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Michael Doldan, D.O.
Family Medicine
Sisters of Charity Hospital
Introduction
 The American Diabetes Association (ADA) estimates
that 23.6 million Americans have this disease. This
represents 7.8% of the total population.
 Patients with diabetes are hospitalized three times
more frequently than patients without the disease.
 The exact prevalence of diabetes in hospitalized
patients is unknown, but 12.4% of adult patients
discharged from U.S. hospitals in 2000 carried a
discharge diagnosis of diabetes; only 8% of these
patients were admitted with diabetes as their primary
diagnosis.
Introduction
• Managing hyperglycemia in the hospital setting may
prove to be more difficult because of stress on the body
and its subsequent hormonal effects, concomitant
illness stemming from exacerbation of co-morbidities,
changes in dietary intake, and cessations/alterations of
medication regimens.
• Additionally, maintenance of tight glycemic control in
diabetic hospitalized patients is a relatively new focus
resulting from recent studies that have defined
therapeutic goals and demonstrated improved patient
outcomes.
Introduction
• Studies show that hyperglycemia adversely affects immune
function, the cardiovascular system, the brain, and a host of
other pathways implicated in the morbidity and mortality
attributed to acute hyperglycemia.
• Some studies have demonstrated that elevation of serum glucose
results in impairment of white blood cell function, specifically
that of phagocytes.
• Older research demonstrated that reducing serum glucose levels
translates to better WBC function and phagocytosis. Although
the data are limited, studies evaluating the effect of
hyperglycemia on immune function consistently show that
improving glycemic control improves immune function.
Introduction
 The macrovascular effects of long-standing diabetes on the
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cardiovascular system are well documented.
However, acute hyperglycemia negatively affects mechanisms, such as
ischemic preconditioning, that protect the heart against ischemic
damage.
Even moderately elevated serum glucose levels may decrease coronary
blood flow and cause myocyte death through either apoptosis or
cellular injury resulting from exaggerated ischemic reperfusion.
In acute hyperglycemia, blood pressure and heart rate may increase
and the risk of arrhythmias such as QTc prolongation is greater.
In addition, inflammation and endothelial-cell dysfunction caused by
hyperglycemia in the setting of acute illness contribute to
cardiovascular complications.
Introduction
 Hyperglycemia may increase a patient's risk of thrombosis.
 Elevations in blood glucose levels, even for a short time,
have been shown to increase platelet activation and
aggregation. Increased Von Willebrand factor activity and
thromboxane A2 production occur during episodes of
hyperglycemia and may contribute to the increased risk of
clot formation seen in hospitalized patients with
hyperglycemia.
 Diabetic patients carry a much greater risk of
cardiovascular disease caused by ischemia, but this risk
appears to be unrelated to hypertension, hyperlipidemia, or
smoking. These findings may explain the mechanism by
which patients with hyperglycemia experience increased
rates of thrombosis.
Introduction
 Brain tissue also may be affected by hyperglycemia.
 When a stroke occurs, the ischemic penumbra is considered to be
viable but appears to be the region that is sensitive to the effects of
hyperglycemia.
 Animal studies have found that outcomes are worse in acute brain
ischemia when hyperglycemia is present.
 Published studies evaluating outcomes with respect to hyperglycemia
and stroke in humans for the most part have been retrospective or
observational, but they also have shown worse outcomes.
 A recent, more controlled trial did not demonstrate that tight glycemic
control improved outcomes in acute stroke, but the investigators
suggested that further study is warranted.
Introduction
 This study assessed the management of inpatient hyperglycemia in
non-critical diabetic patients at SOCH by analyzing the data that came
about as a result of the following six questions:
1) What percentage of the total patient population studied were
placed on an insulin regimen of any kind and what type of insulin
were they started on?
2) What glucose values corresponded with the administration of the
above regimen at the time of admission?
3) Once placed on an insulin regimen, what percentage of patients
had their insulin regimens adjusted at any point during their
hospitalization?
4) What glucose values corresponded with the modification of the
above regimen that prompted the change?
5) What percentage of Type I diabetics who were on basal-bolussupplemental (BBS) coverage at home received it while in the
hospital?
6) What percentage of Type I diabetics were started on BBS coverage
on the day of admission?
Hypothesis
 Greater than 50% of the Type I and Type II diabetic patients that
were studied were placed on an insulin regimen of some kind
during their hospital course.
 Of those patients placed on an insulin regimen, irrespective of
their designation of type I or type II DM and their consequent
pre-hospital medications, the majority of patients are being
placed on sliding scale insulin (SSI) as a solo insulin regimen.
 The blood glucose (BG) and finger stick blood glucose (FSBG)
levels that correspond with the administration of an insulin
regimen at the time of admission will show consistent
hyperglycemia.
Hypothesis
• Even when an insulin regimen is started, the
percentage of patients that get it adjusted in
response to persistently elevated glucose levels
will be minimal to non-existant.
• In the patients who do have their insulin
regimens modified during the course of their
hospital stay, the corresponding glucose levels
at the time that change is made will be
elevated.
Hypothesis
• The percentage of Type I Diabetics, that were
on a BBS insulin regimen at home, that were
started on a BBS regimen during the course
of their hospital stay, will be small.
• The percentage of Type I Diabetics, that were
on a BBS insulin regimen at home, that were
started on a BBS regimen on the day of
admission, will be small.
Methods
 Inpatient randomized retrospective chart review of 50
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patients, carrying a previous diagnosis of Type I or Type II
diabetes, was performed at Sisters of Charity Hospital in
Buffalo, New York.
There were 25 Type I Diabetics and 25 Type II Diabetics in
the study.
The primary diagnosis that prompted their hospital
admission was not required to be Type I or Type II DM, or
complications occuring as a result of uncontrolled DM.
Inclusion criteria consisted of randomly chosen diabetic
patients admitted to Sisters of Charity Hospital between
the dates of January 2009 to April 2010.
Exclusions included neonates and children.
Methods
 The designation of Type I or Type II DM assigned
to patients in the study was determined by both a
thorough review of the admission history and
physical, as well as the scrutinization of the
patient’s home medications.
 The glucose values recorded consisted of both
fasting and non-fasting levels.
 The glucose values recorded were either the BG or
the FSBG values, as both were not available in
some cases.
The Study Was Based Upon the Following
Questions:
3. How many
total patients
had their chosen
insulin
regiments
altered?
2. What
glucose value
prompted the
changed in this
insulin
regiment?
6. How many type 1
diabetics were
started on basalbolus supplemental
coverage on the
day of admission?
5.How many type
1 diabetics were
placed on basalbolussupplemental
coverage?
1. How many total
patients were placed on
insulin of any kind?
4. What glucose value
prompted the change in this
insulin regiments?
Percent of Patients That Received Insulin and the
Specific Type That They Received
Percent with no
Insulin
100
90
Percent SSI
80
70
Percent Basal
Supplemental
60
50
36
38
Percent Basal
and Correction
40
30
14
20
6
10
0
6
Percent Basal
Bolus and
Supplemental
Glucose values (mg/dL)
BG and/or FSBG Levels That Corresponded With the Initiation of
Insulin Administration
188.00
186.00
184.00
182.00
180.00
178.00
176.00
174.00
Average BG
Average FSBG
1
178.55
186.14
Percent of Patients
Without Insulin
Adjustments Compared to
Percent With Insulin
Adjustments
20%
The Average BG and FSBG
Values of Those Who Did
Receive Insulin
Adjustments at the Time of
Change
400
350
355.8
300
250
200
80%
185.33
150
100
50
0
Average Blood Glucose
Average Finger Stick
The Percentage of Type 1 Diabetics
Who Were On a BBS Insulin
Regimen at Home Who Received
BBS Coverage During their Hospital
Stay
The Percentage of Type 1 Diabetics
Who Were On a BBS Insulin Regimen
at Home Who Received BBS Coverage
On the Day of Admission
88
90
92
100
80
90
70
80
70
60
60
50
50
40
40
30
30
20
12
20
8
10
10
0
1 Coverage
% Received BBS
% Not received BBS Coverage
0
% Received BBS
% did not Receive BBS
Conclusions
 The data demonstrated that 64% of the patients
studied did receive some form of insulin coverage
during their hospital course.
 The prescribed regimen, however, was SSI 38% of
the time.
 Because of the unpredictable absorption kinetics
of regular insulin and the reactive nature of the
efforts at glucose control, the sliding scale is nonphysiological and ineffective in controlling glucose
and prone to inducing delayed hypoglycemia.
Conclusions
 The average of the BG and FSBG levels that corresponded
with the initiation of insulin administration was 182
mg/dL.
 This would appear to indicate that the threshold for
initiating insulin regimen’s of any type is too high.
 This observed outcome may be the direct result of a
paucity or absence of studies directly correlating specific
levels of hyperglycemia with specific adverse outcomes.
 The lack of evidence based guidelines places providers in a
precarious position as they do not want to put the patient
in a hypoglycemic state and as such a relative level of
hyperglycemia seems to be tolerated.
Conclusions
 Only 20% of the patients in this study had their insulin
regimen’s changed during the course of their admission
once they were instituted.
 This observation appears to demonstrate a lack of
adaptation to their state-specific physiologic insulin
requirements as well as a lack of recognition that their co
morbid illness alters their metabolic state and potentially
predisposes them to hyperglycemia, thus proportionally
increasing their insulin requirements and necessitating
institution of an insulin regimen that more closely mimics
that found in the physiologic state in a non-diabetic
individual.
Conclusions
 The majority of type 1 diabetics that were on a BBS regimen at home
were not put on the same regimen or a comparable regimen during the
course of their hospital stay.
 Given that patient’s who are admitted to the hospital have a tendency
to be hyperglycemic, for all the reasons previously discussed, it would
seem reasonable to start them back on their home BBS regimen at a
bare minimum (presuming that their home insulin regimen’s were
providing adequate glucose control) .
 This would provide less fluctuation of the patients glucose levels and
more time to adjust the regimen accordingly during their hospital
course.
Conclusions
 The majority of type I diabetics that were placed on a
BBS regimen were not done so on the day of
admission, which may demonstrates a lack of urgency
on the part of the provider in recognizing the
significance of even slightly elevated blood sugars in
the inpatient setting and its potential adverse effects
on the patient.
Limitations of The Study:
 Small sample size.
 Due to the small sample size even a few measurements
of marked hyperglycemia may scue the average glucose
readings thus decreasing the power of the study.
 This study was only done at one hospital.
 The glucose values used were both fasting and nonfasting
 The glucose values were not differentiated between
Type I and Type II diabetics
 There was no range of hyperglycemia studied
Further Studies
 An inpatient retrospective chart review of
hyperglycemia in the hospital setting in the context of
a large multicenter trial.
 An inpatient retrospective chart review of
hyperglycemia in the hospital setting in the context of
post-prandial glucose levels only
 Trials comparing basal and SSI as stand alone therapy
in hyperglycemic control in the inpatient setting.
 Compare morbidity and mortality of Type 1 diabetes
versus Type 2 diabetes in the inpatient setting.
Questions?
References
 Hospital admission guidelines for diabetes. Diabetes
Care 2004; 27 Suppl 1:S103.
 Hypoglycemia and clinical outcomes in patients with
diabetes hospitalized in the general ward, Turchin A;
Matheny ME; Shubina M; Scanlon JV; Greenwood B;
Pendergrass ML, Diabetes Care. 2009 Jul;32(7):1153-7.
References
 Nasraway, SA Jr. Sitting on the horns of a dilemma:
avoiding severe hypoglycemia while practicing tight
glycemic control. Crit Care Med 2007; 35:2435.
 Clement, S, Braithwaite, SS, Magee, MF, et al.
Management of diabetes and hyperglycemia in
hospitals. Diabetes Care 2004; 27:553.
 Moghissi, ES, Korytkowski, MT, DiNardo, M, et al.
American Association of Clinical Endocrinologists and
American Diabetes Association consensus statement
on inpatient glycemic control. Diabetes Care 2009;
32:1119.
Reference
 Inzucchi, SE. Clinical practice. Management of
hyperglycemia in the hospital setting. N Engl J Med
2006; 355:1903.
 Umpierrez GE; Isaacs SD; Bazargan N; You X; Thaler
LM; Kitabchi AE. An independent marker of inhospital mortality in patients with undiagnosed
diabetes. J Clin Endocrinol Metab. 2009
Feb;94(2):564-9. Epub 2008 Nov 18.
References
 Wesorick, D, O'Malley, C, Rushakoff, R, et al. Management
of diabetes and hyperglycemia in the hospital: a practical
guide to subcutaneous insulin use in the non-critically ill,
adult patient. J Hosp Med 2008; 3:17.
 Guillermo E. Umpierrez, MD, Dawn Smiley, MD, Ariel
Zisman, MD, Luz M. Prieto, MD, Andres Palacio, MD,
Miguel Ceron, MD, Alvaro Puig, MD, Roberto Mejia, PHD.
Randomized Study of Basal-Bolus Insulin Therapy in the
Inpatient Management of Patients With Type 2 Diabetes
(RABBIT 2 Trial), Diabetes Care 2007; DOI: 10.2337/dc070295. Clinical trial reg. no. NCT00394407, clinicaltrials.gov.