA. Jones is now with the Department of Pharmacy at the University of North Carolina Health Care, Chapel Hill, NC, USA
| | - Mary Lewis Griffin
- 15472South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Lee Ann Jones
- 15472South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA
| | - Jason Haney
- Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC, USA. Clark is now with the Department of Pharmacy at Tampa General Hospital, Tampa, FL, USA. Griffin is now with the Department of Pharmacy at the University of Virginia Health System, Charlottesville, VA, USA. Jones is now with the Department of Pharmacy at the University of North Carolina Health Care, Chapel Hill, NC, USA
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes 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, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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13
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Bonaventura A, Montecucco F. Steroid-induced hyperglycemia: An underdiagnosed problem or clinical inertia? A narrative review. Diabetes Res Clin Pract 2018. [PMID: 29530386 DOI: 10.1016/j.diabres.2018.03.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Corticosteroids are widely diffused drugs. An important side effect is the impairment of glycemic control both in patients with known diabetes and in normoglycemic ones potentially leading to steroid-induced diabetes mellitus (SIDM). In this review based on papers released on PubMed, MEDLINE, and EMBASE from January 2015 to October 2017, we summarized and discussed main updates about the definition, the diagnosis, and the pathophysiology of steroid-induced hyperglycemia (SIH), with a look to new therapies. Main alterations responsible for the diabetogenic effect of corticosteroids are a negative impact on insulin sensitivity along with a derangement on insulin secretion, explaining the typical post-prandial hyperglycemia linked to the promotion of gluconeogenesis. An early and precise diagnosis of SIH and/or SIDM is necessary, but current criteria do not seem sensible enough. As an afterthought, the treatment should be reasoned and tailored according to proposed glycemic thresholds and patient comorbidities, choosing between antidiabetic oral drugs and insulin, the latter being preferable among hospitalized patients. SIDM and SIH are frequent problems, but often underdiagnosed due to old diagnostic criteria. Dedicated guidelines universally shared are mandatory in order to harmonize the treatment of these conditions, thus overtaking single therapeutic strategies mostly arising from literature.
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Affiliation(s)
- Aldo Bonaventura
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy.
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, 6 viale Benedetto XV, 16132 Genoa, Italy; Ospedale Policlinico San Martino, 10 Largo Benzi, 16132 Genoa, Italy; Centre of Excellence for Biomedical Research (CEBR), University of Genoa, 9 viale Benedetto XV, 16132 Genoa, Italy
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes 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, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Helmle KE, Chacko S, Chan T, Drake A, Edwards AL, Moore GE, Philp LC, Popeski N, Roedler RL, Rogers EJR, Zimmermann GL, McKeen J. Knowledge Translation to Optimize Adult Inpatient Glycemic Management With Basal Bolus Insulin Therapy and Improve Patient Outcomes. Can J Diabetes 2017; 42:505-513.e1. [PMID: 29555341 DOI: 10.1016/j.jcjd.2017.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/19/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To develop and evaluate a Basal Bolus Insulin Therapy (BBIT) Knowledge Translation toolkit to address barriers to adoption of established best practice with BBIT in the care of adult inpatients. METHODS This study was conducted in 2 phases and focused on the hospitalist provider group across 4 acute care facilities in Calgary. Phase 1 involved a qualitative evaluation of provider and site specific barriers and facilitators, which were mapped to validated interventions using behaviour change theory. This informed the co-development and optimization of the BBIT Knowledge Translation toolkit, with each tool targeting a specific barrier to improved diabetes care practice, including BBIT ordering. In Phase 2, the BBIT Knowledge Translation toolkit was implemented and evaluated, focusing on BBIT ordering frequency, as well as secondary outcomes of hyperglycemia (patient-days with BG >14.0 mmol/L), hypoglycemia (patient-days with BG <4.0 mmol/L), and acute length of stay. RESULTS Implementation of the BBIT Knowledge Translation toolkit resulted in a significant 13% absolute increase in BBIT ordering. Hyperglycemic patient-days were significantly reduced, with no increase in hypoglycemia. There was a significant, absolute 14% reduction in length of stay. CONCLUSIONS The implementation of an evidence-informed, multifaceted BBIT Knowledge Translation toolkit effectively reduced a deeply entrenched in-patient diabetes care gap. The resulting sustained practice change improved patient clinical and system resource utilization outcomes. This systemic approach to implementation will guide further scale and spread of glycemic optimization initiatives.
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Affiliation(s)
- Karmon E Helmle
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Sunita Chacko
- Hospitalist Program, Department of Family Medicine, Alberta Health Services-Calgary Zone, Calgary, Alberta, Canada
| | - Trevor Chan
- Hospitalist Program, Department of Family Medicine, Alberta Health Services-Calgary Zone, Calgary, Alberta, Canada
| | - Alison Drake
- Hospitalist Program, Department of Family Medicine, Alberta Health Services-Calgary Zone, Calgary, Alberta, Canada
| | - Alun L Edwards
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Glenda E Moore
- Diabetes, Obesity, and Nutrition Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Leta C Philp
- Diabetes, Obesity, and Nutrition Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Naomi Popeski
- Diabetes, Obesity, and Nutrition Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Rhonda L Roedler
- Pharmacy Services, South Health Campus, Alberta Health Services, Calgary, Alberta, Canada
| | - Edwin J R Rogers
- Clinical Analytics, Analytics, Data Integration, Measurement and Reporting (DIMR), Alberta Health Services, Calgary, Alberta, Canada
| | - Gabrielle L Zimmermann
- Knowledge Translation Platform, Alberta SPOR SUPPORT Unit, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Julie McKeen
- Division of Endocrinology and Metabolism, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Diabetes, Obesity, and Nutrition Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
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16
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Ramos P, MacIndoe J. A Blueprint for Improving Systemwide Inpatient Glucose Management. Jt Comm J Qual Patient Saf 2017; 43:176-178. [DOI: 10.1016/j.jcjq.2017.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Sanz-Paris A, Álvarez Hernández J, Ballesteros-Pomar MD, Botella-Romero F, León-Sanz M, Martín-Palmero Á, Martínez Olmos MÁ, Olveira G. Evidence-based recommendations and expert consensus on enteral nutrition in the adult patient with diabetes mellitus or hyperglycemia. Nutrition 2017; 41:58-67. [PMID: 28760429 DOI: 10.1016/j.nut.2017.02.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 02/03/2017] [Accepted: 02/21/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to develop evidence-based recommendations for glycemic control of patients with diabetes mellitus or stress hyperglycemia who are receiving enteral nutrition (EN). METHODS A Delphi survey method using Grading Recommendations Assessment, Development and Evaluation criteria was utilized for evaluation of suitable studies. RESULTS In patients with diabetes or stress hyperglycemia who were on EN support, the following results were found: CONCLUSIONS: These recommendations and suggestions regarding enteral feeding in patients with diabetes and hyperglycemia have direct clinical applicability.
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Affiliation(s)
- Alejandro Sanz-Paris
- Unit of Nutrition and Dietetics, Service of Endocrinology and Nutrition, Hospital Universitario Miguel Servet, Zaragoza, Spain.
| | - Julia Álvarez Hernández
- Section of Endocrinology and Nutrition, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - María D Ballesteros-Pomar
- Unit of Clinical Nutrition and Dietetics, Section of Endocrinology and Nutrition, Complejo Asistencial Universitario de León, León, Spain
| | | | - Miguel León-Sanz
- Unit of Clinical Nutrition and Dietetics, Service of Endocrinology and Nutrition, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ángela Martín-Palmero
- Unit of Clinical Nutrition and Dietetics, Service of Endocrinology and Nutrition, Hospital San Pedro, Logroño, Spain
| | - Miguel Ángel Martínez Olmos
- Unit of Clinical Nutrition and Dietetics, Service of Endocrinology and Nutrition, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Gabriel Olveira
- UGC Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga/Universidad de Málaga, CIBERDEM, CIBER of Diabetes and Associated Metabolic Diseases (Instituto de Salud Carlos III: CB07/08/0019), Spain
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Pichardo-Lowden A, Haidet P, Umpierrez GE. PERSPECTIVES ON LEARNING AND CLINICAL PRACTICE IMPROVEMENT FOR DIABETES IN THE HOSPITAL: A REVIEW OF EDUCATIONAL INTERVENTIONS FOR PROVIDERS. Endocr Pract 2017; 23:614-626. [PMID: 28225312 DOI: 10.4158/ep161634.ra] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The management of inpatient hyperglycemia and diabetes requires expertise among many health-care providers. There is limited evidence about how education for healthcare providers can result in optimization of clinical outcomes. The purpose of this critical review of the literature is to examine methods and outcomes related to educational interventions regarding the management of diabetes and dysglycemia in the hospital setting. This report provides recommendations to advance learning, curricular planning, and clinical practice. METHODS We conducted a literature search through PubMed Medical for terms related to concepts of glycemic management in the hospital and medical education and training. This search yielded 1,493 articles published between 2003 and 2016. RESULTS The selection process resulted in 16 original articles encompassing 1,123 learners from various disciplines. We categorized findings corresponding to learning outcomes and patient care outcomes. CONCLUSION Based on the analysis, we propose the following perspectives, leveraging learning and clinical practice that can advance the care of patients with diabetes and/or dysglycemia in the hospital. These include: (1) application of knowledge related to inpatient glycemic management can be improved with active, situated, and participatory interactions of learners in the workplace; (2) instruction about inpatient glycemic management needs to reach a larger population of learners; (3) management of dysglycemia in the hospital may benefit from the integration of clinical decision support strategies; and (4) education should be adopted as a formal component of hospitals' quality planning, aiming to integrate clinical practice guidelines and to optimize diabetes care in hospitals.
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Gosmanov AR. A practical and evidence-based approach to management of inpatient diabetes in non-critically ill patients and special clinical populations. J Clin Transl Endocrinol 2016; 5:1-6. [PMID: 29067228 PMCID: PMC5644436 DOI: 10.1016/j.jcte.2016.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/05/2016] [Accepted: 05/06/2016] [Indexed: 12/13/2022] Open
Abstract
Inpatient diabetes is a common medical problem encountered in up to 25-30% of hospitalized patients. Several prospective trials showed benefits of structured insulin therapy in managing inpatient hyperglycemia albeit in the expense of high hypoglycemia risk. These approaches, however, remain underutilized in hospital practice. In this review, we discuss clinical applications and limitations of current therapeutic strategies. Considerations for glycemic strategies in special clinical populations are also discussed. We suggest that given the complexity of inpatient glycemic control factors, the "one size fits all" approach should be modified to safe and less complex patient-centered evidence-based treatment strategies without compromising the treatment efficacy.
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Affiliation(s)
- Aidar R. Gosmanov
- Endocrinology Section, Stratton VAMC, 113 Holland Avenue, Albany, NY 12208, USA
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Tamez-Pérez HE, Quintanilla-Flores DL, Rodríguez-Gutiérrez R, González-González JG, Tamez-Peña AL. Steroid hyperglycemia: Prevalence, early detection and therapeutic recommendations: A narrative review. World J Diabetes 2015; 6:1073-1081. [PMID: 26240704 PMCID: PMC4515447 DOI: 10.4239/wjd.v6.i8.1073] [Citation(s) in RCA: 194] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/24/2015] [Accepted: 06/19/2015] [Indexed: 02/05/2023] Open
Abstract
Steroids are drugs that have been used extensively in a variety of conditions. Although widely prescribed for their anti-inflammatory and immunosuppressive properties, glucocorticoids have several side effects, being hyperglycemia one of the most common and representative. In the present review, we discuss the main epidemiologic characteristics associated with steroid use, with emphasis on the identification of high risk populations. Additionally we present the pathophysiology of corticosteroid induced hyperglycemia as well as the pharmacokinetics and pharmacodynamics associated with steroid use. We propose a treatment strategy based on previous reports and the understanding of the mechanism of action of both, the different types of glucocorticoids and the treatment options, in both the ambulatory and the hospital setting. Finally, we present some of the recent scientific advances as well as some options for future use of glucocorticoids.
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Thabit H, Hovorka R. Glucose control in non-critically ill inpatients with diabetes: towards closed-loop. Diabetes Obes Metab 2014; 16:500-9. [PMID: 24267153 DOI: 10.1111/dom.12228] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/24/2013] [Accepted: 10/28/2013] [Indexed: 01/08/2023]
Abstract
Inpatient glycaemic control remains an important issue due to the increasing number of patients with diabetes admitted to hospital. Morbidity and mortality in hospital are associated with poor glucose control, and cost of hospitalization is higher compared to non-diabetes patients. Guidelines for inpatient glycaemic control in the non-critical care setting have been published. Current recommendations include basal-bolus insulin therapy, regular glucose monitoring, as well as enhancing healthcare provider's role and knowledge. In spite of growing focus, implementation in practice is limited, mainly due to increasing workload burden on staff and fear of hypoglycaemia. Advances in healthcare technology may contribute to an improvement of inpatient diabetes care. Integration of glucose measurements with healthcare records and computerized glycaemic control protocols are currently being used in some institutions. Recent interests in continuous glucose monitoring have led to studies assessing its utilization in inpatients. Automation of glucose monitoring and insulin delivery may provide a safe and efficacious tool for hospital staff to manage inpatient hyperglycaemia, whilst reducing staff workload. This review summarizes the evidence on current approaches to managing inpatient glycaemic control; its utility and limitations. We conclude by discussing the evidence from feasibility studies to date, on the potential use of closed loop in the non-critical care setting and its implication for future studies.
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Affiliation(s)
- H Thabit
- Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
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Evidence for Basal–Bolus Insulin Versus Slide Scale Insulin. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2014. [DOI: 10.1007/s40138-013-0032-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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[Insulin therapy among inpatients]. Presse Med 2013; 42:871-9. [PMID: 23588189 DOI: 10.1016/j.lpm.2013.02.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 02/18/2013] [Indexed: 01/08/2023] Open
Abstract
To identify patients with known diabetes or hospital-related hyperglycemia. To establish blood glucose targets according to patient's clinical state. To draw up protocols by using basal, bolus (nutritional/prandial), and supplemental insulin and not "sliding scale insulin". To avoid hypoglycaemia particularly during intravenous insulin protocols in intensive care unit. To set up glucose monitoring with a regular training of medical staff. To perform HbA1c during hospital stay to plan the treatment after discharge. To organize follow-up of the patients with hospital-related hyperglycemia.
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Rendell M, Saiprasad S, Trepp-Carrasco AG, Drincic A. The future of inpatient diabetes management: glucose as the sixth vital sign. Expert Rev Endocrinol Metab 2013; 8:195-205. [PMID: 30736179 DOI: 10.1586/eem.13.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Diabetes is an ever increasing health problem in our society. Due to associated small and large vessel conditions, patients with diabetes are two- to four-fold more likely to require hospitalization than nondiabetic individuals. Furthermore, hyperglycemia in hospitalized patients results in increased susceptibility to wound infections, worse outcomes postcardiac and cerebrovascular events, longer hospital length of stay and increased inpatient mortality. Several studies suggest that tight control of glucose levels yields improvement in these factors. Conversely, other studies have suggested increased mortality after tight glucose management, perhaps as a result of an increased incidence of hypoglycemic events. The most reasonable approach to control of hyperglycemia is to normalize glucose levels as much as possible without triggering hypoglycemia. In the hospital, insulin therapy of hyperglycemia is preferred due to the ability to flexibly manage glucose levels without side effects associated with many alternative antidiabetic agents. Due to the increasing burden of inpatient diabetes, and the detrimental effects of both hyper and hypoglycemia, the authors predict that blood-glucose levels will become the sixth vital sign to be frequently monitored in hospitalized patients and controlled in a narrow range. The future is in the use of insulin pumps controlled by continuous glucose monitors. This technology is complex and has not yet become standard. The development of future inpatient diabetes care will depend on adaptation of hospital systems to advance the new technology.
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Affiliation(s)
- Marc Rendell
- a Creighton Diabetes Center, 601 North 30th Street, Omaha, NE 68131, USA.
- b The Rose Salter Medical Research Foundation, 660 South 85th Street, Omaha, NE 68114, USA
| | - Saraswathi Saiprasad
- c Department of Internal Medicine, Creighton University School of Medicine, 601 North 30th Street, Omaha, NE 68131, USA
| | - Alejandro G Trepp-Carrasco
- d Department of Endocrinology and Metabolism, Creighton University School of Medicine, 601 North 30th Street, Omaha, NE 68131, USA
| | - Andjela Drincic
- e Department of Endocrinology, The University of Nebraska School of Medicine, Nebraska Medical Center, Omaha, NE 68198-5527, USA
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Vaidya A, Hurwitz S, Yialamas M, Min L, Garg R. Improving the management of diabetes in hospitalized patients: the results of a computer-based house staff training program. Diabetes Technol Ther 2012; 14:610-8. [PMID: 22524682 PMCID: PMC3389378 DOI: 10.1089/dia.2011.0258] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Poorly controlled diabetes in hospitalized patients is associated with poor clinical outcomes. We hypothesized that computer-based diabetes training could improve house staff knowledge and comfort for the management of diabetes in a large tertiary-care hospital. METHODS We implemented a computer-based training program on inpatient diabetes for internal medicine house staff at the Brigham and Women's Hospital (Boston, MA) in September 2009. House staff were required to complete the program and answer a set of questions, before and after the program, to evaluate their level of comfort and knowledge of inpatient diabetes. Chart reviews of all non-critically ill patients with diabetes managed by house staff in August 2009 (before the program) and December 2009 (after the program) were performed. Chart reviews were also performed for August 2008 and December 2008 to compare house staff management practices when the computer-based educational program was not available. RESULTS A significant increase in comfort levels and knowledge in the management of inpatient diabetes was seen among house staff at all levels of training (P<0.02), but the increase was smaller for senior house staff compared with junior house staff. Nonsignificant trends suggesting increased use of basal-bolus insulin (P=0.06) and decreased use of sliding-scale insulin (P=0.10) were seen following the educational intervention in 2009, whereas no such change was seen in 2008 (P>0.90). Overall, house staff evaluated the training program as "very relevant" and the technology interface as "good." CONCLUSIONS A computer-based diabetes training program can improve the comfort and knowledge of house staff and potentially improve their insulin administration practices at large academic centers.
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Affiliation(s)
- Anand Vaidya
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shelley Hurwitz
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Biostatistics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maria Yialamas
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Le Min
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rajesh Garg
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Abstract
Hyperglycemia is frequently encountered in the inpatient setting and is distinctly associated with poor clinical outcomes. Recent literature suggests an association between stringent glycemic control and increased mortality, thus keeping optimal glycemic targets a relevant subject of debate. In the surgical population, hyperglycemia with or without diabetes mellitus may be unrecognized. Factors contributing to hyperglycemia in the hospital include critical illness, use of certain drugs, use of enteral or parenteral nutrition, and variability in oral or nutritional intake as can occur when patients are prepared for procedures or surgery. A sensible approach to managing hyperglycemia in this population includes preoperative recognition of diabetes mellitus and risks for inpatient hyperglycemia. Judicious control of glycemia during the pre-, intra-, and postoperative time periods with avoidance of hypoglycemia mandates the need for a strategy for patient management that extend to time of discharge. We review the consequences of uncontrolled perioperative hyperglycemia, discuss current clinical guidelines and recent controversies, and provide practical tools for glycemic control in the surgical population.
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Affiliation(s)
- Ariana Pichardo-Lowden
- Penn State College of Medicine, Penn State Hershey Diabetes and Obesity Institute, Division of Endocrinology, Diabetes and Metabolism, Hershey, PA, USA.
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