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Update on inpatient diabetes management: call for action.

During the past two decades, there has been increasing interest in determining the impact of inpatient hyperglycemia on clinical outcomes and in conducting clinical trials to determine the best treatment regimens for the management of hyperglycemia and diabetes in hospitalized patients. The results of these studies have shown that hyperglycemia, in patients with and without diabetes, is associated with increased risk of hospital complications and mortality. We have also learned that avoidance of hyperglycemia (glucose level of >180–200 mg/dL) reduces the risk of hospital infections, length of stay, and mortality. In recent years, we have learned that hypoglycemia, as the result of intensive insulin therapy, is associated with increased risk of complications and mortality. Based on these results, clinical guidelines are recommending a glucose target between 140 and 180 mg/dL in the intensive care unit (ICU) and a glucose target of <140 mg/dL before meals and a random glucose level of <180 mg/dL in non-ICU settings. There are numerous areas of controversy and unanswered questions regarding inpatient management of hyperglycemia and diabetes to be addressed in future studies. We list a few interrogates in the area of stress hyperglycemia, hospital management of hyperglycemia and diabetes, and the use of continuous glucose monitoring (CGM) in the hospital setting. Stress hyperglycemia, defined as the development of high glucose values during an acute medical or surgical illness, is reported in 32–38% of community hospitals, 40–50% of cardiac patients with acute coronary syndromes and heart failure, and in up to 80% of ICU patients after cardiac surgery. Several studies have reported a higher in-hospital death rate and complications compared with patients with a known history of diabetes.1,3,4,23 Beside these important findings, there are many questions regarding stress hyperglycemia—what glucose level should be used to define hyperglycemia during acute illness, what is the pathogenesis and who is at risk of developing stress hyperglycemia, if the association between stress hyperglycemia and poor clinical outcomes is causal or merely an underlying paraphenomena of the severity of illness, and what is the best treatment regimen and glucose level that should be targeted in patients with stress hyperglycemia. Finally, what are the long-term ramifications in terms of future diabetes risk? The results from observational and randomized controlled trials indicate that correction of hyperglycemia, in patients with and without diabetes, is associated with reduced risk of hospital complications and mortality. In the 1990s clinical trials of insulin–glucose infusion in diabetes patients with acute myocardial infarction or after coronary artery bypass surgery reported that a blood glucose level reduction from approximately 250 mg/dL to approximately 170 mg/dL resulted in a significant reduction in mortality and hospital complications. With one exception, several recent clinical trials in critically ill patients have failed to demonstrate improvement in mortality with the use of intensive insulin treatment (target glucose level of <110 mg/dL). It is not known, however, if a target glucose level between 110 and 140 mg/dL may result in a lower rate of complications compared with the higher recommended target of 140– 180 mg/dL. This important clinical question needs to be answered in large randomized control trials. Furthermore, the appropriate target may differ among patient populations, such as surgical versus medical patients. In general medical and surgical patients, despite numerous observational studies reporting an increased rate of complications and mortality, only one randomized study has been conducted to determine if improved glucose control reduces the rate of infections and hospital complications in general surgery patients. Today no large studies have been conducted to determine if improved control in non-ICU patients may result in reduced morbidity and mortality in general medicine patients. In addition, clinical trials aiming to determine if a target glucose level of <140 mg/dL is better than a more conservative target of <180 mg/dL must be conducted. Current clinical guidelines recommend the use of intravenous insulin in most hospitalized critically ill patients and subcutaneous basal bolus insulin in most patients outside of the ICU. In general, it is advised that most non-insulin therapies be discontinued at hospital admission. However, this can encourage the ineffective use of sliding-scale monotherapy,