Glucose Targets Are the Least of Your Worries

Glucose Targets Are the Least of Your Worries

Gregory A. Maynard, FACP,  University of California, San Diego

As evidenced by the standing room only crowd in a Friday morning session, everyone in hospital medicine is excited about inpatient glucose control right now.

The recent NICE-SUGAR trial has experts caught up in debate—should glucose targets for hospitalized patients be 110 mg/dL or something higher, such as 140? It’s an important and unresolved question but one that distracts from the many other problems with current inpatient glucose management, said presenter Gregory A. Maynard, FACP.

One major challenge facing hospitalists is the process of transitioning recovering patients off infusion insulin. “It’s a very common transition that is almost always botched,” Dr. Maynard said. One key, he explained, is to administer subcutaneous insulin before the drip is stopped.

A smooth transition is most important for patients with diabetes, because those who have been receiving insulin only due to stress hyperglycemia are more likely to stay under control when taken off the infusion. Specifically, the transition protocol developed by Dr. Maynard and his colleagues at University of California, San Diego, calls for sub-cu insulin for Type 1 diabetics and Type 2s who have been receiving at least one unit of insulin per hour.

Dr. Maynard also offered his algorithm for calculating the patient’s sub-cu insulin requirements. Take the infusion rate and multiply by 20 to get the total daily dose. But if the patient hasn’t been getting nutrition while on the infusion, you’ll need to double that dose. Also, give about half of the daily dose of basal glargine (his therapy of choice) before stopping the infusion. And keep in mind that the patient’s insulin requirements will go down as they recover.

“This methodology is conservative because we want to avoid hypoglycemia. This is a very safe protocol,” he said.
The avoidance of hypoglycemia is an area in which most hospitals could improve a lot, Dr. Maynard said. He noted a recent study, published in the Journal of Hospital Medicine, which found that only a third of patients who had documented hypoglycemia had their blood sugar rechecked within an hour.

“I couldn’t believe this. I thought this must be the worst medical center in the world,” said Dr. Maynard. Then he studied his own hospital and found equally bad statistics. His research also looked at why these hypoglycemic episodes occur, and found that many are due to a nutrition/insulin mismatch.

“You think they’re going to eat and they don’t,” said Dr. Maynard. It could be a change in nutritional orders, but more often it’s new nausea or anorexia that causes the patients to unexpectedly go without food and become hypoglycemic. This problem requires attention from both physicians and nurses, Dr. Maynard said.

Close attention should also be paid to patients who have already had a hypoglycemic episode during the current admission. Dr. Maynard found that more than half of the patients who had hypoglycemia during his study had an episode earlier in their stay.

So, before hospitalists devote all of their attention to debating glucose targets and revising protocols, it’s worthwhile to check out what’s actually going on with glucose management in their hospitals, Dr. Maynard said. “Anywhere you look, you’re going to find problems to fix,” he concluded.

(And if you still really must know, he favors aiming to keep glucose under 140 and thinks 110 is unrealistic.)

Reported from:The American College of Physicians Internal Medicine 2009 Conference