Pitfalls in Outpatient Diabetes Management and Inpatient Glycemic Control

Abstract

T he challenges of treating patients with diabetes are many. Patients usually require oral medications, insulin, or both to control glucose levels. Such medications require careful titration and monitoring for side effects and adverse reactions. Additionally, care providers must educate and motivate patients to monitor their glucose levels, control their carbohydrate consumption, and aggressively participate in self-care to control their disease. These treatments allow patients to minimize the likelihood of developing chronic complications of diabetes such as micro- or macrovascular disease. In addition to the usual challenges, diabetes can also be exacerbated by less common factors such as medication changes, surgery, and illness. Such conditions can lead to acute decompensation of glucose control even in the setting of previously well-controlled disease. Acute complications such as diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) may develop. These conditions can be life-threatening and must be treated aggressively.1 Although it is important for physicians to understand the treatment of acute complications of diabetes, it is perhaps even more important to be versed in techniques of averting acute hyperglycemia. Three common causes of diabetes exacerbation include intercurrent illness, surgery or trauma, and the use of corticosteroids. Furthermore, inpatient diabetes and hyperglycemia management can be complicated and present unique challenges to care providers. Approximately 12–25% of hospitalized patients have diabetes, and the diagnosis of diabetes at hospital admission has increased 2.3-fold to 5.1 million from 1980 to 2003. Numerous studies have associated hyperglycemia with adverse outcomes during hospitalization; however, interventional studies that have attempted to decrease such complications by aggressively treating hyperglycemia have had mixed outcomes.2,3 This installment of our series on the fundamentals of diabetes care will review management recommendations in special outpatient situations and inpatient diabetes care. Intercurrent illnesses can be challenging to any patient with a chronic disease, …