Inpatient diabetes management.

Diabetes mellitus is currently approaching epidemic proportions and disproportionately affects patients in the hospital setting. In the United States, individuals living with diabetes represent over 17 million emergency department visits and 8 million admissions annually. The management of these patients in the hospital setting is complex and differs considerably from the outpatient setting. All patients with hyperglycemia should be screened for diabetes, as in-hospital hyperglycemia portends a greater risk for morbidity, mortality, admission to an intensive care unit, and increased hospital length of stay. However, the definition of hyperglycemia, glycemic targets, and strategies to manage hyperglycemia in the inpatient setting can vary greatly depending on the population considered. Moreover, the presenting illness, changing nutritional status, and concurrent hospital medications often necessitate thoughtful consideration to adjustments of home diabetes regimens and/or the initiation of new insulin doses. This review article will examine core concepts and emerging new literature surrounding inpatient diabetes management, including glycemic targets, insulin dosing strategies, noninsulin medications, new diabetes technologies, inpatient diabetes management teams, and discharge planning strategies, to optimize patient safety and satisfaction, clinical outcomes, and even hospital financial health.

Effects of preprandial versus postprandial nutritional insulin administration in the inpatient setting.

AIMS: Hospitalized patients can have inconsistent nutritional intake due to acute illness, changing diet, or unpredictable meal delivery. The aim of this study was to evaluate whether implementation of a hospital-wide policy shifting nutritional insulin administration from pre-meal to post-meal was associated with changes in glycemic control or length of stay (LOS). METHODS: This retrospective study performed at a community hospital evaluated adult inpatients receiving nutritional insulin across three time periods. pre-intervention, immediate post-intervention, and distant post-intervention. Outcomes included rates of hypoglycemia (glucose ≤ 70 mg/dL), moderate hypoglycemia (< 54 mg/dL), severe hypoglycemia (≤ 40 mg/dL), severe hyperglycemia (≥ 300 mg/dL), daily mean glucose level, and LOS. RESULTS: The number of patient-days analyzed across the cohorts were 1948, 1751, and 3244, respectively. After multivariate adjustment, risk of developing any hypoglycemia and severe hypoglycemia significantly decreased over time (p = 0.001 and p = 0.009, respectively). Daily mean glucose increased over time (194.6 ± 62.5 vs 196.8 ± 65.5 vs 199.3 ± 61.5 mg/dL; p = 0.003), but there were no significant differences among rates of severe hyperglycemia (p = 0.10) or LOS (p = 0.74). CONCLUSIONS: Implementing a hospital-wide shift to postprandial nutritional insulin administration significantly reduced hypoglycemia rates without increasing severe hyperglycemia. This suggests a promising strategy for improving patient safety, but further prospective randomized controlled trials are warranted to confirm these findings.

Clinical Case Report: Dissociation of Clinical Course of Coexisting Autoimmune Hepatitis and Graves Disease.

OBJECTIVE: Concurrent autoimmune disorders, including autoimmune hepatitis (AIH), with Graves disease have been reported. Glucocorticoids can simultaneously lower thyroid hormone levels and treat AIH. Recurrence of hyperthyroidism is associated with recurrence of hepatitis. We present a case of coexisting AIH and Graves thyrotoxicosis, which improved with prednisone, but the thyrotoxicosis recurred during a prednisone taper while the hepatitis stayed in remission. METHODS: Evaluation included measurements of liver enzyme levels, thyroid function tests, and thyroid-stimulating antibodies as well as abdominal ultrasound, magnetic resonance imaging, and liver biopsy. RESULTS: A 47-year-old woman presented with nausea and jaundice. Workup showed an aspartate aminotransferase level of 1956 (reference, 10-42) U/L and alanine aminotransferase level of 1634 (reference, 14-54) IU/L. The liver biopsy was consistent with AIH. Nine months later, she reported palpitations, heat intolerance, and weight loss and was diagnosed with Graves disease. The patient received prednisone at 60 mg daily, and the liver and thyroid functions normalized after 1 month. Prednisone was tapered to 5 mg daily. Seven months later, she presented with a thyroid-stimulating hormone level of 0.049 (reference, 0.340-5.6) µIU/mL) and free thyroxine level of 3.96 (reference, 0.58-1.64) ng/dL. Liver enzymes remained at normal levels. Prednisone was increased from 5 to 20 mg to treat hyperthyroidism. The patient was referred for thyroidectomy for a diagnosis of Graves disease with thyrotoxicosis. CONCLUSION: This case is an example of coexisting autoimmune diseases, Graves disease and AIH, with different clinical courses. Despite initial resolution with glucocorticoid therapy, Graves disease recurred, while AIH stayed in remission.