Nov 22 - Inpatient DM management

The topic of the day - optimizing inpatient management of hyperglycemia.  Linked here are the guidelines for management of diabetes per the American Association of Clinical Endocrinologists.  The section on hospital mamagement is below.  The full document covers how to dx and tx diabetes in the outpatient setting, as well as optimum strategies to manage risk factors such as HTN and hyperlipidemia.  Regardless of the regimen used, the plan should be reviewed and modified on a daily basis of the glucose remains uncontrolled or if hypoglycemia events occur.

Some adverse events reviewed on AHRQ's Web m&M are linked here and here.  The second link goes into more detail about hypoglycemia prevention and pitfalls even when optimum order sets are available.  As with any complex treatment algorithm in medicine these days, a multidisciplinary approach is key.

Finally - the Society of Hospital Medicine has an extensive and well resourced toolkit to enable rapid adoption of current best practices.

From AACE Guidelines:

• If appropriate for the patient, use intravenous insulin infusion (grade A)

• If hyperglycemia is reproducibly present and intravenous insulin infusion is not necessary, order scheduled subcutaneous insulin (grade B)

• For subcutaneous management, order amounts of insulin sufficient to cover basal and nutritional needs (grade B)

• Plan the patterns of glucose monitoring and delivery of insulin to match carbohydrate exposure (grade B)

• Revise the amounts of scheduled insulin daily or more frequently based on patient response (grade B)

• For patients receiving scheduled insulin, order an as needed correction dose of subcutaneous insulin with dosing that is: (a) proportionate to blood glucose elevation and insulin sensitivity of the patient and (b) appropriate to time of day; specify the times or mealtimes to which the order applies (grade B)