2016 ADA Guideline Recommendations |
Types of Diabetes Mellitus |
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2016 ADA Standard of Medical Care Guideline Recommendations |
Cardiovascular Disease and Risk Management |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[2]; Shivani Chaparala M.B.B.S [3]; Tarek Nafee, M.D. [4]
Patient status | Mild hyperglycaemia | Moderate hyperglycaemia | Severe hyperglycaemia |
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Definition | Blood glucose < 200 Patients who are taking less than 2 anti-diabetic drugs (such as oral anti-diabetic drug or GLP-1 receptor agonists) |
201 < Blood glucose <300 Patients who are taking multiple anti-diabetic drug (such as oral anti-diabetic drug or GLP-1 receptor agonists) Patients who are taking less than 0·6 U/kg insulin per day |
Blood glucose > 301 Patients who are taking multiple anti-diabetic drug (such as oral anti-diabetic drug or GLP-1 receptor agonists) Patients who are taking more than 0·6 U/kg insulin per day |
Approach | Low dose basal insulin OR oral anti-diabetic drug†, if there are no contraindications. Further blood glucose correction can be applied by rapid-acting insulin (before meals or every 6 hours) |
Basal insulin OR oral anti-diabetic drug†, if there are no contraindications. Initial insulin dose: 0·2–0·3 U/kg per day (start from 0·15 U/kg per day (if using basal insulin alone) or 0·3 U/kg per day (if using basal–bolus) for patients with high risk of hypoglycemia). Further blood glucose correction can be applied by rapid-acting insulin (before meals or every 6 hours) |
Basal–bolus insulin regimen Initial insulin dose: Reduce patient's home insulin regimen by 20% OR 0·3 U/kg per day (half basal and half bolus) If patient has poor intake, hold the prandial insulin. |
†One of the options which has been studied in randomized controlled trials is dipeptidyl peptidase-4 inhibitor. Although metformin use is common, use it with caution due to high risk of lactic acidosis, especially in high risk patients (such as sepsis, hypoxia, renal insufficiency, shock and hepatic failure)
Patient status | Patients with surgical or other medical conditions‡ | Mild to moderate DKA | Severe DKA or HHS |
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Approach | Continuous insulin infusion § | Continuous insulin infusion OR subcutaneous insulin (consider DKA protocol) | Continuous insulin infusion |
‡Continuous insulin infusion specially could be beneficial in hypoglycemia due to steroid use or in solid organ transplant patients.
§Prompt treatment is recommended in patients with myocardial infarction or ischemic stroke due to possible further harm due to hyperglycemia. ALthough intensive treatment is not recommended due to higher chance of hypoglycemia.
"1. Consider performing an A1C on all patients with diabetes or hyperglycemia admitted to the hospital if not performed in the previous 3 months. (Level of Evidence: C)" |
"2. Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold ≥180 mg/dL (10.0 mmol/L). Once insulin therapy is started, a target glucose range of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for the majority of critically ill patients(Level of Evidence: A)and noncritically ill patients (Level of Evidence: C)" |
"3. More stringent goals, such as 110–140 mg/dL (6.1–7.8 mmol/L) may be ap- propriate for selected critically ill patients, as long as this can be achieved without significant hypoglycemia (Level of Evidence: C)" |
"4. Intravenous insulin infusions should be administered using validated written or computerized protocols that allow for predefined adjustments in the insulin infusion rate based on glycemic fluctuations and insulin dose. (Level of Evidence: E)" |
"5. A basal plus bolus correction insulin regimen is the preferred treatment for noncritically ill patients with poor oral intake or those who are taking nothing by mouth. An insulin regimen with basal, nutritional, and correction components is the preferred treatment for patients with good nutritional intake. (Level of Evidence: A)" |
"6. The sole use of sliding scale insulin in the inpatient hospital setting is strongly discouraged (Level of Evidence: A)" |
"7. A hypoglycemia management protocol should be adopted and implemented by each hospital or hospital system. A plan for preventing and treating hypoglycemia should be established for each patient. Episodes of hypoglycemia in the hospital should be documented in the medical record and tracked. (Level of Evidence: E)" |
"8. The treatment regimen should be reviewed and changed if necessary to prevent further hypoglycemia when a blood glucose value is <70 mg/dL (3.9 mmol/L). (Level of Evidence: C)" |
"9. There should be a structured discharge plan tailored to the individual patient. (Level of Evidence: B)" |
Umpierrez et al (2007) | Glargine–glulisine (basal-bolus) Vs sliding-scale insulin Study has been done on 130 patients with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·4 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration in basal-bolus group has been 166 mg/dL (SD: 1.8) Vs average glucose concentration of 193 mg/dL in sliding-scale insulin group (P value < 0·001). Non of the patients developed hypoglycemia (glucose concentrations less than 40 mg/dl). |
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Umpierrez et al (2009) | Human insulin (NPH and regular) † Vs detemir–aspart (basal-bolus) Study has been done on 130 patients with diabetes type 2 who were on various type of treatments, with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed no difference. 4·5% of patients in detemir–aspart group developed hypoglycemia (glucose concentrations less than 40 mg/dl Vs 1·6% of patients in human insulin. |
Umpierrez et al (2011) | Glargine–glulisine (basal-bolus) Vs sliding-scale insulin Study has been done on 211 surgical patients with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·4 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed better glycemic control in basal-bolus group (P value = 0·003 ). Patients in basal-bolus group showed lower rate of general complications₪, nevertheless rates of hypoglycemia were higher (4% in basal-bolus group Vs 0% in sliding-scale insulin group). |
Schroeder et al (2012) | NPH and regular‡ Vs sliding-scale insulin Study has been done on 141 orthopaedic surgery patients with diabetes type 2 or history of frequent hyperglycemia (>180 mg/dL). Reported average glucose concentration in NPH and regular group has been 161·2 mg/dL Vs average glucose concentration of 175·8 mg/dL in sliding-scale insulin group (P value < 0·0005). Two episodes of severe hypoglycemia have been reported in NPH and regular group. |
Umpierrez et al (2013) | Basal-plus (glargine–glulisine) Vs basal-bolus (glargine–glulisine) Vs sliding-scale insulin Study has been done on 375 patients with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·4 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentrations were akin in both basal-plus and basal-bolus groups. Treatment failure was higher in sliding-scale insulin group (19%), compared to basal-bolus (0%) or basal-plus (2%) groups. |
Mader et al (2014) | Glargine–aspart (basal-bolus) Vs standard treatment (such as oral antidiabetic agents), insulin or combination of both Study has been done on 74 patients with diabetes type 2 who were on various type of treatments, with glucose concentrations higher than 140 mg/dL. Reported average glucose concentration in basal-bolus group (33%) was higher compared to standard treatment group (23%) (P value 0·001) ¶ |
Bueno et al (2015) | Glargine–glulisine (basal-bolus) Vs NPH and regular₳ Study has been done on 134 patients with diabetes type 2 who were not a surgical case. Reported average glucose concentrations were akin in both NPH and regular and basal-bolus groups. Hypoglycemic events were reported as 35% in basal-bolus group, compared to 38% in NPH and regular group. |
Bellido et al (2015) | Glargine–glulisine (basal-bolus) Vs premixed NPH and regular (70/30)¥ Study has been done on 72 patients with diabetes type 2 who were either medical or surgical cases, who were on oral antidiabetic agents, insulin or a combination of both.§ Reported average glucose concentration showed no difference. Objectionably high rate of hypoglycemia have been reported in premixed NPH and regular group. |
Vellanki et al (2015) | Glargine–aspart (basal-bolus) without bedtime addition Vs Glargine–aspart (basal-bolus) with bedtime addition Study has been done on 206 patients with diabetes type 2 who were medical or surgical cases with glucose concentrations of 140–400 mg/dL. Patients were on oral antidiabetic agents, insulin or a combination of both. Reported average glucose concentration showed no difference. Non of the patients developed hypoglycemia (glucose concentrations less than 40 mg/dl). |
Gracia-Ramos et al (2016) | Glargine–lispro (basal-plus) Vs premixed insulin analog (lispro 25/75) ¤ Study has been done on 54 patients with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·4 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentrations showed no difference. Rate of hypoglycemia was simillar in both groups (16%). |
Pasquel et al (2020) | Basal-bolus (glargine U300–glulisine) Vs basal-bolus (glargine U100–glulisine) Study has been done on 176 patients with diabetes type 2 who were on various type of treatments, with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed no difference. Significant lower rate of hypoglycemic events in glargine U300 group. (P value = 0·023) |
†Two-thirds before breakfast and one-third before dinner
₪Patients in basal-bolus group showed lower rate of general complications such as postoperative wound infection, bacteremia, pneumonia, renal insufficiency and respiratory failure.
‡Three times a day
¶Related article didn't provide the absolute numbers
₳NPH insulin has been used twise a day. Regular insulin has been used before meals
¥60% before breakfast and 40% before dinner
§Study terminated after interim analysis.
¤Two-thirds with breakfast and one-third with dinner
Umpierrez et al (2013) | Sitagliptin + sliding-scale insulin or sitagliptin + glargine Vs basal-bolus insulin (glargine–lispro) Study has been done on 90 patients (medical or surgical cases) with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·4 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed no difference. Sole sitagliptin treatment has not been effective in patients who had blood glucose higher than 180 mg/dL. |
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Pasquel et al (2017) | Sitagliptin + glargine Vs basal-bolus insulin (glargine–lispro or glargine–aspart) Study has been done on 278 patients (medical or surgical cases) with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·6 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed no difference. |
Garg et al (2017) | Saxagliptin Vs basal-bolus insulin (glargine–aspart) Study has been done on 66 patients (medical or surgical cases) with diabetes type 2 who were on maximum 1 non-insulin antidiabetic agents or 2 non-insulin antidiabetic agents with HbA1c measure less than 7·5% and 7·0%, respectively. Reported average glucose concentration showed no difference. Patients who received saxagliptin showed less blood glucose variation. |
Vellanki et al (2019) | Linagliptin + sliding-scale insulin Vs basal-bolus insulin (glargine–lispro or glargine–aspart) Study has been done on 250 surgical patients with diabetes type 2 who were on oral antidiabetic agents or low dose insulin (less than 0·5 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed no difference. Less chance of hypoglycemia has been reported in linagliptin group. Sole linagliptin use has not been effective in patients with blood glucose more than 200 mg/dl |
Abuannadi et al (2013) | Exenatide infusion Vs intensive glycemic control (90–119 mg/dL) or moderate glycemic control (100–140 mg/dL) Study has been done on 40 non-diabetic ICU patients with coronary heart disease and type 2 diabetic patients who were on non-insulin antidiabetic agents, with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed good control in exenatide group. (Same result as moderate glycemic control) The main limitation has been the non-randomized study with historical controls. |
Kohl et al (2014) | Native GLP-1 Vs placebo Study has been done on 77 cardiac surgery patients with or without diabetes Reported average glucose concentration showed lower measure in GLP-1 group. |
Besch et al (2017) | Exenatide infusion Vs insulin infusion Study has been done on 104 CABG patients with or without diabetes (on non-insulin treatment) Reported average glucose concentration showed no statistically valuable differences. Study discontinued after futility analysis. |
Polderman et al (2018) | Liraglutide † Vs glucose + insulin + potassium ‡ Study has been done on 150 surgical patients with diabetes type 2 who where on diet, oral antidiabetic agents or insulin doses less than 1 U/kg. Reported average glucose concentration measures 1 hour after surgery showed lower levels in liraglutide group. Nausea has been reported in patients of liraglutide. |
Lipš et al (2017) | Continuous exenatide infusion + insulin treatment Vs 0·9% saline + insulin treatment Study has been done on 40 CABG patients with or without diabetes. Reported average glucose concentration showed lower measures in exenatide group. Decreased demand for temporary pacing after surgery was the only benefit in cardiac function of the exenatide group. |
Fayfman et al (2019) | Exenatide ¶ Vs exenatide + basal insulin (glargine or levemir) Vs basal insulin (glargine or levemir + aspart or lispro) Study has been done on 150 surgical or medical patients with diabetes type 2 who were on diet, oral antidiabetic agents or low dose insulin (less than 0·5 U/kg per day), with glucose concentrations of 140–400 mg/dL. Reported average glucose concentration showed lower measures in exenatide plus basal insulin group, compared to exenatide alone. ALthough reported average glucose concentration showed no differences between exenatide plus basal insulin and basal insulin groups. Exenatide plus basal insulin group was more succesful in keeping the blood glucose within the target goal, compared to the other two groups. (P value = 0·023) |
Kaneko et al (2018) | Liraglutide Vs insulin Study has been done on 92 surgical patients (elective surgery) with diabetes type 2 Reported average glucose concentration showed lower measures in liraglutide group. |
Hulst et al (2020) | Liraglutide ₳ Vs placebo Study has been done on 278 cardiac surgery patients with (16%) or without (84%) diabetes type 2 Reported average glucose concentration showed lower demand for insulin use in liraglutide group. Hypoglycemia has not been reported in non of the groups. |
†Liraglutide has been used subcutaneously with dosage of 0·6 mg before surgery and 1.2 mg after anesthesia induction.
‡Infusion of glucose, insulin and potassium was 30 mintunes before surgery and continued until 4 hours after surgery.
¶Exenatide has been used with dose of 5 mg twice a day.
₳Liraglutide has been used subcutaneously with dosage of 0·6 mg on the evening before surgery and 1.2 mg after anesthesia induction.
The following are some management considerations that are recommended in hospitalized diabetic patients with specific circumstances.
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