13. Diabetes Care in the Hospital

,

doi:10.2337/dc16-s016

Cited by 75 publications

(43 citation statements)

References 33 publications

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“…An increased trend in the use of mealtime insulin, titration of insulin when warranted, (45), and avoidance of sliding scale insulin as monotherapy (34) observed in several of these studies are congruent with the recommendations of leading diabetes societies (10, 12, 67). Compelling research evidence indicates that basal-nutritional-supplemental insulin therapy is preferred over sliding scale insulin as monotherapy (15, 34, 50, 51, 68).…”

Section: Discussionsupporting

confidence: 55%

Perspectives on Learning and Clinical Practice Improvement for Diabetes in the Hospital: A Review of Educational Interventions for Providers

2017

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Objective The management of inpatient hyperglycemia and diabetes requires expertise among many healthcare 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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Section: Discussionsupporting

confidence: 55%

Perspectives on Learning and Clinical Practice Improvement for Diabetes in the Hospital: A Review of Educational Interventions for Providers

2017

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“…The study is important because current clinical practice guidelines recommend insulin for management of all hyperglycemia in hospitalized patients. 11 We estimate that a substantial number of hospitalized patients with diabetes may be eligible for treatment with non-insulin agents. Avoiding insulin in these patients can make the inpatient diabetes management much simpler for the nursing staff and may also alleviate anxiety for the patients.…”

Section: Discussionmentioning

confidence: 99%

“…9 10 The current American Diabetes Association (ADA) guidelines recommend insulin as the preferred treatment for hospitalized patients. 11 It is recommended that most critically ill patients should receive insulin infusion therapy and non-critically ill patients should receive basal-bolus insulin therapy in the hospital. Non-insulin hypoglycemic agents are not recommended due to multiple contraindications against many of these agents in acutely ill patients.…”

Section: Introductionmentioning

confidence: 99%

Safety and efficacy of saxagliptin for glycemic control in non-critically ill hospitalized patients

Garg

Schuman

Hurwitz

et al. 2017

BMJ Open Diab Res Care

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ObjectiveTo evaluate whether saxagliptin is non-inferior to basal-bolus insulin therapy for glycemic control in patients with controlled type 2 diabetes mellitus (T2DM) admitted to hospital with non-critical illnesses.Research design and methodsThis was an open-label, randomized controlled clinical trial. Patients received either saxagliptin or basal-bolus insulin, both with correctional insulin doses. The main study outcome was the mean daily blood glucose (BG) after the first day of randomization.ResultsOf 66 patients completing the study, 33 (age 69±10 years, 40% men) were randomized to saxagliptin and 33 (age 67±10 years, 52% men) to basal-bolus insulin therapy. The mean daily BG was 149.8±22.0 mg/dL in the saxagliptin group and 146.9±30.5 mg/dL in the insulin group (p=0.59). With an observed group difference of 2.9 mg/dL and an a priori margin of 20 mg/dL, inferiority of saxagliptin was rejected in favor of non-inferiority (p=0.007). There was no significant difference in the percentage of high or low BG values. The insulin group received a higher number of insulin injections (2.3±1.7/day vs 1.2±1.9/day; p<0.001) as well as a higher daily insulin dose (13.3±12.9 units/day vs 2.4±3.3 units/day; p<0.001) than did the saxagliptin group. Continuous BG monitoring showed that glycemic variability was lower in the saxagliptin group as compared to the insulin group. Patient satisfaction scores were similar in the two groups.ConclusionsWe conclude that saxagliptin use is non-inferior to basal-bolus insulin in non-critically ill hospitalized patients with T2DM controlled on 0–2 oral agents without insulin. Saxagliptin use may decrease glycemic variability in these patients.Trial registration numberNCT02182895.

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“…Depending on the definition of hyperglycemia, its prevalence varies from 44 to 90% [9] for patients receiving parenteral nutrition and around 40% [10] for patients on enteral nutrition. Clinical societies have different thresholds for hyperglycemia [11,12]. According to the Americand Diabetes Association, insulin therapy should be initiated for treatment of persistent hyperglycemia starting threshold 180 mg/dL.…”

Section: Introductionmentioning

confidence: 99%

“…According to the Americand Diabetes Association, insulin therapy should be initiated for treatment of persistent hyperglycemia starting threshold 180 mg/dL. Once insulin therapy is started, a target glucose range 140-180 mg/dL is recommended for the majority of critically and noncritically ill patients [12]. However, even considering the great number of patients who need to treat hyperglycemia and its associated complications in daily clinical practice, there are no guidelines to recommend the best regimen of insulin therapy to treat hyperglycemia in NS.…”

Section: Introductionmentioning

confidence: 99%

Insulin Regimens to Treat Hyperglycemia in Hospitalized Patients on Nutritional Support: Systematic Review and Meta-Analyses

Viana

Viana²,

Tavares³

et al. 2017

Ann Nutr Metab

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Background: The best insulin regimen to treat hyperglycemia in hospitalized patients on nutritional support (NS) is unclear. Methods: We searched electronic databases to identify cohort studies or randomized clinical trials in order to evaluate the efficacy of different insulin regimens used to treat hyperglycemia in hospitalized patients on NS on diverse outcomes: mean blood glucose (MBG), hypoglycemia, length of stay in hospital, and mortality. Results: Seventeen studies from a total of 5,030 were included. Enteral Group included 8 studies; 1,203 patients using rapid, glargine, NPH, or Premix insulin; MBG 108-225 mg/dL; hypoglycemia 0-13%. In indirect meta-analyses, NPH insulin ranked best for glucose control (MD 95% CI -2.50 mg/dL [2.65 to -2.35]). Parenteral Group included 4 studies; 228 patients using regular and glargine or NPH insulin; MBG 137-202 mg/dL; hypoglycemia 0-40%. In meta-analyses comparing regular insulin added to parenteral nutrition bag with glargine, MBG (MD 95% CI -3.78 mg/dL [-11.93 to 4.37]; I² = 0%) or hypoglycemia frequency (RR 95% CI 1.37 [0.43-4.32]; I² = 70.7%) did not differ. The description related to hospital length of stay and mortality was inconsistent between groups. Conclusions: The best insulin regimen to treat hyperglycemia in hospitalized patients on NS has not been established; best results using insulin regimens with NPH in enteral nutrition do not seem to be clinically relevant.

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13. Diabetes Care in the Hospital

Cited by 75 publications

References 33 publications

Perspectives on Learning and Clinical Practice Improvement for Diabetes in the Hospital: A Review of Educational Interventions for Providers

Perspectives on Learning and Clinical Practice Improvement for Diabetes in the Hospital: A Review of Educational Interventions for Providers

Safety and efficacy of saxagliptin for glycemic control in non-critically ill hospitalized patients

Insulin Regimens to Treat Hyperglycemia in Hospitalized Patients on Nutritional Support: Systematic Review and Meta-Analyses

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