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Consensus State..

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Patients with diabetes are more likely to be hospitalized and have longer durations of hospitalization than those without diabetes.1 There is substantial evidence linking hyperglycemia in hospitalized patients to poor outcomes as evidenced by several cohort studies.2-4 Interventions directed at reducing blood glucose (BG) levels has resulted in improved outcomes, especially in patients in critical care units.

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Recently, the American Association of Clinical Endocrinologists and the American Diabetes Association have updated their consensus guidelines on inpatient glycemic control.5 A summary of the recommendations for glycemic control are provided below.

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I. CRITICALLY ILL PATIENTS

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  • Insulin therapy should be initiated for treatment of persistent hyperglycemia, starting at a threshold of no greater than 180 mg/dl (10.0 mmol/L).
  • Once insulin therapy has been started, a glucose range of 140 to 180 mg/dL (7.8 to 10.0 mmol/L) is recommended for the majority of critically ill patients.
  • Intravenous insulin infusions are the preferred method for achieving and maintaining glycemic control in critically ill patients.
  • Validated insulin infusion protocols with demonstrated safety and efficacy, and with low rates of occurrence of hypoglycemia, are recommended.
  • With IV insulin therapy, frequent glucose monitoring is essential to minimize the occurrence of hypoglycemia and to achieve optimal glucose control.

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II. NONCRITICALLY ILL PATIENTS

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  • For the majority of noncritically ill patients treated with insulin, the premeal BG target should generally be <140 mg/dL (<7.8 mmol/L) in conjunction with random BG values <180 mg/dL (<10.0 mmol/L), provided these targets can be safely achieved.
  • More stringent targets may be appropriate in stable patients with previous tight glycemic control.
  • Less stringent targets may be appropriate in terminally ill patients or in patients with severe comorbidities.
  • Scheduled subcutaneous administration of insulin, with basal, nutritional, and correction components, is the preferred method for achieving and maintaining glucose control.
  • Prolonged therapy with SSI as the sole regimen is discouraged.
  • Noninsulin antihyperglycemic agents are not appropriate in most hospitalized patients who require therapy for hyperglycemia.
  • Clinical judgment and ongoing assessment of clinical status must be incorporated into day-to-day decisions regarding treatment of hyperglycemia.

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III. SAFETY ISSUES

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  • Overtreatment and undertreatment of hyperglycemia represent major safety concerns.
  • Education of hospital personnel is essential in engaging the support of those involved in the case of inpatients with hyperglycemia.
  • Caution is required in interpreting results of POC glucose meters in patients with anemia, polycythemia, hypoperfusion, or use of some medications.
  • Buy-in and financial support from hospital administration are required for promoting a rational systems approach to inpatient glycemic management.

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IV. COST

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  • Appropriate inpatient management of hyperglycemia is cost-effective.

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V. DISCHARGE PLANNING

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  • Preparation for transition to the outpatient setting should begin at the time of hospital admission.
  • Discharge planning, patient education, and clear communication with outpatient providers are critical for ensuring a safe and successful transition to outpatient glycemic management.

1. American Diabetes Association. Economic costs of diabetes in ...

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