EXPERT ANALYSIS AT THE ADA ADVANCED POSTGRADUATE COURSE
Balancing blood sugar in any hospitalized patient can be a tightrope walk, but it is especially challenging when patients can’t eat or are taking steroids.
These patients need a proactive approach that prevents both hyper- and hypoglycemia, both of which have long been tied to poorer outcomes in critically ill patients, Dr. Mary Korytkowski said at the annual advanced postgraduate course held by the American Diabetes Association.
All hospitalized patients should have a blood glucose test on admission. This baseline measure will determine in-hospital glycemic management, which can be fairly straightforward as long as patients are eating regularly. Things get tricky if patients can’t take any food orally and need enteral or parenteral nutrition. Glucocorticoids can also wreak havoc on blood sugars, even in nondiabetic patients.
“There is no question that [blood sugar extremes] impact outcomes, whether or not the patient has [a history of] diabetes,” said Dr. Korytkowski of the University of Pittsburgh. “The question is, what do we do about it?”
The NICE-SUGAR study determined that low-end blood sugar targets may actually be dangerous for hospitalized patients. Since its publication in 2012, glycemic goals have been increased. For non–critically ill patients, a pre-meal blood glucose level should be somewhere between 100-140 mg/dL. For critically ill patients, the goal is more generous at 110-180 mg/dL. Management should aim to sustain those levels, with as few out-of-goal fluctuations as possible.
Patients who have diabetes and are NPO (nothing by mouth) should have their scheduled nutritional insulin held, and their glucose levels maintained with basal and correction insulin, Dr. Korytkowski said. The dose of insulin glargine or insulin detemir will have to be decreased by up to 40% to stay within target; the dose of NPH insulin will probably have to be decreased by 30%-50%.
Those who are converted to NPO after getting their full insulin dose should then be put on a 5% or 10% dextrose solution, which should continue as long as they are getting insulin. “We have this written into our standing orders now,” Dr. Korytkowski said. Of course, routine blood glucose monitoring is essential here.
All patients who receive enteral or parenteral nutrition need a baseline blood glucose level and point-of-care testing regardless of their diabetes history. For those without diabetes, testing can be discontinued if blood glucose stays below 140 mg/dL for 48 hours without insulin.
Those with diabetes should get basal insulin twice a day in addition to their normal regimen, plus correction insulin doses as needed. If this regimen stabilizes glucose at 140-180 mg/dL, it can continue. If levels are above 180 mg/dL on at least two measurements within 24 hours, then adding 25%-50% to the correction insulin dose, along with the scheduled insulin, is indicated.
Steroid diabetes is not uncommon among patients who have been getting glucocorticoids for an extended time, such as those with chronic inflammatory disorders. Steroids oppose insulin action and stimulate gluconeogenesis, leading to an increase in hepatic glucose output. NPH insulin is indicated for these patients. A suggested schedule is 0.1 unit of NPH insulin for every 10 mg prednisone. For example, 0.4 U/kg per day for 40 mg prednisone; 0.3 U/kg per day for 30 mg, and so on.
Dr. Korytkowski disclosed that she is a consultant for Sanofi-Aventis.
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