Appropriate Antidiabetic Protocols

The family physician must determine if it is appropriate to continue the outpatient treatment schedule in the hospitalized diabetic patient, depending mainly on the reason for hospitalization. If the patient can eat, the regular outpatient treatment (oral agents and/or insulin) should be continued with appropriate adjustments. Supplementing this with basal/bolus insulin may be appropriate if significant hyper-glycemia (>200 mg/dL) occurs associated with the stress of illness and hospitalization. The outpatient regimen should not be discontinued in favor of a fixed sliding-scale insulin schedule, which will take days to titrate to the patient's needs and may result in erratic hyper- and hypoglycemic intervals. If the patient cannot be fed and glucose values are drifting above the 150- to 180-mg/dL range because of stress-mediated gluconeogenesis, treatment to prevent further hypergly-cemia is appropriate.

Basal insulin can be given to fasting patients at starting dosages of 0.25 U/kg/day and further adjusted as the glycemic pattern becomes apparent. Periodic corrections in bolus insulin dosage may be necessary until titrated to levels achieving glucose values in the mid-100-mg/dL range. Once a safe basal dosage is determined, it should not be withheld if the patient is to be kept fasting for a procedure. Basal insulin will somewhat block hyperglycemic surges after catecholamine release in response to procedure stress. Patients with any remaining risk of hypoglycemia are given dextrose 5% at 75 to 100 mL/hr with continued basal insulin, which also blocks lipolysis from fasting, promoting gluconeogenesis and peripheral insulin resistance. After illness, diabetic patients not previously treated with insulin may require weeks before they can be titrated to their prior oral agents. This partly depends on regaining their lean body mass and state of fitness, which improves sensitivity to their endogenous insulin reserve. In some patients, insulin dependency becomes necessary indefinitely.

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