Objective: The aim was to formulate practice guidelines on the management of hyperglycemia in hospitalized patients in the non-critical care setting. Participants: The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee of The Endocrine Society, six additional experts, and a methodologist. Evidence: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. Consensus Process: One group meeting, several conference calls, and e-mail communications enabled consensus. Endocrine Society members, American Diabetes Association, American Heart Association, American Association of Diabetes Educators, European Society of Endocrinology, and the Society of Hospital Medicine reviewed and commented on preliminary drafts of this guideline. Conclusions: Hyperglycemia is a common, serious, and costly health care problem in hospitalized ...

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Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline

Background: Studies comparing the use of basal bolus with insulin analogs vs. split-mixed regimens with human insulins in hospitalized patients with type 2 diabetes are lacking.

Research Design and Methods: In a controlled multicenter trial, we randomized 130 nonsurgical patients with blood glucose (BG) between 140 and 400 mg/dl to receive detemir once daily and aspart before meals (n = 67) or neutral protamine Hagedorn (NPH) and regular insulin twice daily (n = 63). Insulin dose was started at 0.4 U/kg · d for BG between 140 and 200 mg/dl or 0.5 U/kg · d for BG 201-400 mg/dl. Major study outcomes included differences in mean daily BG levels and frequency of hypoglycemic events between treatment groups.

Results: Glycemic control improved similarly in both groups from a mean daily BG of 228 ± 54 and 223 ± 58 mg/dl (P = 0.61) to a mean daily BG level after the first day of 160 ± 38 and 158 ± 51 mg/dl in the detemir/aspart and NPH/regular insulin groups, respectively (P = 0.80). A BG target below 140 mg/dl before meals was achieved in 45% of patients in the detemir/aspart group and 48% in the NPH/regular group (P = 0.86). During treatment, 22 patients (32.8%) in the detemir/aspart group and 16 patients (25.4%) in the NPH/regular group had at least one episode of hypoglycemia (BG <60 mg/dl) during the hospital stay (P = 0.34).

Conclusions: Treatment with basal/bolus regimen with detemir once daily and aspart before meals results in equivalent glycemic control and no differences in the frequency of hypoglycemia compared to a split-mixed regimen of NPH and regular insulin in patients with type 2 diabetes.

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Comparison of inpatient insulin regimens with detemir plus aspart versus neutral protamine hagedorn plus regular in medical patients with type 2 diabetes.

Organic and inorganic antibacterial approaches in combating bacterial infection for biomedical application

Purpose Consensus recommendations to help ensure safe insulin use in hospitalized patients are presented.

Summary Insulin products are frequently involved in medication errors in hospitals, and insulin is classified as a high-alert medication when used in inpatient settings. In an initiative to promote safer insulin use, the American Society of Health-System Pharmacists (ASHP) Research and Education Foundation convened a 21-member panel representing the fields of pharmacy, medicine, and nursing and consumer advocacy groups for a three-stage consensus-building initiative. The panel’s consensus recommendations include the following: development of protocol-driven insulin order sets, elimination of the routine use of correction/sliding-scale insulin doses for management of hyperglycemia, restrictions on the types of insulin products stored in patient care areas, and policies to restrict the preparation of insulin bolus doses and i.v. infusions to the pharmacy department. In addition, the panelists recommended that hospitals better coordinate insulin use with meal intake and glucose testing, prospectively monitor the coordination of insulin delivery and rates of hypoglycemia and hyperglycemia, and provide standardized education and competency assessment for all hospital-based health care professionals responsible for insulin use.

Conclusion A 21-member expert panel convened by the ASHP Foundation identified 10 recommendations for enhancing insulin-use safety across the medication-use process in hospitals. Professional organizations, accrediting bodies, and consumer groups can play a critical role in the translation of these recommendations into practice. Rigorous research studies and program evaluations are needed to study the impact of implementation of these recommendations.

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Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel

Background Perioperative diabetic ketoacidosis (DKA) with near-normal blood glucose concentrations, termed euglycaemic ketoacidosis (EDKA), is an adverse effect associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i). Guidelines are still evolving concerning the perioperative management of patients on SGLT2i. We performed a systematic review of published reports of DKA from SGLT2i in the surgical setting to understand better the clinical presentation and characteristics of SGLT2i-associated DKA. Methods We searched PubMed, Embase, and ProQuest for reports of perioperative DKA involving SGLT2i up to January 2019. Results Forty-two reports of EDKA and five cases of hyperglycaemic diabetic ketoacidosis (HDKA) were identified from 33 publications. Canagliflozin was implicated in 26 cases. Presentation time varied from a few hours up to 6 weeks after operation. Precipitating factors may include diabetes medication changes, diet modifications, and intercurrent illnesses. There were 13 cases (12 EDKA and one HDKA) of bariatric surgery, 10 of them noted very-low-calorie diet regimes as a precipitating factor. No precise association between interruption of SGLT2i and the occurrence of DKA could be identified. Seven patients required mechanical ventilation, and acute kidney injury was noted in five. Five cases needed imaging to rule out anastomotic leak and pulmonary embolism, all of them revealed negative findings. Outcome data were available in 32 cases, all of them recovered completely. Conclusions EDKA is likely to be under-recognised because of its atypical presentation and may delay the diagnosis. Understanding this clinical entity, vigilance towards monitoring plasma/capillary ketones helps in early identification and assists in the management.

Perioperative diabetic ketoacidosis associated with sodium-glucose co-transporter-2 inhibitors: a systematic review

OBJECTIVE

To determine the incidence and manifestations of hypoglycemia in hospitalized patients receiving antihyperglycemic therapy.



RESEARCH DESIGN AND METHODS

The study was a 3-month prospective review of consecutive medical records of all adult, nonpregnant hospitalized patients at a 675-bed university hospital who experienced at least 1 blood glucose (BG) ≤ 60 mg/dL within 48 hours of receiving an antihyperglycemic agent.



MEASUREMENTS AND RESULTS

Of 2174 patients receiving antihyperglycemic agents, 206 (9.5%) experienced 484 hypoglycemic episodes. Of these episodes, 29% occurred in patients with type 1 diabetes, 23% in the ICU, and 72% in patients receiving only insulin for hyperglycemia. More than 1 episode was experienced by 44% of the 206 patients. Furthermore, 4% (20 of 484) of the hypoglycemic episodes were associated with a hypoglycemia-related adverse event, defined as symptoms, signs, or injury. The mean BG of these episodes was 43.0 mg/dL, significantly lower than the mean BG of 50.9 mg/dL for the 464 episodes without adverse events (P = .01). One-third of the adverse events occurred with a BG between 50 and 60 mg/dL; half the adverse events, 10 episodes or 2% of all hypoglycemic episodes, were serious, involving seizures or an unresponsive patient. A decrease in enteral intake accounted for 40% of the episodes; none was attributed to medication error. Less than half the hypoglycemic patients had documented euglycemia within 2 hours. Sulfonylurea agents were associated with higher rates of hypoglycemia than were other oral agents.



CONCLUSIONS

Hypoglycemia in hospitalized patients taking antihyperglycemic agents is common; 1 in 25 episodes is associated with an adverse event. Opportunities exist to improve care, particularly around discontinuation of feeding. Journal of Hospital Medicine 2007;2:234–240. © 2007 Society of Hospital Medicine.

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Hypoglycemia in hospitalized patients treated with antihyperglycemic agents.

Introduction: Kidney stones affect 1 in every 11 people in the United States each year. There is a significant high recurrence rate without a stone prevention protocol. Alkali citrate is beneficial in decreasing stone recurrence, but because of the cost and gastrointestinal side effects there is a low adherence rate. This study aims to serve as a review of some of the most commonly used alkalizing over-the-counter supplements that are advertised to prevent and treat kidney stones. Methods: Data were gathered by a comprehensive online literature search and company inquiries for kidney stone prevention supplements. An additional informal poll of the authors selected supplements that are most commonly taken by their patients. A total of eight supplements were evaluated for cost, alkali equivalent provided, dosing, and regulatory information. Results: Eight of the most commonly used supplements were reviewed with a focus on alkalizing agents. Information reviewed revealed dosing recommendations resulting in decreased citrate alkali equivalents per day compared with prescription-strength potassium citrate. Cost, peer-reviewed study results, and regulatory data were reviewed, tabulated, and analyzed. Cost per alkali equivalent was substantially decreased for each supplement compared with the prescribed drug. All supplements were found to be readily available online. Conclusion: Over-the-counter alkalizing agents are available to patients and may be an appropriate alternative to cost-prohibitive potassium citrate when treating urolithiasis patients. Additional testing will be necessary in the future to determine the efficacy of these supplements in the treatment and prevention of urinary stone disease.

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Alkalinizing Agents: A Review of Prescription, Over-the-Counter, and Medical Food Supplements.

Background: Euglycemic diabetic ketoacidosis (euDKA) is a potential side effect associated with inhibitors of the sodium–glucose cotransporter 2 (SGLT-2). This effect is most often recogni...

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Euglycemic Diabetic Ketoacidosis Due to Sodium-Glucose Cotransporter 2 Inhibitor Use in Two Patients Undergoing Pancreatectomy.

HPR152 Continuous Wound Infiltration: A Post-Surgical Pain Relief Solution That Reduces Opioid Use but Causes Pain in the Patient’s Wallet Due to Lack of Insurance Reimbursement

Vanessa Gleason

Papers

Hypoglycemia in hospitalized patients treated with antihyperglycemic agents.

Alkalinizing Agents: A Review of Prescription, Over-the-Counter, and Medical Food Supplements.

Euglycemic Diabetic Ketoacidosis Due to Sodium-Glucose Cotransporter 2 Inhibitor Use in Two Patients Undergoing Pancreatectomy.

HPR152 Continuous Wound Infiltration: A Post-Surgical Pain Relief Solution That Reduces Opioid Use but Causes Pain in the Patient’s Wallet Due to Lack of Insurance Reimbursement