Scheduled subcutaneous insulin therapy is recommended for all patients, consisting of basal or intermediate-acting insulin once or twice daily in combination with rapid- or short-acting insulin administered before meals in patients who are eating. Prolonged use of sliding-scale therapy should be avoided as the sole method for glycemic control.
Dr. Hellman noted that basal/bolus therapy is a key recommendation of the new guideline. It is based on data from two recent studies led by Dr. Umpierrez, both showing superiority of basal-bolus insulin regimens over sliding scale insulin treatment. One of those studies was done in noncritically ill hospitalized patients with type 2 diabetes (Diabetes Care 2007;30:2181-6), and the other in type 2 patients undergoing general surgery (Diabetes Care 2011;34:256-61).
"Both trials showed that basal/bolus insulin was clearly better than the use of sliding scale–only insulin, which is probably a predominant choice by many physicians, and it is in error. It is wrong," Dr. Hellman said.
At discharge, a preadmission insulin regimen, or oral and noninsulin injectable antidiabetic drugs, can be reinstituted for patients with acceptable preadmission glycemic control and without a contraindication to their continued use. Initiation of insulin administration at least 1 day before discharge is suggested, to allow assessment of the efficacy and safety of this transition. Patients and their caregivers should receive both oral and understandable written instructions for home glycemic management.
Special situations covered in detail in the document include transitions from intravenous to subcutaneous insulin therapy in patients with type 1 and type 2 diabetes, glycemic management of patients who are receiving enteral or parenteral nutrition, perioperative blood glucose control in type 1 and type 2 patients, and management of glucocorticoid-induced diabetes.
For hypoglycemia management, the panel recommends the development of protocols with specific directions for hypoglycemia avoidance and management, implementation of hospital-wide, nurse-initiated hypoglycemia treatment protocols, and implementation of a system for tracking frequency of hypoglycemic events with root cause analysis. The document lists key components of such protocols, and provides suggested nurse-initiated strategies.
Hospitals are advised to provide administrative support for an interdisciplinary steering committee targeting a systems approach to improve care of inpatients with hyperglycemia and diabetes. The establishment of uniform methods for collecting and evaluating POC testing data and insulin use information in hospitals is recommended, as are the provision of accurate devices for glucose measurement at the bedside with ongoing staff competency assessments.
Diabetes self-management education is recommended for patients, including both short-term "survival skills" education in the hospital and referral to community sources for ongoing patient education following discharge. Ongoing staff education is also recommended.
In all, Dr. Hellman commented, the 34-page document is meant to give a broad yet detailed overview of diabetes management in a variety of noncritical hospital settings and for a heterogenous population with hyperglycemia. "There’s a lot of rich information there for clinicians."
Dr. Hellman and Dr. Umpierrez have no financial disclosures, but three other members of the panel declared relationships with manufacturers of diabetes-related products.