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VOLUME 9 NUMBER 1 • MARCH 2012
43
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REPORT
In-hospital diabetes management
of non-critical care patients
Dr Graham Ellis
There are two vital measures to ensure
better in-hospital care of patients experi-
encing hyperglycaemia. First, all patients
admitted to hospital should have non-fast-
ing blood glucose levels measured. If above
7.8 mmol/l, an HbA
1c
determination should
be done to assess undiagnosed diabetes.
Second, the nursing staff needs to be edu-
cated and informed on the standard proto-
col for the general medical ward (non-critical
care patients) so that they can implement
and manage patients appropriately.
‘The in-hospital management of hyper-
glycaemia suffers from a dearth of evidence,
however, and good clinical trials are few. As
a result, expert guideline committees world-
wide have used clinical experience to guide
their therapeutic choices’, Dr Ellis pointed
out.
‘The hyperglycaemic patient may be cat-
egorised as: diabetic, or with undiagnosed
diabetes prior to admission, or as a patient
suffering from stress hyperglycaemia, which
returns to normal after the crisis is past’, Dr
Ellis noted. ‘On admission, an HbA
1c
level
higher than 6.5% would indicate an undi-
agnosed diabetic’, he added.
Stress hyperglycaemia (> 7.8 mmol/l)
is commonly seen (32–38%) in patients
admitted to general hospital wards. The
prevalence among critically ill patients is
higher: 41% in patients with acute coro-
nary syndromes (ACS), 44% in heart failure
patients and 80% in patients who undergo
interventional cardiac surgery.
‘Lessons from strict or intense glucose
control in critically ill patients have influ-
enced clinical care of the non-critically
ill patient’, Dr Ellis noted. ‘In both these
groups of patients, intensive glucose control
has disappointingly not improved mortality,
or occurrence of stroke or myocardial infarc-
tion, but has led to an increase in hypogly-
caemia, with adverse consequences.’
The recent guidelines for the manage-
ment of hyperglycaemia, issued in January
2012 by the American Diabetes, Endocrine
and Heart Association,
1
provide comprehen-
sive guidelines for hospitalised type 2 diabe-
tes patients in the non-critical care setting.
‘Useful targets are set for a fasting blood
glucose level of 5.6–7.8 mmol/l and a non-
The diabetologist/cardiologist debate: a meeting of the minds
fasting level of less than 10 mmol/l. Obvi-
ously in patients with terminal illness or high
risk of hypoglycaemia, the target can be set
less stringently to less than 11 mmol/l’, Dr
Ellis noted.
The clinician has the option of oral ther-
apy: metformin and sulphonylurea therapy
with caution in the elderly, and DDP-4
inhibitors, which are rendered less efficient
in patients who are not eating. ‘Insulin is
however key to therapy. We should bury the
sliding scale, as a number of studies, includ-
ing the Rabbit 2 trials,
2,3
have shown better
results with a basal-bolus approach using
glargine (once daily) and glulisine before
meals’, Dr Ellis noted.
‘Generally the sliding scale of insulin usage
has resulted in patients not receiving enough
insulin to reach the set targets. Hospitalisa-
tion is a great time to initiate insulin therapy
in our type 2 diabetes patients as nursing and
clinical support is available’, Dr Ellis noted.
The protocol for the ward management
of non-critically ill patients involves a step-
wise approach: (1) stopping oral medica-
tion, and (2) assessing the patient’s insulin
needs based on age, blood glucose levels,
body mass index and renal function, initially
using 0.2–0.5 U/kg, to a maximum of 70 U
to reach target blood glucose levels of 7.8–
11.1 mmol/l.
The insulin dose should be given as 50%
basal insulin, using Levemir (once daily or
bid), Lantus (daily) or NPH (bid) insulin. The
balance is given in three equally divided
doses before each meal if the patient is
eating. If the patient is not eating, blood
glucose levels should be measured four to
six hourly and the dosage adjusted. Supple-
mentary insulin may need to be given if the
glucose levels are not at target.
‘We need to take special care not to cause
hypoglycaemia (< 3.9 mmol/l) as this is a
marker of adverse outcomes. If a hypogly-
caemic level is recorded, reducing insulin
by 20% is a useful guide. Risk of hypogly-
caemia is raised in the older ill patient with
impaired renal function and patients stop-
ping or reducing glucocorticoid (cortisone)
therapy’, Dr Ellis warned.
Ageing and type 2 diabetes
Dr Sophia Rauff
The physiological changes of ageing and the
pathology of diabetes are cumulative. Dr
Sophia Rauff, an endocrinologist and cur-
rently a specialist in the Department of Geri-
atrics, University of KwaZulu-Natal noted
that type 2 diabetes is a growing problem in
older patients (defined by the World Health
Organisation as those over the age of 60
years).
The need to individualise therapy to each
older patient was stressed. In the case of
the frail older patient, particularly when tar-
geting glucose control, one should seek to
avoid hypoglycaemia, and an HbA
1c
level of
8% would be an acceptable target. In the
older patient, angiography frequently shows
worse atherosclerotic disease than the dura-
tion and severity of diabetes may suggest.
Emphasis was placed on early introduction
of primary prevention measures.
With regard to blood pressure measure-
ment in the older patient, there is clinical
value in using the standing blood pressure
rather than sitting blood pressure, as ortho-
static hypotension can lead to damaging
falls in the elderly. The HYVET trial,
4
using a
low-dose diuretic (inadapamide sustained
release 1.5 mg daily) and perindopril (2–4
mg) achieved excellent results with an on-
treatment reduction in mortality. Of inter-
est is that the open-label extension of the
HYVET trial has recently been published and
the benefits of reduction in total and cardio-
vascular mortality were retained
5
in patients
on sustained therapy (achieved blood pres-
sure of 146/76 mmHg).
The results of this study of blood pressure
control in the active, free-living elderly show
that benefits are derived early (within one
year) and sustained on treatment for a fur-
ther year. People over 80 years should have
their blood pressure checked regularly, and
if they have sustained levels over 160 mmHg
these should be treated to a target of 150
mmHg.
5
Reasonable targets for the frail older
patient are fasting plasma glucose values
of 7.0–8.9 mmol/l, HbA
1c
levels of 7.5–
8.5% and blood pressure of < 150/< 90
mmHg – Dr Sophia Rauff
Contrast nephropathy
Dr Graham Cassel
There is an increase in demand for radio-
logical tests such as CT scans with contrast,