Richard Hellman

Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline

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 patients. Observational and randomized controlled studies indicate that improvement in glycemic control results in lower rates of hospital complications in general medicine and surgery patients. Implementing a standardized sc insulin order set promoting the use of scheduled basal and nutritional insulin therapy is a key intervention in the inpatient management of diabetes. We provide recommendations for practical, achievable, and safe glycemic targets and describe protocols, procedures, and system improvements required to facilitate the achievement of glycemic goals in patients with hyperglycemia and diabetes admitted in non-critical care settings.

American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control.

This report is being published concurrently in 2009 in Endocrine Practice and Diabetes Care by the American Association of Clinical Endocrinologists and the American Diabetes Association. From the 1Department of Medicine, University of California Los Angeles, Los Angeles, California, 2Department of Medicine, Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania, 3Division of Endocrinology and Metabolism, Veterans Affairs Pittsburgh Health Center and University of Pittsburgh School of Nursing PhD Program, Pittsburgh, Pennsylvania, 4Scripps Whittier Diabetes Institute, La Jolla, California, University of California San Diego School of Medicine, San Diego, California, and Diabetes and Endocrine Associates, La Jolla, California, 5Department of Medicine, University of Missouri-Kansas City School of Medicine and Hellman and Rosen Endocrine Associates, North Kansas City, Missouri, 6Department of Medicine, University of Washington School of Medicine, Seattle, Washington, 7Department of Medicine, Section of Endocrinology, Yale University School of Medicine and the Yale Diabetes Center, Yale-New Haven Hospital, New Haven, Connecticut, 8Department of Medicine, Physiology and Biophysics, Division of Clinical and Molecular Endocrinology, Case Western Reserve University, Cleveland, Ohio, 9Clinical Affairs, American Diabetes Association, Alexandria, Virginia, and 10Department of Medicine/Endocrinology, Emory University, Atlanta, Georgia. Address correspondence and reprint requests to Dr. Etie S. Moghissi, 4644 Lincoln Boulevard, Suite 409, Marina del Rey, CA 90292.

Comprehensive Foot Examination and Risk Assessment A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists

It is now 10 years since the last technical review on preventative foot care was published (1), which was followed by an American Diabetes Association (ADA) position statement on preventive foot care in diabetes (2). Many studies have been published proposing a range of tests that might usefully identify patients at risk of foot ulceration, creating confusion among practitioners as to which screening tests should be adopted in clinical practice. A task force was therefore assembled by the ADA to address and concisely summarize recent literature in this area and then recommend what should be included in the comprehensive foot exam for adult patients with diabetes. The committee was cochaired by the immediate past and current chairs of the ADA Foot Care Interest Group (A.J.M.B. and D.G.A.), with other panel members representing primary care, orthopedic and vascular surgery, physical therapy, podiatric medicine and surgery, and the American Association of Clinical Endocrinologists. The lifetime risk of a person with diabetes developing a foot ulcer may be as high as 25%, whereas the annual incidence of foot ulcers is ∼2% (3–7). Up to 50% of older patients with type 2 diabetes have one or more risk factors for foot ulceration (3,6). A number of component causes, most importantly peripheral neuropathy, interact to complete the causal pathway to foot ulceration (1,3–5). A list of the principal contributory factors that might result in foot ulcer development is provided in Table 1. View this table: Table 1— Risk factors for foot ulcers The most common triad of causes that interact and ultimately result in ulceration has been identified as neuropathy, deformity, and trauma (5). As identification of those patients at risk of foot problems is the first step in preventing such complications, this report will focus on key components of the …

Effect of Intensive Treatment of Diabetes on the Risk of Death or Renal Failure in NIDDM and IDDM

OBJECTIVE To examine the effectiveness and safety of long-term intensive therapy in NIDDM and IDDM. RESEARCH DESIGN AND METHODS In a private practice setting with a multi-disciplinary team, we compared the rates of total mortality, cardiac-specific mortality, and severe renal failure over 14 years in a cohort of 780 eligible patients, 209 patients with a longer duration of intensive therapy (median duration > 11 years, group I) and 571 patients with shorter duration of intensive therapy (median duration < 1 year, group II). A comorbidity index was used to assess the degree of prognostic risk at baseline. A comprehensive diabetes program was the therapeutic intervention. The endocrinologists and diabetes care team provided primary care, aggressive cardiovascular screening, and risk reduction. Intensive insulin therapy was used in 95.7% of group I IDDM and 66.0% of group I NIDDM patients. RESULTS The overall median HbA1c for group I was 7.3%. Compared with group II, the overall reduction in cumulative total mortality in group I was 22%. In the cohort with less severe initial comorbidity, the reduction in total mortality was 45%. We found similar reductions in renal failure rates in IDDM and in cardiac mortality in NIDDM patients on intensive insulin therapy. CONCLUSIONS This comprehensive diabetes program is associated with lowered mortality and morbidity in both IDDM and NIDDM. Intensive insulin therapy in long-term patients with NIDDM does not increase cardiac mortality. Intensive therapy is safe and effective in NIDDM within the context of a comprehensive program.

Inpatient Management of Diabetic Foot Disorders: A Clinical Guide

The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders, and optimize the transition from inpatient to outpatient care. Essential skills that are required for an inpatient team include the ability to stage a foot wound, assess for peripheral vascular disease, neuropathy, wound infection, and the need for debridement; appropriately culture a wound and select antibiotic therapy; provide, directly or indirectly, for optimal metabolic control; and implement effective discharge planning to prevent a recurrence. Diabetic foot ulcers may be present in patients who are admitted for nonfoot problems, and these ulcers should be evaluated by the diabetic foot team during the hospitalization. Pathways should be in place for urgent or emergent treatment of diabetic foot infections and neuropathic fractures/dislocations. Surgeons involved with these patients should have knowledge and interest in limb preservation techniques. Prevention of iatrogenic foot complications, such as pressure sores of the heel, should be a priority in patients with diabetes who are admitted for any reason: all hospitalized diabetic patients require a clinical foot exam on admission to identify risk factors such as loss of sensation or ischemia. Appropriate posthospitalization monitoring to reduce the risk of reulceration and infection should be available, which should include optimal glycemic control and correction of any fluid and electrolyte disturbances.

Glucose meter inaccuracy and the impact on the care of patients

Blood glucose testing utilizing point‐of‐care (POC) glucose meters has become increasingly common – in hospital settings, in outpatient areas, and in the self‐care of patients. It is rightly considered an essential tool for the management of diabetes. But many who rely on these meters are unaware of the pitfalls in their use and do not realize that there are settings where misleading results obtained by POC glucose meters may alter clinical decisions in the care of persons with diabetes and in some cases have caused catastrophic errors in care, even deaths. Their use in critical care settings is of great concern because many of the factors that increase the risk of inaccuracy of the POC glucose meters exist in critical care settings. Unfortunately, many clinicians are still uncritically accepting data from the POC glucose meters, to the potential detriment of the care of the patients.

Comprehensive foot examination and risk assessment

Ten years have elapsed since the last American Diabetes Association (ADA) technical review on preventive foot care was published (1), which was followed by an ADA position statement on preventive foot care in diabetes (2). Numerous published studies have proposed a range of tests that might usefully identify patients at risk for foot ulceration, creating confusion among practitioners about which screening tests should be adopted in clinical practice. Therefore, a task force was assembled by the ADA to review and provide a concise summary of the recent literature in this area and then recommend what factors should be included in the comprehensive foot examination for adult patients with diabetes. The committee was cochaired by the immediate past and current chairs of the ADA Foot Care Interest Group (A.J.M.B. and D.G.A.), with other panel members representing primary care, orthopedic and vascular surgery, physical therapy, podiatric medicine and surgery, and the American Association of Clinical Endocrinologists.