Treatment of Diabetes in Older Adults: An Endocrine Society* Clinical Practice Guideline.

OBJECTIVE: The objective is to formulate clinical practice guidelines for the treatment of diabetes in older adults. CONCLUSIONS: Diabetes, particularly type 2, is becoming more prevalent in the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation. Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes complications. Each section in this guideline covers all aspects of the etiology and available evidence, primarily from controlled trials, on therapeutic options and outcomes in this population. The goal is to give guidance to practicing health care providers that will benefit patients with diabetes (both type 1 and type 2), paying particular attention to avoiding unnecessary and/or harmful adverse effects.

Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients.

OBJECTIVE: To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point. METHODS: Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive care unit patients and those in specific subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Elements that contribute to safe and effective insulin infusion therapy were determined through literature review and expert opinion. The majority of the literature supporting the use of insulin infusion therapy for critically ill patients lacks adequate strength to support more than weak recommendations, termed suggestions, such that the difference between desirable and undesirable effect of a given intervention is not always clear. RECOMMENDATIONS: The article is focused on a suggested glycemic control end point such that a blood glucose ≥ 150 mg/dL triggers interventions to maintain blood glucose below that level and absolutely <180 mg/dL. There is a slight reduction in mortality with this treatment end point for general intensive care unit patients and reductions in morbidity for perioperative patients, postoperative cardiac surgery patients, post-traumatic injury patients, and neurologic injury patients. We suggest that the insulin regimen and monitoring system be designed to avoid and detect hypoglycemia (blood glucose ≤ 70 mg/dL) and to minimize glycemic variability.Important processes of care for insulin therapy include use of a reliable insulin infusion protocol, frequent blood glucose monitoring, and avoidance of finger-stick glucose testing through the use of arterial or venous glucose samples. The essential components of an insulin infusion system include use of a validated insulin titration program, availability of appropriate staffing resources, accurate monitoring technology, and standardized approaches to infusion preparation, provision of consistent carbohydrate calories and nutritional support, and dextrose replacement for hypoglycemia prevention and treatment. Quality improvement of glycemic management programs should include analysis of hypoglycemia rates, run charts of glucose values <150 and 180 mg/dL. The literature is inadequate to support recommendations regarding glycemic control in pediatric patients. CONCLUSIONS: While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infusion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy.

Stress hyperglycaemia.

Results of randomised controlled trials of tight glycaemic control in hospital inpatients might vary with population and disease state. Individualised therapy for different hospital inpatient populations and identification of patients at risk of hyperglycaemia might be needed. One risk factor that has received much attention is the presence of pre-existing diabetes. So-called stress hyperglycaemia is usually defined as hyperglycaemia resolving spontaneously after dissipation of acute illness. The term generally refers to patients without known diabetes, although patients with diabetes might also develop stress hyperglycaemia-a fact overlooked in many studies comparing hospital inpatients with or without diabetes. Investigators of several studies have suggested that patients with stress hyperglycaemia are at higher risk of adverse consequences than are those with pre-existing diabetes. We describe classification of stress hyperglycaemia, mechanisms of harm, and management strategies.

Effects of outcome on in-hospital transition from intravenous insulin infusion to subcutaneous therapy.

It is widely accepted by medical practitioners that diabetes is a major independent risk factor for the development of cardiovascular disease. However, less attention has been directed toward elevated blood glucose as a predictor of poor outcomes in hospitalized patients in cardiac critical care. This has occurred despite documentation of hyperglycemia in a significant proportion of patients admitted for cardiac care and considerable data supporting the use of intravenous (IV) insulin to achieve glycemic control. The increased risk for mortality due to hyperglycemia provides a strong rationale for an intensive approach using insulin to control blood glucose levels in cardiac patients being treated in acute care and surgical settings. IV insulin infusion is the therapy of choice for patients in cardiac critical care units, with transition to a subcutaneous insulin therapy regimen when appropriate. The timing of this transition can be critical. Strong evidence from studies on patients who have undergone cardiac surgery suggests that glycemic control by insulin infusion should be maintained for > or =3 postoperative days. Nonetheless, transition from IV to subcutaneous therapy must occur at some point during the hospital stay. In conclusion, the implementation of measures to achieve glycemic control in acute cardiac care hospital settings can significantly reduce morbidity and mortality and can substantially decrease the costs associated with prolonged hospital stays. This report reviews recent clinical data on the benefits of IV insulin infusion in cardiac patients in critical care and provides recommendations on transitioning patients from IV insulin infusion to subcutaneous therapy.

The transition from insulin infusions to long-term diabetes therapy: the argument for insulin analogs.

After cardiac surgery, it is medical mismanagement to place an order for sliding scale insulin at the time of transitioning from intravenous insulin. Use of basal-prandial-correction therapy with insulin analogs constitutes a suitable transitioning regimen for inpatient management of hyperglycemia after heart surgery, to be ordered before interruption of intravenous insulin infusion, in conjunction with a program of blood glucose monitoring before meals, at bedtime, and midsleep. In the ambulatory setting, in comparison to neutral protamine Hagedorn, long-acting insulin analogs reduce hypoglycemia. In comparison to regular insulin, rapid-acting insulin analogs reduce hypoglycemia and improve postprandial control. A standardized approach to order entry for basal-prandial-correction therapy enhances safety and staff familiarity while preserving individualization of patient care. Proposed predictors of successful transition are described. Dose requirements during intravenous insulin infusion can be used to guide initial dose assignments of basal insulin therapy. As the patient approaches discharge, the total daily doses of subcutaneous insulin and basal insulin dose are decreased, and the proportion of prandial insulin approaches or exceeds 50% of the total daily dose as the absolute amount of prandial insulin increases. Before discharge, hyperglycemic patients not known to have diabetes should be advised of the need for outpatient reassessment, and those known to have diabetes but requiring intensification of therapy should participate in decision-making concerning their options for intensified treatment.

Description and evaluation of a glycemic management protocol for patients with diabetes undergoing heart surgery.

OBJECTIVE: To evaluate a protocol for glycemic management in the treatment of postoperative heart patients with diabetes in the setting of a community hospital. METHODS: The protocol included a standardized guideline in tabular form for nurse-implemented insulin infusion ("drip") therapy for postoperative glycemic control. At the time of discontinuation of the insulin drip, the glycemic status of patients with diabetes was managed by the endocrine department. Overall, 29 patients were assessed without and 29 patients with use of the protocol in a community hospital. RESULTS: From postoperative days 0 through 4, use of the protocol resulted in a greater number of blood glucose determinations, a trend toward greater utilization of insulin drip therapy without a significant increase in the number of patients treated with insulin drip, and no change in the frequency of hypoglycemic episodes. During the same time interval, the percentages of postoperative days during which at least one blood glucose value equaled or exceeded 250 mg/dL were 27.5% without the protocol and 16.8% with use of the protocol (P = 0.0318). The principal finding of the study was reduction in the percentage of postoperative days during which mean blood glucose values equaled or exceeded 200 mg/dL to less than half the previously observed frequency-from 38.4% without the protocol to 16.8% with the protocol (P = 0.0001). The effectiveness of the insulin drip component of the protocol is suggested by a trend, shown on postoperative days 2 through 4, of 70 patient days with mean blood glucose levels <200 mg/dL (58 of these days without insulin drip therapy) and 15 patient days with mean blood glucose values > or =200 mg/dL (none of these days associated with same-day insulin drip therapy). CONCLUSION: A standardized approach to insulin drip therapy, in combination with subspecialty consultation for follow-up glycemic management with use of subcutaneous administration of insulin, can improve glycemic control in postoperative heart patients without continuation of insulin drip therapy outside the critical-care unit. The trends observed on postoperative days 2 through 4, that most patients maintained glycemic control without insulin drip therapy and that all failures of glycemic control occurred among patients who no longer received insulin drip therapy, suggest the possibility of developing criteria for selection of patients for continuation of insulin infusion outside the critical-care unit.