Hyperglycemia among Inpatients Costs Money and Lives

Hyperglycemia among noncritically ill medical and surgical patients is a huge problem in hospitals throughout the United States, experts said in a special educational session here at the American Association of Clinical Endocrinologists 19th Annual Meeting and Clinical Congress.

Occurring in patients with controlled or uncontrolled diabetes mellitus, patients with previously undiagnosed diabetes, and those whose diabetes is brought on by the stress of being ill and in hospital, it is associated with significant morbidity and mortality, Faramarz Ismail-Beigi, MD, PhD, Professor of Medicine and Physiology and Biophysics at Case Western Reserve University, Cleveland, Ohio, told delegates.

During stress or serious illness a variety of hormones are secreted, especially cortisol and glucagon, which both lead to increased glucogenesis and insulin resistance, he explained.

Several studies have shown that inpatient hyperglycemia is associated with longer hospital stays, more admissions to the intensive care unit, increased in-hospital complications, and fewer home discharges, in addition to increased risk of death, Ismail-Beigi said.

New cases of hyperglycemia are associated with significantly higher mortality both in the ICU and in the non-ICU setting. Not only is in-hospital hyperglycemia potentially deadly, it is very costly. “It costs a lot more to treat a patient with hyperglycemia than one with normal glycemia,” he noted.

Unfortunately, most hospitals continue to use sliding scale insulin — prandial or correction insulin only without basal insulin to manage blood sugar, “despite our pleading,” Ismail-Beigi noted.

Patients with insulin levels below 60 mg/dL and above 300 mg/dL are both sides of a problem. “Hospitals continue to use sliding scale insulin, it’s what’s been taught to medical residents, it is reactive, not proactive, it can exacerbate hyper or hypoglycemia, and a review of the literature shows that it is quite inferior to basal bolus regimens.”

Barriers that contribute to hyperglycemia in the hospital setting include insufficient staff, lack of staff trained in diabetes management, and inappropriate medication prescriptions.

“Education about insulin protocols is needed to address these knowledge deficits,” Ismail-Beigi noted. “In a survey of medical residents, almost 60% said they did not know which insulin type or regimen worked the best. We need to correct this.”

Irl B. Hirsch, MD, Professor of Medicine at the University of Washington School of Medicine, Seattle, Washington, said that strategies for managing hyperglycemia among noncritically ill inpatients include continuous variable-rate intravenous insulin drips with regular or rapid-acting insulin, basal-bolus therapy using NPH and regular insulin or long-acting and rapid-acting insulin analogs, and premixed insulin using intermediate-acting and rapid-acting insulin for patients transitioning to outpatient care.

“Glycemic control should be achieved through scheduled insulin protocols,” Hirsch said. “Subcutaneous insulin is the preferred inpatient therapy for noncritical care. Avoid sliding scale insulin as sole therapy, and remember that basal plus prandial plus correction doses should equal the total daily insulin dose,” he told delegates.

Philip Raskin, MD, Clifton and Betsy Robinson Chair in Biomedical Research and Professor of Medicine at Parkland Memorial Hospital and The University of Texas Southwestern Medical Center in Dallas, Texas, said that hospitalization provides a window of opportunity for diagnosing and treating diabetes and identifying patients at risk of future diabetes.

“When you have them in hospital, you can do something with them. There is time to improve their diabetes management.”

As important as in-hospital management of glycemic control is, helping patients stay in control when they leave hospital is also crucial, he said.

“There are several insulin regimens that can improve glycemic control in newly diagnosed patients with type 2 diabetes, and in previously diagnosed patients who are poorly controlled on oral agents alone. Some insulin regimens result in high rates of adherence, even in previously insulin-naïve patients,” he said.

Raskin added: “Discharge planning should include diabetes self management education for all newly diagnosed patients and for patients sent home on insulin.”