Management of diabetes and hyperglycaemia in the hospital

Abstract

Hyperglycaemia in people with and without diabetes admitted to the hospital is associated with a substantial increase in morbidity, mortality, and health-care costs. Professional societies have recommended insulin therapy as the cornerstone of inpatient pharmacological management. Intravenous insulin therapy is the treatment of choice in the critical care setting. In non-intensive care settings, several insulin protocols have been proposed to manage patients with hyperglycaemia; however, meta-analyses comparing different treatment regimens have not clearly endorsed the benefits of any particular strategy. Clinical guidelines recommend stopping oral antidiabetes drugs during hospitalisation; however, in some countries continuation of oral antidiabetes drugs is commonplace in some patients with type 2 diabetes admitted to hospital, and findings from clinical trials have suggested that non-insulin drugs, alone or in combination with basal insulin, can be used to achieve appropriate glycaemic control in selected populations. Advances in diabetes technology are revolutionising day-to-day diabetes care and work is ongoing to implement these technologies (ie, continuous glucose monitoring, automated insulin delivery) for inpatient care. Additionally, transformations in care have occurred during the COVID-19 pandemic, including the use of remote inpatient diabetes management-research is needed to assess the effects of such adaptations.

Glycocalyx engineering with heparan sulfate mimetics attenuates Wnt activity during adipogenesis to promote glucose uptake and metabolism

“…The mainstream therapeutic approach is to improve insulin-mediated glucose clearance or to restrict dietary glucose intake. 9 An alternative approach may involve reprogramming of newly generated fat tissues to increase their overall cellular metabolism and glucose demand. [11][12][13][14] Here we present evidence that we can steer the adipogenic program to generate newly matured adipocytes with enhanced oxidative glucose metabolism to drive an increase in basal inulin-independent glucose uptake.…”

“…Current treatment strategies focused on increasing insulin perception, augmenting oxidative tissue activity or decreasing excessive food consumption or nutrient absorption, have been limited by poor efficacy or detrimental side-effects as exemplified by the COVID-19 pandemic. [8][9][10] An alternative approach to increase insulin-independent glucose clearance is to capitalize on adipose tissue expandability and its functional metabolic flexibility and reprogram adipogenesis to increase basal glucose clearance capacity in adipose tissue. [11][12][13][14] The cellular glycocalyx has been well-established to play a regulatory role during adipogenesis and in adipocyte function and can serve as a potential target for therapeutic intervention in T2D.…”

Managing hyperglycaemia in inpatients

“…Patients on oral hypoglycaemic agents (OHAs) may require insulin depending on the degree of hyperglycaemia. 3 The chosen insulin regimen should take into account patient characteristics, hypoglycaemia risk and local protocols and involve the specialist diabetes team. Patients newly initiated on SC insulin should have the long-term suitability of this reviewed pre-discharge.…”

“…The choice of insulin should be discussed with the specialist diabetes team and could include short-, rapid-, mixed, intermediate-or long-acting preparations depending on the feed duration. 3,16,17 Patients with T1D requiring alternative feeding must continue their long-acting insulin. 18 Depending on the type of feed (continuous vs bolus), they are likely to require additional doses of rapid-acting insulin at the start of the feed and at set intervals thereafter.…”

“…1,2 Inpatient hyperglycaemia is associated with poor patient outcomes; the majority of inpatients with diabetes are admitted with nondiabetes-related conditions and are primarily cared for by a clinician who does not specialise in diabetes. 3,4 Fluctuating glycaemic control is typically seen in acutely unwell patients. While most people with type 1 diabetes (T1D) are trained in selfadjusting insulin doses in response to hyperglycaemia, their ability to make these changes in hospital may be affected by multiple factors including access to insulin and their ability to reliably titrate insulin when unwell.…”