Inpatient care and diabetes: putting poor glycaemic control to bed

Abstract

A hospital stay for a patient with diabetes involves many factors that challenge good glycaemic control. Acute illness or surgery, change in diet and activity levels, use of new medication, and loss of patient autonomy can make patients vulnerable to hyperglycaemia and hypoglycaemia, both of which have been associated with longer hospital stays and adverse outcomes. The proportion of inpatients with diabetes is now higher than ever—17% in the UK and more than 20% in the USA—yet many hospitals lack specialised teams that are the key to providing these patients with optimum and cost-effective care. Hospitals generally have a means of identifying, treating, and monitoring patients with diabetes, but procedures vary widely within and between countries. According to US guidelines, non-critically ill inpatients with diabetes should be treated with a basal–bolus insulin regimen including basal insulin plus nutritional and correctional insulin according to food intake, irrespective of the patient's usual treatment. In the UK and Europe, the approach is typically more individualised, with more frequent use of oral antidiabetic drugs and less frequent use of basal insulin. Despite these variations, both overtreatment and undertreatment are common problems, and glycaemic control for inpatients with diabetes is often far from optimal. According to the 2015 National Diabetes Audit in England and Wales, 22% of inpatients with diabetes had one or more hypoglycaemic episode in the previous 7 days, with 10% having had severe hypoglycaemia. More than a third of patients had at least one medication error in the previous 7 days, and such errors were more common in those who had severe hypoglycaemia. 31% of hospitals in England and Wales do not have specialist inpatient diabetes nurses, and 9% have no consultant time for diabetes inpatient care. Although nationwide data are not available for other countries, the picture is similar in many hospitals worldwide, and is probably much worse in low-income and middle-income countries. Encouragingly, however, there is evidence that care is improving for inpatients with diabetes, at least in the UK. Among other improvements, the National Diabetes Audit suggests that patient referrals and contacts have increased, and medication errors and episodes of severe hypoglycaemia have decreased, since 2010 in England and Wales. In December, 2016, NHS England announced that £8 million would be made available for new or expanded diabetes inpatient specialist nursing services. On Feb 24, 2017, a Diabetes Inpatient Care Bill will be given its second reading in the UK Parliament, which if approved could trigger further improvements to funding and care. Additional resources to support specialised diabetes teams and training of hospital staff, especially in high risk wards, are crucial for improving care, but more evidence about the best interventions for glycaemic control in different types of inpatients is vital. In this issue of The Lancet Diabetes & Endocrinology, Francisco Pasquel and colleagues report the results of the Sita-Hospital trial, which show that basal insulin plus the oral dipeptidyl peptidase-4 inhibitor sitagliptin was non-inferior to a basal–bolus insulin regimen for glycaemic control in inpatients with type 2 diabetes admitted to general medicine and surgery services. There was no difference between groups in the proportion of patients with treatment failure, hypoglycaemia, or complications, but insulin dose and number of injections were reduced in the sitagliptin–basal group, suggesting that this regimen could reduce demands on staff. More trials such as this are warranted in different subgroups of inpatients to guide safer and more individualised approaches to glycaemic control and, in turn, improve patient outcomes. Addressing the needs of inpatients with diabetes should not stop at the end of the hospital stay, but should ideally involve any necessary adjustments to usual treatment at discharge and a coordinated follow-up with primary care. Unfortunately, evidence from the USA suggests that a high proportion of patients admitted to hospital with poor glycaemic control receive no change in therapy or short-term follow-up appointments with primary care. Inpatients with diabetes typically have more severe disease than average. A hospital stay is an event that can encourage some to make substantial changes to their lifestyle or diabetes treatment; thus, it also represents a window of opportunity for specialist teams to optimise patient care, and in so doing possibly also reduce their chances of readmission. Efficacy of sitagliptin for the hospital management of general medicine and surgery patients with type 2 diabetes (Sita-Hospital): a multicentre, prospective, open-label, non-inferiority randomised trialThe trial met the non-inferiority threshold for the primary endpoint, because there was no significant difference between groups in mean daily blood glucose concentrations. Treatment with sitagliptin plus basal insulin is as effective and safe as, and a convenient alternative to, the labour-intensive basal–bolus insulin regimen for the management of hyperglycaemia in patients with type 2 diabetes admitted to general medicine and surgery services in hospital in the non-intensive-care setting. Full-Text PDF