adsguidelinesforroutineglucosecontrolinhospitalfinal2012_000

8/12/2019 ADSGuidelinesforRoutineGlucoseControlinHospitalFinal2012_000

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AustralianDiabetesSociety

GuidelinesforRoutineGlucoseControlinHospital

2012


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Contents

Introduction Page3

Section1 MethodologyandProcess Page5

Section2 Whatglucosetargetshouldbeaimedforinacutemyocardialinfarction? Page6

Section3 Whatglucosetargetshouldbeaimedforinacutestroke? Page8

Section4 Whatareappropriateglucosetargetsforpatientsingeneralhospital

wards?

Page9

Section5 Whatspecialmeasuresneedtobeundertakenforpeopleonenteralor

parenteralnutrition?

Page11

Section6 Howissteroidinducedhyperglycaemiabestmanaged? Page13

Section7 Whatistheoptimalmeansofachievingandmaintainingglycaemic

controlinhospitalisedpatientswhoarenotcriticallyill??

Page15

Section8 Howshouldpatientsoninsulinpumptherapybemanagedinhospital? Page16

Section9 Whatisappropriateglucosecontrolinendoflifesituations? Page18

Section10 Atwhatlevelishyperglycaemiainhospitalpredictiveofdiabetesand

howshouldpatientswithnewlydiscoveredhyperglycaemiabefollowed

up?

Page20

Section11 Whatistheroleofaspecialistdiabetesinpatientteam? Page22

Section12 Whatroutinemeasuresshouldbeundertakenforpeoplewith

diabetesadmittedtohospital?

Page23

Appendices Page24

Contributors Page59

Glossary Page60

References Page61


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Introduction

Diabetesisestimatedtoaffect7.4%oftheAustralianpopulation1,andisincreasingannuallyby0.8%

2.People

withdiabeteshaveahigherutilisationofbothprimaryandtertiaryhealthservices.In200405,9%ofall

hospitaladmissionswererecordedashavingdiabetes3.Thisislikelytobeanunderestimateasclinicalaudits

fromAustraliaandoverseashavefoundhospitalratesofdiabetesof1125%49

andfurthermore,manycases

areundiagnosedatthetime10.Australiandataindicatethattheproportionofpeoplewithdiabetesasa

diagnosisinhospitalhasbeenincreasing,witha35%increaseinnumbersbetween200001and2004053.

Theyalsohavelongerlengthsofhospitalstay,beingabout2dayslongerthanpeoplewithoutdiabetes3,9

.The

AustralianInstituteofHealthandWelfarehasestimatedthecostofdiabetestohospitalservicesin200405

was$371M3.

Diabetesandhyperglycaemiahasbeenshowninanumberofobservationalstudiestobeassociatedwithpooreroutcomesandaremarkersofmorbidityandmortality.Reasonsfortheincreasedmorbidityand

mortalitymayberelatedtopoorimmuneresponse,delayedhealing,inflammationandthrombosisassociated

withhyperglycaemiaaswellasahigherrateofcomorbidconditionsinthispatientgroup11

.

Independentofdiabetes,hyperglycaemiaperseisalsoassociatedwithworsehospitaloutcomes.Thisisthe

casewhetherthepersonhasdiabetesornot,buttherelationshipisstrongerforpeoplewhodonothave

diabetes.Therelationshipbetweenhyperglycaemiaandadversehospitaloutcomes,inparticularmortality,

hasbeenclearlydemonstratedinmanydifferenthospitalsettings,includingmyocardialinfarction,stroke,

generalmedicalandsurgicalwards,trauma,cardiothoracicsurgery,TPN,intensivecare,andemergency

admissions.Forhyperglycaemicpeoplewhoarenotknowntohavediabetes,itisunclearifthehigher

mortalityisduetothehyperglycaemia,orifthehyperglycaemiaisbutamarkerofunderlyingcriticalillness.

Mostofthehighqualitystudiesdemonstratingbenefitoftightglycaemiccontrolhavecomefromcriticalcare

situations,andeventhesehaveproducedconflictingresults.

Forpatientswithhyperglycaemiathatisnewlydiscoveredinhospital,thereisahighprobabilityof

undiagnoseddiabetes,orfuturediabetes.However,atpresentfollowupisoftenhaphazard,andthe

opportunityforearlydiagnosisandtreatmentofdiabetesandtherebypreventionofacuteandlongterm

complicationsmaybemissed.

Theaimofthisdocumentistoprovideguidanceforthemanagementofhyperglycaemiainarangeofhospital

situations.TheADShasfocusedonthemanagementofhyperglycaemiainpatientswithmyocardialinfarction

andstroke,ongeneralhospitalwards,receivingenteralandparenteralnutrition,withsteroidinducedor

exacerbatedhyperglycaemia,andinendoflifesituations.Theoptimalmeansofachievingtightcontrol,the

roleofthespecialistinpatientdiabetesteam,inpatientmanagementofinsulinpumptherapy,andgeneral

measuresfordiabetesmanagementhavealsobeenexamined.Wealsoprovideguidanceforthefollowupof

patientswithnewlydiscoveredhyperglycaemia.Therecommendationswerebasedonevidenceobtained

fromsystematicreviewswheretrialshadbeenperformed;otherwisetheyweremadebyconsensus.


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Itisnottheintentionoftheseguidelinestodealwithscreeningfordiabetes,themanagementofdiabetic

emergenciessuchasdiabeticketoacidosis,hyperglycaemichyperosmolarstate,andhypoglycaemia,nordo

theycoverpaediatrics,obstetricsorintensivecare.Otherwisetheyshouldprovideguidanceforthe

managementofpatientswithhyperglycaemiainthemajorityofhospitalwards,andarecomplementarytothe

Australian

Diabetes

Society

Perioperative

Diabetes

Management

Guidelines.

Wesoughttoachieveconcordanceinourrecommendationtoasingletargetglucoselevelforthemajorityof

clinicalsituations,althoughtherearesomedifferencesinthelimiteddatafordifferentscenarios.Theoverall

recommendationisthatformosthospitalpatientswithhyperglycaemia,treatmentshouldbeinstitutedto

achieveandmaintainbloodglucose(BG)levelsbelow10mmol/L,butbecauseofthepotentialdangersof

hypoglycaemia,treatmentshouldnotaimtolowerglucoselevelsbelow5mmol/L.


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Section1: MethodologyandProcess

Systematicreviewswereconductedtoprovidethebestpossibleevidencebasefortherecommendations.

PICOsearchesoftheCochraneDatabaseforSystematicReviews,andPubmedClinicalQuerieswere

undertaken.Systematicreviews,metaanalysesandexistingguidelinesrelatingtoourquestionswere

reviewedbyamemberoftheWritingGroup,andsummarised(Appendix1).Keycitedarticleswerealso

reviewed.Wheresystematicreviewswerenotavailable,generalsearchesoftheliteraturewereundertaken.

TheevidencewasdiscussedinanADSworkshopcomprisinganexpertpanelofEndocrinologistsandDiabetes

Educators,heldinJuly2011.Atthisworkshop,recommendationsforeachsectionoftheguidelines,and

overallrecommendationswereagreedupon.Wheretherewaslittleornoevidence,thenthecommittee

reliedonexperience,judgmentandconsensustomaketheirrecommendations.Issuesarisingfromthe

discussion,forwhichthereisnoevidencebase,areincludedaspracticepoints.TheWritingGroupdraftedthis

document,whichwascirculatedforfurtherfeedbackfromtheparticipantsoftheWorkshop,andotherswhowereunabletoattend.


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Section2: WhatGlucoseTargetShouldbeAimedforinAcuteMyocardialInfarction?

HyperglycaemiaandCardiacMortality

Hyperglycaemiaiscommonwithmyocardialinfarction.Datafromnumerousobservationalstudiesshowa

clearandconsistentassociationbetweentheinitialadmissionglucoselevelandinfarctoutcomes,inparticular

mortality.AmetaanalysisbyCapesetal12showedthatamongstpatientswithoutdiabetes,thosewithan

admissionbloodglucoselevel(BGL)6.18.0mmol/Lhada3.9fold(95%CI2.95.4)higherriskofdeaththan

thosewithlowerBGL.Forpatientswithdiabetes,thosewithaBGL1011.0mmol/Lhada1.7fold(95%CI1.2

2.4)increasedriskofdeath.Themajorityofstudiesinthispublicationwereperformedintheprethrombolytic

era,butnewerpublicationsshowsimilarresults(Appendix2,Table2.1).Virtuallyallhaveshownadose

relationshipandaglucosethresholdforincreasedmortalityofaround68mmol/L.Inaddition,thereare

observationaldatademonstratingarelationshipbetweenglucoselevelsinthefirst24hoursaftermyocardial

infarctionandmortality(Appendix2,table2.2).Theseindicatethatpersistenthyperglycaemia,evenifmild,is

alsoassociatedwithincreasedmortalityfollowingmyocardialinfarction.

Hypoglycaemia

Moststudieshaveconcentratedontherelationshipbetweenhyperglycaemiaandincreasedmortality.There

arealsosomedatathathypoglycaemiaisassociatedwithadverseoutcomes,withaUshapedrelationship

beingdescribedinseveralobservationalstudies15,23,25

.Theincreasedriskwasseeninpatientswithadmission

BGLsrangingfrom


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achievealargeenoughdifferentialinglucoselevelsbetweenthearmsofthestudy,ii)glucoselevelsinthe

controlarmbeingonlyminimallyelevated,iii)theadventofmoderntreatmentsforAMI(PTCA,thrombolysis,

antiplatelettherapy,betablockade,statintherapy),overwhelminganybenefitofglucosecontrol53

.

Existing

guidelines

covering

glucose

control

in

myocardial

infarction

have

given

diverse

recommendations

(Appendix2,Table2.5)5457.Twoofthe4guidelinesdidnothavespecificrecommendationsformyocardial

infarction,butencompassedmyocardialinfarctionwithinbroaderguidelinesforhospitalglucosecontrol55,57.

TwooftheguidelinesrecommendedtargetBGs


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Section3: WhatGlucoseTargetShouldbeAimedforinAcuteStroke

HyperglycaemiaandStrokeMortality

Datafromnumerousobservationalstudiesshowanassociationbetweeninitialglucoselevelsandoutcomesof

stroke,inparticularmortality.AnothermetaanalysisbyCapesetalshowedthatamongstpatientswithout

diabetes,thosewithanadmissionBGL 6.18.0mmol/Lhada3.07fold(95%CI2.503.79)higherriskofdeath

thanthosewithlowerBGL58

.Therewasnoincreaseinriskamongstpatientswithdiabetesattheselevels(RR

1.3,95%CI0.493.43)increasedriskofdeath.Mortalityfromhaemorrhagicstrokemortalitywasnot

associatedwithadmissionhyperglycaemia.Morerecentpublicationsshowsimilarresults(Appendix3,Table

3.1).Observationaldataalsoindicatethatthereisarelationshipbetweenglucoselevelsduringthefirst24

hoursafterstrokeandmortalityorinfarctsize(Appendix3,Table3.2).

ClinicalTrialDataandExistingRecommendations

The3systematicreviewsexaminingstudiesoftightglucosecontrolinstrokecametodivergentconclusions

(Appendix3,Table3.3)36,75,76

.Althoughnoneofthestudiesrevieweddemonstratedabenefitofglucose

control,onereviewrecommendedinsulintherapyifglucoselevelsexceed10mmol/L75

.Therewere7

randomisedcontrolledtrialsoftightglycaemiccontrolforstroke.Onehadalargesamplesizebutwas

discontinuedearlyduetoslowrecruitmentandfailedtodemonstrateabenefitofglucosecontrol78

.Mostof

theothertrialsweremoreofapilotnature(Appendix3,Table3.4).AnadditionalrecentAustralianstudy

wheretherewasaglucosecontroltargetof48demonstrateda16%reductioninmortalitywiththe

interventionarm85

.Howeverglucosecontrolwasonlyoneof3factorsintheinterventionpackage(theothers

beingmanagementofswallowingandfever),anditisdifficulttodeterminethecontributionofglucosecontrol

totheoutcome.Thisstudyhadnotbeenincludedinanyoftheabovesystematicreviews.

Twosetsofstrokeguidelineswhichprovidedsomerecommendationsregardingglucosecontrolwere

identified(Appendix3,Table3.4).BothsuggestedaimingtokeepBGsbelowalevelaround10mmol/L,but

admitthattheevidenceforthisisweak.

Conclusions

Observationaldataindicateaclearassociationbetweenhyperglycaemiaandmortalityinacutethrombotic

stroke.Thereisalackofclinicaltrialevidenceregardingappropriateglucosetargetsinstroke,andthe

recommendationismadeonthebasisofextrapolationfromotherclinicalsituations,andconsensus.

RecommendationsandPracticePoints

1. Patientsadmittedtohospitalwithacutethromboticstrokewhohavehyperglycaemia,shouldbe

treatedtoachieveandmaintainglucoselevelslessthan10mmol/L.

2. Hypoglycaemiamustbeavoided,andthereforeitwouldbeprudenttoavoidtreatmentwhichlowers

theglucosebelow5mmol/L.


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Section4: WhatareAppropriateGlucoseTargetsforPatientsinGeneralHospitalWards?

HyperglycaemiaandComplicationsinGeneralHospitalWards

Anumberofobservationalstudieshavedemonstratedanassociationbetweenglucoselevelsandadverse

outcomesinpatientsingeneralhospitalwards.Thesehaveshownahigherriskofadverseoutcomesabovea

randomglucoselevelof812.2mmol/L(Appendix4,Table4.1).Theadverseoutcomesincludeinfection,

mortality,andlongerlengthofstay.Thereisalsoadoserelationshipbetweenglucoselevelsandmortality9193.

Therelationshipbetweenhyperglycaemiaandmortalityinthegeneralwardsismuchstrongeramongthose

withnewlydiscoveredhyperglycaemiathanamongthosewithknowndiabetes.

Systematic

Reviews

and

Existing

Guidelines

Threesystematicreviewshaveexaminedclinicaltrialsoftightglycaemiccontroloutsideoftheintensivecare

situation,andnotspecificallyfocusingonmyocardialinfarctionorstroke(Appendix4,Table4.2).Moststudies

includedinthesereviewswereintheperioperativecontext,orincludedsubjectswithmyocardialinfarction.

Thefindingshavebeenmixed,withonereviewfindingareductioninmortalitywithtightglycaemiccontrol

withcardiacsurgery94

,onefindingnobenefitinthenonICUorperioperativesettings36

,andathirdfindinga

reductionininfectionrateonly95.Thereisarecentstudyingeneralsurgicalpatientswhichfoundthattreating

toapremealglucosetargetof


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shouldnotaimtoreducetheglucoselevelsbelow5mmol/L,whichallowsforanaddedmarginofsafety.If

aimingfortightglycaemiccontrol,frequentglucosetestingisrequired.

Recommendationsand

Practice

Points

1. Mostpatientsingeneralhospitalwardswithhyperglycaemiashouldbetreatedtoachieveand

maintainglucoselevelslessthan10mmol/L.

2. Hypoglycaemiamustbeavoided.Itwouldbeprudenttoavoidtreatmentwhichlowerstheglucose

below5mmol/L.

3. Toachievetightglucosecontrolsafely,frequentglucosemonitoringisrecommended


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Section5: WhatSpecialMeasuresNeedtobeUndertakenforPeopleonEnteralor

ParenteralNutrition?

Hyperglycaemiaand

Enteral

and

Parenteral

Feeding

Hyperglycaemiaisacommonoccurrenceinpatientsreceivingnutritionalsupporteitherintheformofenteral

orparenteralnutrition.Thespecificeffectofhyperglycaemiaonclinicaloutcomesinpatientsreceiving

nutritionsupporthasonlybeenreportedbyoneobservationalstudy.Aretrospectivestudyof111patients

receivingtotalparenteralnutrition(TPN)foundthatincreasedbloodglucoselevelswereassociatedwithan

increasedriskofcardiaccomplications,infection,sepsis,acuterenalfailureanddeath91

.ThosereceivingTPN

withmeanglucoselevels>9.1mmol/lhada10foldgreaterriskofmortalitythanthosewithmeanglucose

levels6.9mmol/l.Thisassociationwasindependentofage,sexandpresenceofpreexistingdiabetes.This

addsfurtherweighttotheoverwhelmingevidenceofaclearrelationshipbetweenhighbloodglucoselevelsandadverseoutcomesincriticallyillorhospitalisedpatients,asreviewedintheearliersectionsofthis

guideline.

Amajorgoalinthemanagementofpatientswithdiabetesreceivingnutritionalsupportistheachievementof

goodglycaemiccontrol,avoidingbothhyperglycaemiaandhypoglycaemia,withtheirassociatedrisksoffluid

imbalanceanddehydration,ketoacidosisandhyperosmolarcoma,infectionandneurologicalevents.

However,howbesttoachievegoodglycaemiccontrolinthesepatientsremainsunclear.Acriticalfactorfor

considerationiswherethepatientwillbecaredfor:intheICUorgeneralward.Otherimportant

considerationsincludethemethodofnutritionaltherapy(enteralvsparenteral)andcompositionofthefeeds

particularlycarbohydrate/dextrosecontent.Ingeneral,diabeticenteralformulas(lowcarbohydratehigh

monounsaturatedfattyacidformulas)arepreferabletostandardhighcarbohydrateformulasinpatientswith

diabetes107

.ClosemonitoringofBGLsandreviewofdiabetesmanagementisessentialwhen

enteral/parenteralfeedsceaseandoralintakeresumes.

ClinicalTrials

Nostudiesinvestigatingtheeffectsoforalglucoseloweringagentsonbloodglucoselevelsandoutcomesin

patientsreceivingenteralorparenteralnutritionwereidentified.Thereare2studies,bothofpoorqualityand

athighriskofbias,whichhaveinvestigatedtheeffectsofdifferentinsulinregimensinpatientsreceiving

enteralnutrition(Appendix5,Table5.1),butnoneinthesituationofparenteralnutrition.Onecomparedthe

effectsofslidingscaleinsulintoslidingscaleinsulinandregularsubcutaneousglargineinsulin,showingno

differencesinbloodglucoselevels,adverseoutcomesorlengthofstay108

.However,asignificantproportionof

thepatientsintheslidingscalealonegroupalsoreceivedNPHinsulinduringfollowup.Thissuggeststhata

basalinsulinontopofacorrectionalinsulinregimen,hasaroleinachievingadequateglycaemiccontrolin

patientsreceivingenteralnutrition.Asecond(nonrandomized)pilotstudywitharetrospectivecontrolgroup

foundthatabasalbolusinsulinprotocolachievedlowermeanglucoselevelsthanavariabledosepreprandial


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insulinregime,attheexpenseofasmallincreaseinhypoglycaemia109.Thenurseledinsulinprotocolwas

implementedintheICUsettingwhichlimitsitsgeneralisability.

Conclusions

Onthebalanceofthelimitedevidence,insulintherapyislikelytobethemosteffectiveagentforimmediate

controlofbloodglucoselevelsinpatientsreceivingenteralandparenteralnutritionalsupport.The

recommendationsmadearebasedonexperienceandconsensus.


1. Individualisednutritionalplansshouldbeprovidedasinsulintherapywilldependonthenatureofthe

feedingcycle.

2. Slidingscaleinsulinshouldnotbeusedalonetooptimizeglucosecontrolinpatientsreceivingenteral

orparenteralnutrition.

3. Insulintherapyshouldincluderegularbasalinsulin(intermediateorlongactinginsulin)withprandial

andcorrectionalinsulinifrequired.

4. PerformBGtesting46hourly.WithbolusenteralorparenteralnutritionperformBGtestingbefore

eachbolusisgiven.

6. Patientswithunstablemetaboliccontrolorvariableparenteralfeedingmaybenefitfroman

intravenousinsulininfusiontherapy.

7. Closeliaisonwiththedietitianorteammanagingtheenteralorparenteralnutritioniscritical

particularlyifcalorieintakeischanging,asinsulindoseswillneedtobeadjusted.


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Section6: HowisSteroidInducedHyperglycaemiaBestManaged?

Prevalenceandriskfactors

Hyperglycaemia is common amongst inpatients who are receiving glucocorticoids (GC), with reported

incidencesof6471%110,111.Riskfactorsfordevelopmentofhyperglycaemiaamongstinpatientsincludeapre

existingdiagnosisofdiabetes110,112

,higherHbA1c113

, increasingage111

,steroiddose114

,and familyhistoryof

diabetes115,116.

ThereislittledataontemporalBGprofileofindividualsreceivingGC.Anopenprospectiveobservationaltrial

performed on acute hospital wards examined the interstitial glucose profiles of pts admitted with COPD

treated with at least prednisone 20mg/day as compared to pts with COPD, not known to have diabetes,

admittedforanother indicationwhodidnotreceiveGC117.Patients receivingGC inthemorninghadhigher

BGLsintheafternoonandevening,ascomparedtothosenotreceivingGCs(withthegreatestelevationseen

in those with known diabetes). A rise in fasting glucose is also seen when extremely high dose GC (e.g.

methylprednisone2501000mg/day)areadministered113

.Basedonambulatorydata,theeffectofGConBG

profile is rapid, with a change seen within 23 hours of administration of GC118,119

. This is also rapidly

reversible,inthatlowerglucoselevelsareseenonGCfreedaysinpatientswhoreceivealternatedayGC120.

ScreeningfordevelopmentofhyperglycaemiaandmonitoringinthosewithDM

Priortooruponthe initiationofGC, it isprudenttoexcludethepresenceofundiagnoseddiabetesthrough

measurement of serum glucose (see section 11). Screening for development of steroidinduced

hyperglycaemiabyafternoonfingerprickBGassessmentislikelytodetectthedevelopmentofmostcasesof

hyperglycaemia112

,and twicedailyGC inducedhyperglycaemia should stillbedetected.Relianceon fasting

glucoseisinadequate.Ifhyperglycaemiaisdetected,BGmonitoringshouldoccurasperthegeneraldiabetes

protocol.

Managementofglucocorticoidinducedhyperglycaemia

TherearenoprospectivetrialsontheuseofanyantidiabeticmedicationforthemanagementofGCrelated

hyperglycaemia.ThelimitedobservationaldataareoutlinedinAppendix6,Table6.2.Sulphonylureashavea

limited role in the treatment of steroidinduced hyperglycaemia in hospital. There are reports of

thiazolidinedioneuse in thesettingoforgan transplantation,but theseagentsarealsounsuitable formost

patients in hospital. The management of new onset diabetes after transplantation has been addressed in

otherguidelines140

andwillnotbefurtherdiscussedinthisdocument.

Althoughtherearenotrialsofitsuseinsteroidinducedhyperglycaemia,insulinisconsideredtobetheagent

of choice for the management of steroidinduced hyperglycaemia in hospital. Benefits provided by insulin

include greater dose flexibility, more rapid onset of action and titration and that there is usually no dose

ceiling as compared to other glucose lowering agents. Insulin dose requirements will always need to be

individualised,andrequirepreemptivetitrationastheGCdoseisadjusted,usuallyonadailybasis.Theinsulin


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regimen should predominantly target postprandial control, and with morning GC administration, the

afternoonhyperglycaemia.Theuseof isophane insulin formanagementof steroidinducedhyperglycaemia

hasbeenadvocated,withtheinitialdosedeterminedaccordingtoGCdoseandpatientweight124,139

.Isophane

typeinsulincanbesupplementedwithultraquickinsulinanaloguewithmeals139.Withtwice,thriceor4times

a

day

GC

regimens,

isophane

insulin

twice

daily

with

prandial

rapid

acting

analogue

can

be

initiated.

A

regime

thatcontrolledglycaemiaonpreviousoccasionscanbe reinitiated,e.g.whencyclicalGCsare required,as

longastherehasbeennomajorintervalchangeinweightorrenalfunction.Forthosewithpreexistinginsulin

requiringdiabetes,apreemptiveincreaseininsulinwillberequired,andfurtheradjustmentbasedonblood

glucoseresponse.


1. Inpatientsreceivingglucocorticoids,undiagnoseddiabetesshouldbeexcluded.Thosefreeofdiabetes

should be screened for the development of hyperglycaemia by random blood glucose monitoring

performedintheafternoonfollowingmorningadministrationofGC.

2. Hyperglycaemia isbestmanagedwith insulin:basal insulinas isophanetype insulin,andrapidacting

analoguewithmealsasrequired.

3. In individuals already on insulin the likely need for increased insulin should be recognised. Dose

requirementsneedtobeindividualisedandrequiredailyreview.


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Section7: WhatistheOptimalMeansofAchievingandMaintainingGlycaemicControlin

HospitalisedPatientswhoarenotCriticallyIll?

Thissectionexaminestheoptimalmethodsforachievingandmaintaininggoodroutineglycaemiccontrolinhospital.Itdoesnotdiscusstheuseofinsulininfusiontherapy,orperioperativemanagement.Forthelatter,

wereferthereadertotheAustralianDiabetesSocietyPerioperativeDiabetesManagementGuidelines141.

Thereisapaucityofdatainthenoncriticallyillpatientgroupastothebestmethodofmaintainingglycaemic

control.Thisgroupofpatientsdiffersgreatlyfromthosecriticallyillastheyareofteneating.Intensiveinsulin

therapyhasbeenshowntobebeneficialinacriticallyillpatientpopulation,buttherehavebeennostudies

evaluatingoutcomesingeneralmedicalwards.Themainadverseeventwithintensivesubcutaneousinsulin

therapyishypoglycaemiawhichcanbequitesevere.

Intensiveinsulintherapyrequiresfrequentmonitoringandshouldnotjustbereactivetochangesinglucose

loads,e.g.food.Itsapplicationrequiresaspecificskillsetforstafftomaintain.Traditionallyslidingscaleshave

beenusedtomaintainbloodglucoselevelsinnoncriticalhospitalizedpatients.Thismethodofinjectingaset

doseofinsulinatsettimesisoftenreactivetohighlevelsofbloodglucose.BGsoftenfluctuatefromhighto

low,whichcanpotentiallybedetrimental.Slidingscaleadministrationofinsulinisnotrecommended,and

Americanguidelinesrecommendthataninsulinregimenwithbasal,nutritionalandsupplemental(correction)

componentsbeutilizedforhospitalisedpatientswithdiabetesorstresshyperglycaemia142.

Therearefewstudiesthathaveexamineddifferentsubcutaneousinsulinregimensinnoncriticalhospitalised

patients(Appendix7).Moststudieshavemoderatetohighriskofbiasandoutcomemeasureshavebeen

inconsistentbetweenthedifferentstudies.Basalbolusregimenshavebeenshowntobesuperiortosliding

scaleregimensforglucosecontrol102,104

,andslidingscaleinsulinalonehasbeennomoreeffectivethan

continuationofthepatientsusualdiabetesmedication101

.Effectiveuseofbasalbolusinsulinrequires

frequentandregularbloodglucosemonitoring(atleast4andpreferably68timesdaily).Basedonclinical

expertise,currentpracticesandthelimitedliterature,thefollowingconsensusrecommendationsweremade.


1.

Slidingscaleinsulinshouldnotbeusedtooptimiseglucosecontrolintheinpatientgeneralmedicalor

surgicalsetting.

2. Oralhypoglycaemicagentsorpremixedinsulincanbeusedincertainstablehospitalisedpatientswho

areeatingregularly.Supplementalinsulinshouldbewrittenupinaddition.

3. Insulintherapyinhospitalisedpatientsshouldotherwiseconsistofabasalinsulin,prandialand

supplementalinsulin.


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Section8: HowShouldPatientsonInsulinPumpTherapybeManagedinHospital?

ContinuousSubcutaneousInsulinInfusionTherapyinHospital

Continuoussubcutaneousinsulininfusion(CSII)orinsulinpumptherapyisusedinthemanagementofgrowing

numbersofpatientswithType1diabetesinAustralia.Anecdotalreportssuggestthatpatientsestablishedon

CSIIusuallyprefertocontinueontheirpumpsduringhospitaladmissions.Hospitalhealthcareproviderswill

increasinglybefacedwiththeissueofhowtomanagesuchinpatients.Anumberofpublicationshavedetailed

guidelinesregarding inpatientmanagementofpatientspreviouslyestablishedonCSII144147.Whilstthereare

no data from randomised trials available, observational reports indicate that patients admitted to hospital

continued on CSII who are managed with bestpractice consensus protocols fare at least as well as those

changedovertosubcutaneousinsulininjectionsandmanagedbytheendocrinologyteam.Thedataregarding

hypoglycaemiaisconflictingwithonestudyindicatingalowerincidenceinthoseinpatientscontinuedonCSII

whichwasnotconfirmedwithasubsequentstudy148,149

.Acaveat isthatthesereportshavestemmedfrom

tertiary academic medical centres in the United States and their applicability to a spectrum of hospitals

(includingcommunityhospitals)inAustraliaisyettobedetermined.Therecommendationsbelowarebased

uponaconsensusopinion.

ManagementofCSIIinHospital

General recommendations forCSII therapy inhospitalareoutlined inAppendix8,Table8.1. Inappropriate

circumstances,CSIImaybethepreferredmethodof insulindelivery.However,deviceoperatingmenusand

programs

vary

not

only

according

to

the

manufacturer

but

also

from

model

to

model.

It

is

highly

unlikely

that

nonspecialised medical and nursing staff will be familiar with the operation of all available devices. We

thereforerecommendthatCSIItherapyisbecontinuedinhospitalonlyinthosesituationswherethepatient

(or guardian) has the ability to safely selfmanage their insulin dosing and the pump. The competency

requirementsareoutlinedinAppendix8,Table8.2.IfthesecriteriaarenotmetCSIImustbesubstitutedwith

eitherasubcutaneousinsulinregimenoranintravenousinsulininfusion.ContraindicationstoCSIItherapyare

listedinAppendix8,Table8.3.AllaspectsofCSIImanagementshouldbedocumented(Appendix8,Table8.4)

anditisrecommendedthattheEndocrineteambeinvolved.

CSIIandSurgery

Surgery itself is not an absolute contraindication to continuation of CSII. If CSII is to be continued intra

operatively this decision must be made in conjunction with the anaesthetist, surgeon/proceduralist, and

endocrinologyteamwiththedocumentedconsentofthepatientortheirguardian.CSIIandan intravenous

insulininfusionshouldnotbeusedsimultaneouslyforanyextendedperiod150

.Thesituationsappropriatefor

intraoperativeCSIIorforitssubstitutionwithanintravenousinsulininfusionareoutlinedinAppendix8,Table

8.5. When CSII is being used intraoperatively, it is important for there is a protocol for its management

(Appendix8,Table8.6.).Appropriateoverlapandtiming is importantwhenswitchingapatientfromCSIIto

insulininfusionormultiplesubcutaneousinsulininjections,andviceversa(Table8.6.).


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1. Ingeneral,CSIIshouldbecontinuedinhospitalwherethepatientcancompetentlyandsafelyself

managethepumpandselfdosing.

2. Detailsofpumptherapyshouldbedocumented,andsupportedbytheendocrineteam

3. CSIImaybecontinuedforshortoperativeproceduresifthoseresponsibleforthepatients

intraoperativecarearecomfortablewithitsuse.


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Section9: WhatisAppropriateGlucoseControlinEndofLifeSituations?

DiabetesandEndofLife

Forpatientswithdiabetesandadvanceddisease limitingtheir lifeexpectancy there isnobodyofevidence

availableregardingtheimpactoftightglycaemiccontrolonoutcomes.Lifelimitingdiseaseincludes,butisnot

limited to, cancer and includes any disease process such as advanced dementia, end stage cardiac and

respiratory failure,which is incurableandsignificantlyshortens thepatients lifeexpectancy.Asthepatient

with diabetes approaches the end of their life the guidelines regarding glucose monitoring and glycaemic

targets detailed earlier in this document may no longer be appropriate with a potential for discomfort,

inconvenience and significant morbidity relating to hypoglycaemia. Tight glycaemic control is questionable

benefit and the avoidance of longterm complications is no longer relevant. Conversely it is important to

maintaina levelofglycaemia topreventhyperglycaemiaassociated thirst,dehydration,polyuriaassociated

urinaryfrequency,alteredconsciousstateandsymptomatichypoglycaemia.Treatmentregimensneedtobe

individualisedaccordingtothepatientscircumstances.

Palliativecareisdefinedasmedicalorcomfortcarethatreducestheseverityofadiseaseorslowsitsprogress

rather than providing a cure. Currow et al151

have described 4 phases in the end of life pathway: Stable,

unstable, deteriorating, and terminal (see Appendix 9, Table 9.1 for details). Palliative patients may be

admitted to hospital for management of an acute illness, either intercurrent or related to their primary

underlyingdisorderor for terminalcare.There isanabsenceof level Idata though thereareanumberof

valuableconsensusbasedguidelinesaddressingtheglobalmanagementofpalliativepatientswithdiabetes151

153.Thefollowingrepresentsaconsensusofopinionintheabsenceofasuitableevidencebase,andisinpart

basedonthe2010GuidelinesforManagingDiabetesattheEndofLife152

.Thisconsensusdocumentfocuses

on the inpatient management of hyperglycaemia in those patients with diabetes deemed as requiring

palliative care. As management should be individualised to each patients needs this document provides

general principles for the inpatient management of palliative care patients with diabetes and detailed

protocolscannotbeprovided.

GlucoseManagementinEndofLifeSituations

Glucosemanagementduring inpatientadmissionswilldependonthetypeofdiabetesandthephaseofthe

endoflifepathway(seeAppendix9,Table9.2fordetails).Ingeneral, intheearlierstagesofendoflife,the

persons usual diabetes medication would be continued, with adjustments based on the many situational

factorswhichwouldaffectglycaemicstability(Appendix9,Table9.3).Thedecisiontosimplifyandrationalise

treatment regimes and targets would need to be made on an individual basis. As the person progresses

throughthephasesofendof life,theemphasisshiftstowardsmaintenanceofcomfort,withcorresponding

reductionsinmedicationandglucosetesting,andsomeliberalisationoffoodrestriction.Thisdoesnotimplya

nihilisticapproachinthemetabolicmanagementofpalliativepatients.Avoidanceofmarkedhyperglycaemiais

still

relevant,

particularly

in

hospital,

to

avoid

symptoms

of

hyperglycaemia,

and

improve

wound

healing

and


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19

resistance to infection.Hypoglycaemiamustalsobeavoided.With type1diabetes,ketoacidosis is likely to

precipitatedeath,soitshouldbepreventeduntiladecisionismadetowithdrawalltreatmentintheterminal

phase. Therefore until then, some glucose testing and insulin administration may remain necessary. It is

reasonabletocontinueoninsulinpumptherapyinthosepatientsestablishedonthesedevices.

Theviewsof thepatientand their familyneed tobedetermined.Theymay requireadviceandcounseling

regardingthemanagementofthepatientsglucoselevelsasmanyyearsmayhavebeenspentwhereglucose

levelshavebeendiligentlymaintainedinatargetrange.Therealisationthatlongtermsurvivalisnolongera

viable proposition and that maintenance of tight glycaemic control is of dubious value and could even

adverselyimpactqualityoflifecanbeconfronting.Ultimatelythedecisionofthepatientandtheirfamilywill

takeprecedence.Thestatusofthepatientmaybeevolvingcontinuouslyrequiringtheongoingreassessment

ofglycaemicmanagementstrategiesbythemedicalteam.


1. Palliative care patients may still benefit from a level of glucose control in hospital so diabetes

treatmentremainsrelevant.

2. Thelevelofinterventionwouldgenerallybelessintensivethanforotherhospitalpatients,andneeds

tobeindividualised,dependingonthephaseofendoflife,andothersituationalfactors.


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Section10: AtWhat Level isHyperglycaemia inHospital PredictiveofDiabetes andHow

ShouldPatientswithNewlyDiscoveredHyperglycaemiabeFollowedup?

StressHyperglycaemia

Patientswithaknownhistoryofdiabetescommonlyhavehyperglycaemiainhospital,butpatientswithouta

historyofdiabetesmayalsobefoundtohaveelevatedbloodglucoselevels.Hyperglycaemiainpatientsnot

knowntohavediabetesmaybesecondarytostressortoundiagnoseddiabetes.Itisoftendifficultto

distinguishthecauseofhyperglycaemiainashorthospitalstay.

Stresshyperglycaemiamostcommonlyoccursinpatientswithacuteorcriticalillnessandismorelikelyto

occurinamorecriticallyillpatient.Hyperglycaemiaispostulatedtobemediatedthroughcytokines,the

sympatheticnervoussystemandthehypothalamicpituitaryadrenalaxis155.Itisnotclearwhetherpatients

whomanifeststresshyperglycaemiahaveanunderlyingimpairmentintheirglucosemetabolism,butinthe

longterm,inpatienthyperglycaemiamayheraldundiagnoseddiabetesorthedevelopmentofdiabetesinthe

future.Theprevalenceofundiagnoseddiabetesvariesindifferentinpatientsettingsandcanbeupto60%

(Appendix10,table10.1).Itisimportanttodiagnosepatientswithdiabetesearlytoensureappropriate

management,bothlifestyleandmedicationtopreventthedevelopmentoflongtermcomplications.

Thereislimitedliteraturetoguidethelevelofhyperglycaemiapredictiveofdiabetesortosuggestan

appropriatealgorithmfordetectionofdiabetesintheacutehospitalsetting.TheAmericanAssociationof

ClinicalEndocrinologists/AmericanDiabetesAssociationconsensusrecommendationsdefinesaBSL

>7.8mmol/LasinpatienthyperglycaemiaandsuggestanHbA1cmayassistindiagnosisofdiabetes.HbA1c

>6.5%(48mmol/mol)isstronglysuggestiveofunderlyingdiabetes55,160

.However,thereisconsiderableheterogeneityamongststudieslookingatpredictorsofdiabetesininpatientpopulations(Appendix10,table

10.1).Differentglucosevalueshavebeenusedtodefinehyperglycaemia.HbA1clevelsusedtodefinea

diagnosisofdiabetesandthepopulationsstudiedhavealsobeenquitevariable.WhilstHbA1chasnotbeen

ratifiedforthegeneraldiagnosisofdiabetesinAustralia,thereisnodoubtthatforapatientwith

hyperglycaemia,itisastrongindicatorofunderlyingdiabetes.

Whilstinhospital,patientswithnewlydiagnoseddiabetesshouldbereferredtotheSpecialistDiabetes

InpatientTeam(section12)ortheEndocrineTeamformanagement.Irrespectiveofwhetherdiabetesis

definitivelydiagnosedinhospital,patientswithinpatienthyperglycaemiashouldreceivefollowuptoensure

thatthediagnosisisclarified,andappropriatecounselingandmanagementinstituted.Notificationofthe

generalpractitionerisvitaltothisprocess.

Asuggestedalgorithmfortheapproachforthediagnosisandfollowupofaninpatientwithnewlydiscovered

hyperglycaemiaisgiveninAppendix11,Figure11.1.


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21


1. Allinpatientswithnewlydiscoveredhyperglycaemia(randomplasmaglucose>7.8mmol/L)should

haveanHbA1cperformed.

2. Allinpatientswhoarenewlydiagnosedwithdiabetesshouldbemanagedappropriatelyfordiabetes.If

thereisdiabetesexpertiseavailable,anearlyreferralshouldbemade.

3. Allpatientswithabnormalglucosemetabolismdetectedinhospitalshouldhaveadequatefollowup

arranged,andthefindingsshouldbecommunicatedtotheusualcarepractitioner.


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Section11: WhatistheRoleofaSpecialistInpatientDiabetesTeam?

Improvingglycaemiccontrolhasbeenshowntoreducetheriskofadverseoutcomesassociatedwith

hyperglycaemia,buttheevidencefortheseclinicalbenefitshavebeenobtainedinandlimitedtospecific

individual

clinical

units.

Translating

these

improved

outcomes

to

a

whole

hospital

is

more

challenging

and

requiresadifferentapproach.Ratherthanfocusingonimprovedclinicaloutcomes,oronspecificblood

glucosetargets,hospitalwideapproacheshavefocusedonreducingthedifferenceinlengthofstayforpeople

withdiabetesbyimprovingoveralldiabetesmanagement.Thedriversforthisapproacharenotsomuchan

improvementinqualityofcareorclinicaloutcomes,butratherreductionsinassociatedcostsandimproved

bedutilisation.Thefactorscontributingtoincreasedlengthofstayandpooreroutcomesassociatedwith

diabetesthatarepotentiallymodifiableincludebloodglucosecontrol,inappropriatediabetesmanagement

anddelayedinvolvementofspecialistdiabetesservices.

Differentapproachestothisproblemhavebeenutilised,withvaryinglevelsofevidencetosupportthe

intervention.Thesevaryfromthetraditionalconsultativeservice,tosystematichospitalwidediabetes

programmes,tothenewerconceptoftheSpecialistDiabetesInpatientManagementTeam(Appendix11,

table11.1).Therehasnowbeenonerandomisedcontrolledtrial164

andanumberofcomparativestudies

whichhavedemonstratedimprovedoutcomeswiththelatterapproach(Appendix11,Table11.2).

TheseteamsusuallycomprisededicatedDiabetesInpatientSpecialistNurses(DISN),usuallyledbya

consultantindiabetes.Theroleofsuchteamshasincludedimprovingdiabetesmanagementexpertise

throughoutthehospital,thedevelopmentandimplementationofdiabetesmanagementprotocols,direct

managementofdiabeteswithspecificreferralcriteria,wardliaison,troubleshooting,managementadvice,and

discharge

planning

(Appendix

11,

Table

11.3).

DISNs

are

currently

involved

in

30

50%

of

UK

hospitals

171

,

with

DiabetesUKrecommendingaratioofoneDiabetesDISNforevery300beds172

.TheNHS(UK)hasadoptedthis

approachtoimprovediabetesinpatientmanagementthroughthewholehealthsystem,resultingin

reductionsinadverseoutcomesandlengthofhospitalstay9.InAustralia,theintroductionofSpecialist

DiabetesInpatientManagementTeamswillrequireadditionalresources,butthelongtermeconomic

argumentiscompelling.Theliteraturesuggeststhathospitalswhichhaveintroducedtheseteamshave

realisedshorterlengthsofstayandsignificantcostsavings165,166,167,170.Healthadministratorsneedtoinvestin

suchteamswhichshouldresultinbetterinpatientdiabetescare,shorterlengthsofhospitalstay,andcost

savingstothehealthsystem.Forwardplanningisalsoneededforthetrainingofthespecialisedworkforce

required

for

Diabetes

Inpatient

Management

Teams.

Recommendation

1. HospitalsshouldconsidertheintroductionofSpecialistDiabetesInpatientManagementTeams


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Section12: What Routine Measures Should be Undertaken for People with Diabetes

AdmittedtoHospital?

Effectiveinpatientdiabetesmanagementshouldbeprovidedearlyandcontinuouslythroughoutthehospital

admission.Tosupportoptimalglycaemiccontrolinhospitalanddiabetesmanagementafterdischarge,itis

importanttohaveestablishedroutineprocessesandprotocolsforthecareofpeoplewithdiabetesinhospital.

Theserecommendationsaregenerallybasedongoodgeneralhospitalpractice,experience,andcommon

sense.Generalrecommendationsinclude:clearidentificationofdiabetesinthemedicalrecord,bloodglucose

monitoring,ahypoglycaemiamanagementprotocol,HbA1ctesting,amultidisciplinaryteamapproach,

dieteticassessment,diabetesselfmanagementeducationwhenappropriate,anddischargeplanning142

.

Insulinisacommonsourceofmedicationerror171,172,andmustbeminimisedbymechanismssuchasstaff

education,pharmacistoversight,anddedicatedinsulinprescriptioncharts173

.

BloodGlucose

Monitoring

Wheretightglycaemiccontrolisdesired,andparticularlyforpatientsoninsulin,itisimportantforblood

glucosemonitoringtooccurbeforeandaftermeals.Thisiscriticaltofacilitateappropriateadjustmentstothe

patientsinsulindosage,andmonitorforhypoglycaemia.Additionaltestingatbedtimeandovernightisoften

alsohelpful.Forstablepatients,orthosewheretightglucosecontrolisnotanaim,testingcanbereduced

accordingly.

DischargePlanningandDiabetesEducation

Whilstthisdocumentfocusesonthemanagementinhospital,itisimportanttotaketheopportunitytoimprovethepostdischargemanagementofdiabetesaswell.Liaisonwiththegeneralpractitionerisan

importantcomponentofthis.Notonlymightthisimprovepatientoutcomes,butitmayreducetheneedfor

readmissiontohospital.Thevariousteammembersparticipatingininpatientmanagementalsohavearolein

promotingandfacilitatingbetterdiabetescarepostdischarge(Appendix12,Table12.1).Appropriatediabetes

educationisacriticalcomponentofinpatientpatientcareanddischargeplanning.Afocusonthecontinuityof

carewherethepatientisthecentralmemberinthemanagementofdiabetesisimportant,andtheirfamily

membersmayneedtobebroughtintothediscussion.


1. Ensureclearprocessesandprotocolsareimplementedinthehospitalforroutinediabetescare.

2. Ensuredischargeplanningwhichfacilitatesoptimallongtermdiabetesmanagement.


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25

Appendix2:LiteraturereviewedforWhatGlucoseTargetShouldbeAimedforinAcuteMyocardialInfarctio

Table2.1.Recentstudiesexaminingtherelationshipbetweenadmissionglucoselevelsandmortalityfollowing

Study Subjects Characteristics Elevatedadmission

glucosepredictive

ofmortality?

Thresholdlevel

foreffect?

Comments

Wong200413 158 STEMI Yes 8mmol/L Similarrelationshipforbothinp

monthmortalityRelationshipbetweenBGandd

withandwithoutreperfusionth

Stranders

200414

846 AnyAMI Yes 11.1mmol/Lfor

nondiabetics

Above11.1mmol/L,nondiabet

sameriskasthosewithdiabete

Timmer

200415

356 STEMIwith

PTCAor

reperfusion

Yes 7.8mmol/L Alsoassociationwithlargerinfa

reducedLVfunction

Kosiborod

200516

141680 Age>65 Yes 6.1mmol/Lfor

nondiabetes

13.3

mmol/L

for

diabetes

Similarresultsfor30dayandon

mortality

Straumann

200517

978 AllhadPTCA Yes 7.8mmol/L Similarresultsfor30dayandlo

mortality

Meier200518 227 AllAMI Yes 7.4mmol/Lfor

nondiabetics,

7.9mmol/Lfor

diabetes

Survival>3.5yearswasassesse

Goyal200619 1469 Subanalysisof

CARDINAL

Trial

Yes(onlyfornon

diabetics)

Lowermortalityamongstnond

wheretherewasagreaterdrop

24hrs

Bhadriraju

200620

9020

Subanalysis

of

OPUSTIMI

trial

Yes

5.6

mmol/L

Relationship

stronger

for

non

dResultsalsovalidatedinsubana

TACTICSTIMItrial

Naber200921 5866 Nondiabetic

STEMI(ACOS

Registry)

Yes 8.3mmol/L Inpatientand1yearmortality

Sinnaeve 13526 Globalregistry Yes 6.9mmol/L RandomBGLassociatedwithin


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26

200922 (random)

5.6mmol/L

(fasting)

mortalityonly,fastingBGLasso

bothinpatientand6monthmo

Ishihara

200923

3750 Within48hrs

ofAMI

Yes 7mmol/L Ushapedcurveforpatientswit

increasedmortalityifBGL


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27

Table2.2.Observationaldataofarelationshipbetweenaverageglucoselevelsorglucoselevelsachievedinthe

infarctionandmortality.

Study Subjects Characteristics Glucose

parameter

Elevated

glucose

predictiveof

mortality?

Threshold

levelfor

effect?

Comments

Cheung

200628,

200829

240 Myocardial

infarct with

known diabetes

oradmissionBG

7.8mmol/L

12hourly

capillaryBGs

Yes 8mmol/L

Kosiborod

200830

7820 AllAMI Meanglucose

measurements

Yes 6.1mmol/L Mortalityloweri

treatedpatients


28/70


29/70

29

Trial Subjects EntryCriteria InsulinRegimen Glucose

Target

Primary

Outcome

Secondary

Findings

Comm

DIGAMI,

Malmberg

199531

,

199751

620 Myocardialinfarct

andadmissionBG

>11.0mmol/L.

Variablerate

glucoseinsulin

solutionforat

least24hrs.

710

mmol/L

Reducedone

yearmortalityin

insulininfusion

group(18.6%vs

26.1%,

p=0.027).

Greatestbenefit

topatientswith

lowpremorbid

cardiovascular

riskprofile.

Amon

gluco

than

124.

receiv

after

contrGIPS,van

derHorst

200348

940 Within24hrsofST

segmentelevation

infarct(allhad

PTCA).

20%glucose

potassium

solutionat

3mls/kg/hrwith

insulinat

variablerate.

711

mmol/L.

Nosignificant

reductionin30

daymortality

(4.8%vs5.8%).

Medi

GIKg

(NS).

DIGAMI2,

Malmberg

200544


andeitherknown

type2diabetesor

admissionBG>11.0

mmol/L.

Variablerate

glucoseinsulin

solutionforat

least24hrs.

710

mmol/L

Noreductionin

mortalitywith

insulininfusion.

BGat

group

conve

(9.1

mmo

HI5,

Cheung

200628


withknown

diabetesor

admissionBG7.8

mmol/L.

Variablerate

insulinwith5%

dextrose80

mls/hr.

410

mmol/L

Noreductionin

mortalitywith

insulininfusion.

Mortalityhigher

insubjectswith

mean24hour

bloodglucose

level>8.0

mmol/L.

Mean

group

conve

(8.3

Othertrialsof insulinglucosetherapywheretherewerenoglucosetargetswereexcludedfromconsiderati

CREATEECLA(2005)47

,GIPSII(2006)52

Table2.5.Guidelinesregardingglucosecontrolinmyocardialinfarction

Guideline Population Recommendation

ESCandEASDguidelinesondiabetes,

prediabetesandcardiovasculardisease,

Peoplewith

diabetesandAMIThereisreasonableevidencetoinitiateglucoseco

infusionindiabeticpatientswhoareadmittedfor


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30

200754 bloodglucoselevelsinordertoreachnormoglyca

IIa,LevelB)

AACE/ADAconsensusstatementon

inpatientglycemiccontrol,200955

Allhospitalized

patients

Insulininfusionshouldbeusedtocontrolhyperglycaem

patientsintheICUsetting,withastartingthresholdof

7.810mmol/L,andgreaterbenefitmayberealizeda

Formajorityofnoncriticallyillpatients,premeal


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31

Appendix3:LiteraturereviewedforWhatGlucoseTargetShouldbeAimedforinAcuteStroke?

Table3.1.Recentstudiesexaminingtherelationshipbetweenadmissionglucoselevelandstrokeoutcomes.

Study Subjects Characteristics Relationbetween

admissionglucose

andmortality?

Relationbetween

admissionglucoseand

otheroutcome?

Thresholdlevelfor

effect?

Baird200359 25 Ischaemicstroke N/A Yes,infarctsize,NIHSS

andmRS

7mmol/L

Allport200460 31 Acuteischaemic

stroke

N/A Yes,insularcortical

ischaemia

N/A

AlvarezSabin

200461

138 MCAterritory

treatedwithtPA

N/A YeswithNIHSSandmRS N/A

Farrokhnia

200562

447 Acutestroke Yes(onlyfornon

diabetic)

N/A Diabetes:10.3

mmol/L,non

diabetics:6.3

mmol/L

Stollberger

200563

992 Allacutestroke Yes N/A 9.2mmol/Lfor

nondiabeticsGentile2006

64 960 Ischaemicstroke Yes N/A 7.2mmol/L

Yong200865 748 ReceivedtPAfor

acutehemispheric

stroke

Yes Yes,withBI,mRS,7day

neurological

improvement

7.8mmol/L

Fuentes200966 476 Acuteischaemic

stroke

Yes YeswithmRS 8.6mmol/L

Stead200967 447 Acuteischaemic

stroke

Yes Yeswithstrokeseverity

andfunctional

impairment

7.2mmol/L

Poppe200968 1098 Acuteischaemic

stroketreatedwithtPA

Yes Yes,withsymptomatic

intracerebralhaemorrhage andmRS

N/A

Ntaios201069 1446 Ischaemicstroke N/A Yes,withNIHSSand

mRS

7.2

mmol/L

Ahmed201070 16049 Ischaemicstroke

treatedwith

thrombolysis

Yes Yes,withNIHSSand

mRS

6.7mmol/L


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32

Dziedzic201071 302 Ischaemicstroke Yes N/A N/A

Saposnik201172 8223 Acuteischaemic

strokeinregistry

Yes N/A 7.5mmol/L

Kimura201173 97 ReceivedtPA

within3hoursof

strokeonset

N/A Infarctvolumelarger

andworsemRS

7.2mmol/L

Hu201274 774 Acutestroke Notreported Yes,withNIHSS,BIand

mRS

Diabetes:8.9

mmol/L,non

diabetics:6.8mmol/L

NIHSS=NationalInstitutesofHealthStrokeScale,BI=BarthelIndex,mRS=modifiedRankinScore


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33

Table3.2.Studiesexaminingtherelationshipbetweenmeanglucoselevelsandstrokeoutcomes:

Study Subjects Characteristics Glucose

parameter

Elevatedglucose

predictiveof

mortality?

Relationbetween

admissionglucoseand

otheroutcome?

Thresh

Baird

200359

25 Ischaemicstroke Meancapillary

andmeanCGMS

N/A Yes,infarctsize,NIHSS

andmRS

7mmo

Farrokhnia,

200562

447 Acutestroke Meancapillary Yes N/A 10.3m

fornon

Yong

200865

748 ReceivedtPAfor

acutehemispheric

stroke

Glucoseat24hrs Yes Yes,BI.mRS,7day

neurologicalrecovery.

7.8mm

Fuentes

200966

476 Ischaemicstroke Maximum

capillaryglucose

Yes Yes,mRS 8.6mm

NIHSS=NationalInstitutesofHealthStrokeScale,BI=BarthelIndex,mRS=modifiedRankinScore


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Table3.3.Systematicreviewsofrandomizedcontrolledtrialsoftightglucosecontrolinstroke,wheretheprima

ofdisability.

Review SearchMethod SelectionQuestion Studies Subjects Result/Conclusion

Kansagara

201136

MEDLINE,Cochrane

Databaseof

SystematicReviews,

ClinicalTrials.gov

RCTsusinginsulinto

achievestrictglycaemic

control.Subanalysis:

strokeandacutebrain

injury

Walters200677

,Gray

200778

,Azevedo

2007

79

,

Bruno

2008

80

,

Yang200981

NonICUsetting: 9st

reductioninshortter

mortality(RR1.0,95%

1.07)

Strokeandacutebrai

Noreductioninmort

Kruyt

201075

Notstated Studiesinvestigatingthe

feasibilityandefficacy

oftightglycaemic

controlinpatientswith

ischaemicstroke

Walters200677,Gray

200778,Bruno2008

80

BG>10mmol/Lshou

insulinadministration

Bellolio

201176

CochraneStroke

GroupTrials

Register,CENTRAL,

MEDLINE,EMBASE,

CINAHL,Science

CitationIndex,Web

ofScience,Scopus

RCTscomparing

intensivelymonitoredinsulintherapyversus

usualcareinadultpatients

withacuteischaemic

stroke.

Vinychuk200582,

Walters200677,Gray

200778,Staszewski

2007*,Bruno200880,

Kreisel200983,

Johnston200984

1296 Nodifferenceindeat

disabilityanddepend1.00,95%CI0.78to1

finalneurologicaldefi

0.12,95%CI 0.23to

Bold=studiesofstrokeonly,*Unpublished

Table3.4.Randomisedcontrolledtrialsofstrokewithaspecificglucosetarget.


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35

Trial Subjects EntryCriteria Insulin

Regimen

Glucose

Target

Glucose

Achieved

Primary

Outcome

Secondary

Findings

Comme

Vinychuk

200582

128 Within24

hoursof

ischaemic

strokeonset,

admissionBG

716mmol/L

Glucose

potassiu

minsulin

infusion


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36

Middleton

201185

1126 Within48

hoursof

acutestroke

Variable

rate

insulin

infusionif

BG>=11

mmol/Lif

diabetes,

>=16for

nondiabetics,

upto72

hours

48

mmol/L

orlocal

guidelin

esonce

insulin

infusion

comme

nced

7.0vs6.8

mmol/L,

p=0.02

(Notesmall

difference

only)

Differencein

mortalityor

dependency

42%vs58%

(p=0.002)

Nodifference

inBarthel

index,but

higherSF36

PhysicalHealth

Scorein

intervention

Interve

package

fever,a

manage

possible

contrib

control

Table3.4.Guidelinesregardingglucosecontrolinstroke

Guideline Population

Recommendation

AHA/ASAguidelinesfortheearly

managementofadultswith

ischemicstroke,200786

Ischaemicstroke Serumglucoseconcentrations(possibly>7.8to10.3m

shouldtriggeradministrationofinsulin(ClassIIa,Leve

EuropeanStrokeGuidelines,200887 Ischaemicstroke Treatmentofserumglucoselevels>10mol/Lwithin

recommended(ClassIVevidence).

Severehypoglycaemia[


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37

Appendix4:LiteratureReviewedforQuestionWhatareAppropriateGlucoseTargetsforPatientsinGenera

Table4.1.Observationalstudiesexaminingtherelationshipbetweenhyperglycaemiaandoutcomesinhospital

intensivecare,myocardialinfarctionandstroke.

Study Subjects Finding Comment

Pomposelli

1999Study8897

patients

undergoing

generalsurgerySingle

BGL

>12.2

mmol/L

predictive

of

nosocomial

infection

Golden

199989

411CABGpatients MeancapillaryBGL 11.5mmol/L associatedwith

increasedinfection

Umpierrez,

200290

2030admissionstoa

communityteaching

hospital

2xFastingBGL7.0mmol/LorrBGL 11.1mmol/L

associatedwithincreasedmortality,needforICUand

longerLOS

Riskhigherfo

diabetes

Cheung

200591

122subjectsonTPN MeanBGL7.9mmol/L associatedwithincreasedinfection

MeanBGL9.1mmol/L associatedwithincreasedmortality

Baker200892 903patientsingeneral

medicalward

AdmissionBGL5.6mmol/Lassociatedwithincreased

mortality

Noassociatio

mortalityam

diabetes.HbA

mortalityinn

Cheung,

200893

6187admissionstoa

teachinghospital

AdmissionBGL>8.0mmol/Lpredictiveofmortalityand

longerLOS

Riskhigherfo

diabetes

Table4.2.Systematicreviewsofstudiesexaminingtrialsoftightglycaemiccontroloutsideoftheintensivecare

focusingonmyocardialinfarctionorstroke


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38

Review SelectionQuestion Studies Total

subjects

Result/Conclusion

Haga

201194

Effectsoftightversus

normalglycaemiccontrol,peri

andpostoperatively,inpatients

undergoingcardiacsurgery.

3studies:Groban200242,Lazar

200496,Ingels200697

686 48%reductioninmortali

0.52,95%CI0.3 0.91,p

Maybesomebenefittot

glycaemiccontrolduring

cardiacsurgery.

Kansagara

201136

RCTsusinginsulintoachieve

strictglycaemiccontrol.

Subanalysis:NonICUstudies

Subanalysis:Perioperative

9nonICUstudies:Malmberg

199531,VanderHorst200341,

Butterworth2005,Li2006,

Cheung200628,Oksanen2007

50,

Azevedo200779,Yang200981,

5perioperativestudies:Smith

200243,Lazar200439,Butterworth

200598,Li200699,Barcellos2007100

NonICU:

2677

NonICUsetting: noredu

shorttermmortality(RR

95%CI0.941.07).

Perioperative:noreducti

shorttermmortality.

Murad

201295

Observationalorrandomized

studiesthatcomparedthe

effectofintensiveglycaemic

controltoacontrolgroupseekinglessaggressive

normalization

ofglycaemiclevels.Intensive

caresettingexcluded.

19studies:RCTsMalmberg

199531,Dickerson2003101,vander

Horst200348,Malmberg200531,

Cheung200628,Walters200677,Umpierrez2007102,Umpierrez

2009103,Umpierrez2011104

Variedfor

different

analyses

Noassociationbetween

glucosecontrolandrisko

myocardialinfarctionors

Associationwithreducedinfection(RR0.41,95%CI

0.77).Trendtoincreased

hypoglycaemia.


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Table4.3.Existingguidelinesforglucosetargetsinnoncriticallyillpatientsinhospital.

Guideline Population Recommendation

AACE/ADA,200955 Allhospitalized

patients

Insulininfusionshouldbeusedtocontrolhyperglycaemiainthema

patientsintheICUsetting,withastartingthresholdofnohighertha

10mmol/L,andgreaterbenefitmayberealizedatthelowerendof

Formajorityofnoncriticallyillpatients,premeal


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Appendix6:LiteraturereviewedfortheQuestionHowissteroidinducedhyperglycaemiabestmanaged?

Table6.1.Incidenceofsteroidinducedhyperglycaemia.

Author StudyDesign Steroid Incidenceofsteroidinduced

hyperglycaemia

Riskfactorsforsteroid

hyperglycaemia

Fajans1954115 steroidgiven

priortoaGTT

CRHorcortisone N/A Firstdegreerelativew

diabetes

Gurwitz1994114

Casecontrolstudy

Anyoralglucocorticoids N/A Steroiddose(oddsratifrom1.77for39mg/da

hydrocortisoneequiva

to10.34for120mg/da

FeldmanBillard

2005113

Retrospective

audit

Pulse

methylprednisolone

64%hadatleastoneBG14

mmol/L

HigherHbA1c

Donihi2006110 Retrospective

audit

Atleastprednisone40

mg/dayorequivalent

for2days

Overall64%hadatleastone

BG11.1mmol/L.

56%amongstnondiabetics.

Preexistingdiabetes

Fong2011111

Prospective

audit

Atleastprednisone25

mg/dayfor2days

71%hadatleastoneBG

10mmol/L

Age

Burt,2011112

Prospectivestudy

Atleastprednisone20mg/dayfor2days

53%hadatleastone BG10mmol/L

Preexistingdiabetes


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settingofrenaltransplantation,preventsthedevelopmentof

subsequentnewonsetdiabetes135.

Inresponsetoprednisone60mg/dayaseriesof10patientswith

T1DMmanagedwithsubcutaneousinsulinpumprequiredan

increaseofbetween30100%136.

and prior control. Preemptive inc

requiredasGCdoseisadjusted.This

Generallythe insulinregimenoradju

should predominantly target postp

GCadministration,theafternoonhy

the use of isophane insulin

hyperglycaemia124,theinitialdosede

patientweight (e.g.prednisone10m

isophane insulin;prednisone40mgdtitratedaccordingtoresponse.Fora

be added to the existing regimen. T

continueupondischargethanmore

tobesuccessfulifpatientshaveaco

consumptionfromdaytoday138.Isop

with ultraquick insulin analogue w

insulin is likely to be required in pa

>50mg prednisone/day) where prior

hadbeen initiatedwithout preemp

GC are given as split dose. With

isophane insulintwicedailywithpra

initiated.Aregimethatcontrolledgl

bereinitiatedwhencyclicalGCsare

nomajorintervalchangeinweightor


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managementof

generalmedical

patientswithtype2

diabetes.

characteristicssame.

Unrestrictededucational

eventfromSanofiAventis

p


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46

Appendix8:HowShouldPatientsonInsulinPumpTherapybeManagedinHospital?

Table8.1.Generalrecommendationsfordiabeticpatientswhocontinuecontinuoussubcutaneousinsulininfus

CSIItherapyistobecontinuedinhospitalonlyinthosesituationswherethepatientortheirguardianhavethe

dosingandthepump(buttonpushingandsetchanges)safely.

CSIIshouldneversubstituteforanintravenousinsulininfusiontotreatpatientswithdiabeticketoacidosis.

Inametabolicallystablepatient,whoisabletoeat,CSIImaybemoreappropriatethananintravenousinsulinin

regimen. RegardlessastowhetherCSIIistobecontinuedorceasedduringthepatientshospitalizationitisstronglyrecom

consultation(ifavailable) isobtainedforallpatientsatthetimeofadmission.Theendocrinologistusuallyresp

shouldbenotifiedatthetimeofadmission.

Thepatientwillberesponsible(inconsultationwiththeendocrineteam)forsettingbasalrates,determiningbo

ortocorrectelevatedglucoselevelsandforsetchanges.

ComprehensivedocumentationallaspectsofCSIImanagementisrequired.

CSIItherapymustbesubstitutedwitheitherasubcutaneousinsulinregimenoranintravenousinsulininfusionif:

1/Thepatientorguardianisnotabletodemonstratethattheyareabletosafelyandreliablymanagetheinsulinp

2/Asevereacuteillnessispresent.

3/AprocedureorinvestigationisplannedpotentiallyrenderingCSIItherapyineffectiveortheanaestheticstaffar

regardingthemanagementofthepump.4/Thereareconcernsregardingamalfunctioninthepump.

Shouldtherebeconcernsregardingthetechnicalfunctioningofthepumpmanufacturershelplineshouldbecon

CSII therapy should never bediscontinued without firstensuring theprovision of insulin via an alternative r

injection)

ThepatientsadmissiontohospitalshouldbeusedasanopportunitytoreviewallaspectsofCSIImanagementby


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Table8.2.MinimumpatientcompetencyrequirementsforcontinuedinpatientCSIItherapy.

Abilitytooperatethemanagementmenuofthedevicetoalterbasalrates.

Ability to operate the management menu of the device to modify parameters of and operate the bolus ca

proficiencyincarbohydratecounting)

Abilitytoperformasetchangeandmanagelineocclusionsorleaksandhaverelevantsuppliestoimplementase

Table8.3.ContraindicationstocontinuedinpatientCSIItherapy.

Patientisunabletodemonstrateabasiclevelofcompetencyintheoperationoftheirinsulinpump.

Impairedorfluctuatingconsciousstate.

Majorpsychiatricdisorder(psychosis)

Severeacuteillness(includingdiabeticketoacidosis)requiringaninsulininfusion

Lackofsupplies(infusionsets,batteriesandotherequipmentrequiredtocontinuethepatientonCSIItherapy)

Extensiveskininfectionsorinflammation.

Concernsregardingtechnicalmalfunctionofthepump. Numerous radiological procedures (CT and MRI). The pump should be suspended and disconnected prior to

scanner.

Patientundergoinglengthyorcomplicatedsurgery,orseriousmedicalillnesslikelytobeaccompaniedbysignific


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Table8.4.HospitaldocumentationrecommendedforinpatientscontinuingCSII.

ThemodelofthepumpanddurationofCSII.

Datecurrentpumppurchased.

Detailsofinsulindeliveryline.

Thenameoftheinsulininfusedwithanindicationthatitisbeingdeliveredviaapump.

Insulindeliveryparametersincludingbasalrates,insulintocarbohydrateratios,correctionfactors,durationofin

Anychangestothepumpinsulindeliverysettingsshouldbeclearlydocumentedatthetimetheyareimplemen

thatthesechangeshavebeenclearlyconveyedtoandconfirmedbythepatientortheirguardian.

Thedateandtimeofsetchanges.Afollowupfingerprickglucoseshouldbeperformed2hrslateranddocument

Fingerprickglucosereadings.Atleast4(premealandbedtime)andpreferably7(premeal,2hourpostmeal

readingsarerecommended.Theseshouldbedocumentedontheglucosemonitoringchart.

Ketonereadings.Bloodketonesarepreferabletourinaryketonemeasurements.

A signed agreement with the patient that clearly documents the patients responsibilities with regard

recommended.

Table8.5.IntraoperativeconditionsappropriateforCSIIorswitchtotemporaryinsulininfusion

SituationsappropriateforintraoperativeCSII Indicationsforintraoperativeintraven

Procedureofshortduration(e.g.D&C).

Medicalandanaestheticstaffthatarefamiliarwithpumps.

Patientawakeandalertintraoperatively.

Patientmetabolicallystable.

Patient alert and to resume eating shortly after completion of the

procedure.

Prolonged and complicated

surgery).

Medicalandanaestheticstaffu

Patientcriticallyunwellandme

Prolongedpostoperativereco


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the insulinregimene.g.singlebasal insulin injectionwithtopups

ofshortactinginsulinanaloguetomaintaincomfort.Lessfrequent

BGmonitoring(12perday)andketonechecksarerecommended.

AimforBGsbetween5.015.0mmol/L.Removefoodrestrictions.

Review the need for any nondiabetes medications exacerbating

hyperglycaemia or hypoglycaemia. If patient is to be discharged

homefromhospital,considermodifyinginsulinregimenaimingfor

simplicityandminimisationof the risk forhypoglycaemia.Ensure

followupandsupportofthepatientpostdischarge.

currentinsulinregimenshouldbe

frequentBGmonitoring(12perd

mmol/L.Removefoodrestrictions

diabetes medicationsexacerbatin

hypoglycaemia.Ensurefollowup

discharge.

Terminal Thepatientspreferencesorthoseoftheircarertakeprecedence.

Theprimaryobjectiveistomaintainpatientcomfort.Asingledaily

injection of basal insulin administration may be required to

maintain comfort by addressing severe hyperglycaemia and to

preventfrankketoacidosis.Considerminimising/ceasingallglucose

and ketonemonitoring after the appropriatediscussionwith the

patientortheircarer.

Theprimaryobjectiveistomainta

glucosemonitoring.Considerceas

hypoglycaemicagents.Ifseverehy

symptomaticfromhyperglycaemi

injectionofbasalinsulin.

Table9.3.Factorspotentiallyinfluencingmanagementofglycaemia.

Anorexiaandweightloss.

Confusionandalteredconsciousstate.

Thestressresponsetopain,anxiety,infectionandunrelatedintercurrentillness.

Disturbanceinglucosemetabolismresultingfromsomemalignanttumours.

Useofcorticosteroidsandotherdiabetogenicmedications.

Metabolicderangementincludingrenalandhepaticdysfunction.


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Appendix10:HowShouldPatientswithNewlyDiscoveredHyperglycaemiabeFollowedUp?

Table10.1.IncidenceofnewlydiagnoseddiabetesatvariousglucoseandHbA1cscreeningthresholds

Study Aim Glucose

thresholdand

diabetes

prevalence

Subjects

above

Threshold

Quality Levelof

evidence

Riskof

Bias

Measuresofaccura

HbA1c

Krebs2000156

Prevalencestudy.

Retrospect

ivetrial.

22%prevalenceofundiagnosed

diabetesat

randomplasma

glucose7.8

mmol/l.

88

Subjects

not

described

Nodeclarationofconflictof

interest.

Inclusion/

exclusioncriteria

unclear.

IV Moderate

Atplasmaglucoseo7.8mmol/LandHb

6.0%.

Sensitivity47%.

Specificityunableto

calculatefromthed

Greci

2003157

Studyof

diagnostic

yield.

60%prevalence

ofundiagnosed

diabetesat

randomplasma

glucose6.9

mmol/l.

35

Subjects

were

described

Nodeclarationof

conflictof

interest.

Smallnumberof

patients.

Inclusion

/

exclusioncriteria

detailed.

IV High Sensitivityandspec

atrandomBG6.9

mmol/landHbA1c>

were57%and100%

respectively.

Sensitivity

and

specatrandomBG6.9

mmol/landHbA1c5

were100%and50%

respectively.

PPVat>6%100%,N


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53

mmol/l. detailed.

Wong

2010155

Prevalence

substudyof

RCToftight

glucose

controlfor

myocardial

infarction.

8%prevalence

ofundiagnosed

diabetesat

randomplasma

glucose7.8

mmol/l.

55

Subjects

were

described

Declarationthat

therewereno

conflictsof

interest.

Inclusion/

exclusioncriteria

detailedpreviously.

IV Mode

rate

HbA1cnotreported

Valentine

2011160

Studyof

diagnostic

yield,but

also

prevalence

study.

11%prevalence

ofundiagnosed

diabetesat

randomplasma

glucose5.5

mmol/l.

2672

Subjects

were

described

Declarationof

conflictof

interestfrom

authors.

Noinclusion/

exclusioncriteria

IV Mode

rate

Nomeasuresofacc

De

Mulder

2011161

Study

of

diagnostic

yield,but

also

prevalence

study.

25%

prevalence

ofundiagnosed

diabetesat

randomplasma

glucose7.8

mmol/l.

109

Subjects

were

described

Declaration

that

therewereno

conflictsof

interest.

Inclusion/

exclusioncriteria

detailed.

IV

Mode

rate At

random

BG

of

7.8mmol/LandHb

6.5%.

Sensitivity29%,spe

100%,PPV100%,N

71%

Figure11.1.Suggestedapproachtodiagnosisofdiabetesandfollowupofinpatientwithnewlydiscoveredhyp


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54

Elevatedrandomblood

glucose>7.8mmol/L

DetermineHbA1c

6.5%*

(48mmol/mol)


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56

2001165 analysisofdiabetic

admissionspreand

postintervention

specialistnurse amongstmedicalpatientsand8to5days(p


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57

Appendix12:WhatRoutineMeasuresShouldbeUndertakenforPeoplewithDiabetesAdmittedtoHospital?

Table12.1:Roleofvariousteammembersinensuringoptimalroutinediabetescareinhospitalandafterdischa

Teammember Roleinhospitalmanagement Roleindischargeplanning

Diabetes

Educator

Ensureappropriatebloodglucosetesting

andqualitycontrolofglucosetestingkits,

supporttowardnursingstaff.

Provideclinicalleadershipandcontinuing

stablecareinanenvironmentoftransitional

androtatingmedical,nursingandallied

healthworkforce.

Reportbacktothediabetesteamifinput

shouldbeofferedtothereferringunit.

Assessandconsolidateknowledgeandskillsregardin

selfmonitoring,medicationusage,insulinadjustmen

care.

Qualifiedprofessionalsare"ADEACredentialledDiab

theservicesofadiabeteseducatorareusefulinthee

liaisoncanbeestablished.

Dietitian Ensureappropriatedietinhospitaland

nutritionalneedsaremet.

LiaisewithDiabetesTeamregardingchanges

indietparticularlyinthesituationofenteral

andparenteralnutrition.

Assessreadinesstochangeeatingbehaviour,anddie

innovativeandspecifictotherequirementsoftheind

Providedieteticinterventionrecommendationstha

daycarbohydrateintake,substitutionofsucrosecon

intake,cardioprotectivenutritioninterventions,weig

regularphysicalactivity

Pharmacist Medicinesreview Homemedicinesreviewondischargeforpatientswit

Podiatrist Podiatricadviceandinitialmanagementof

highriskfoot

Organisefollowupmanagementofhighriskfoot.No

CareitemavailableforGPreferrals.

AboriginalHealth

Worker

Providingculturallyappropriateandpracticalsupport

care,thusimprovingpatientunderstandingandadhe

SocialWorker Liaisonwithfamilyandsocialservices Withoutensuringotheraspectsofthepatientandhis

for,gooddiabetesmanagementmaybechallengingt


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GLOSSARYOFTERMSUSEDRELATINGTOINSULIN

Slidingscaleinsulin Theprescriptionofinsulingiveninavariabledosedependingon

the

glucose

level

at

the

time.

Often

this

is

the

sole

insulin

prescribed.

Supplementalinsulin Theadministrationofvariabledoseinsulintocorrect

hyperglycaemia,giveninconjunctionwithappropriateadjustments

tothepatientsscheduledantidiabetictherapy.

Correctionalinsulin Thistermisusedinterchangeablywithsupplementalinsulin

Basalinsulin Intermediateorlongactinginsulinprovidingbackgroundinsulin(eg

Protaphane,HumulinNPH,Lantus,Levemir)

Prandialinsulin Rapidactinginsulingivenatmealtimes(egNovorapid,

Humalog,Apidra)

Basalbolusinsulin Insulinregimecomprisingthecombinationofabasalinsulinwith

multipledailydosesofprandialinsulin

Ispohaneinsulin Intermediateactinginsulin(egProtaphane,HumulinNPH)

Continuoussubcutaneousinsulin

infusion(CSII)

Insulinadministeredbycontinuoussubcutaneousinfusionviaan

patientselfmanagedinsulinpump


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