CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 2, March 2012
AFRICA
115
Drug Trends in Cardiology
The diabetologist/cardiologist debate: a meeting of the minds
Sponsored by Servier
In-hospital diabetes management
of non-critical care patients
Dr Graham Ellis
There are two vital measures to ensure
better in-hospital care of patients experi-
encing hyperglycaemia. First, all patients
admitted to hospital should have non-
fasting blood glucose levels measured. If
above 7.8 mmol/l, an HbA
1c
determina-
tion should be done to assess undiag-
nosed diabetes. Second, the nursing staff
needs to be educated and informed on the
standard protocol for the general medical
ward (non-critical care patients) so that
they can implement and manage patients
appropriately.
‘The in-hospital management of
hyperglycaemia suffers from a dearth
of evidence, however, and good clinical
trials are few. As a result, expert guideline
committees worldwide have used clini-
cal experience to guide their therapeutic
choices’, Dr Ellis pointed out.
‘The hyperglycaemic patient may be
categorised as: diabetic, or with undiag-
nosed diabetes prior to admission, or as
a patient suffering from stress hypergly-
caemia, which returns to normal after the
crisis is past’, Dr Ellis noted. ‘On admis-
sion, an HbA
1c
level higher than 6.5%
would indicate an undiagnosed diabetic’,
he added.
Stress hyperglycaemia (
>
7.8 mmol/l)
is commonly seen (32–38%) in patients
admitted to general hospital wards. The
prevalence among critically ill patients
is higher: 41% in patients with acute
coronary syndromes (ACS), 44% in heart
failure patients and 80% in patients who
undergo interventional cardiac surgery.
‘Lessons from strict or intense glucose
control in critically ill patients have influ-
enced clinical care of the non-critically
ill patient’, Dr Ellis noted. ‘In both these
groups of patients, intensive glucose
control has disappointingly not improved
mortality, or occurrence of stroke or
myocardial infarction, but has led to an
increase in hypoglycaemia, with adverse
consequences.’
The recent guidelines for the manage-
ment of hyperglycaemia, issued in
January 2012 by the American Diabetes,
Endocrine and Heart Association,
1
provide comprehensive guidelines for
hospitalised type 2 diabetes patients in the
non-critical care setting. ‘Useful targets
are set for a fasting blood glucose level
of 5.6–7.8 mmol/l and a non-fasting level
of less than 10 mmol/l. Obviously in
patients with terminal illness or high risk
of hypoglycaemia, the target can be set
less stringently to less than 11 mmol/l’,
Dr Ellis noted.
The clinician has the option of oral
therapy: metformin and sulphonylurea
therapy with caution in the elderly, and
DDP-4 inhibitors, which are rendered
less efficient in patients who are not
eating. ‘Insulin is however key to therapy.
We should bury the sliding scale, as a
number of studies, including the Rabbit
2 trials,
2,3
have shown better results with
a basal-bolus approach using glargine
(once daily) and glulisine before meals’,
Dr Ellis noted.
‘Generally the sliding scale of insulin
usage has resulted in patients not receiv-
ing enough insulin to reach the set targets.
Hospitalisation is a great time to initiate
insulin therapy in our type 2 diabetes
patients as nursing and clinical support is
available’, Dr Ellis noted.
The protocol for the ward manage-
ment of non-critically ill patients involves
a step-wise approach: (1) stopping oral
medication, and (2) assessing the patient’s
insulin needs based on age, blood glucose
levels, body mass index and renal func-
tion, initially using 0.2–0.5 U/kg, to a
maximum of 70 U to reach target blood
glucose levels of 7.8–11.1 mmol/l.
The insulin dose should be given as
50% basal insulin, using Levemir (once
daily or bid), Lantus (daily) or NPH (bid)
insulin. The balance is given in three
equally divided doses before each meal
if the patient is eating. If the patient is
not eating, blood glucose levels should
be measured four to six hourly and the
dosage adjusted. Supplementary insulin
may need to be given if the glucose levels
are not at target.
‘We need to take special care not to
cause hypoglycaemia (
<
3.9 mmol/l) as
this is a marker of adverse outcomes. If a
hypoglycaemic level is recorded, reducing
insulin by 20% is a useful guide. Risk of
hypoglycaemia is raised in the older ill
patient with impaired renal function and
patients stopping or reducing glucocorti-
coid (cortisone) therapy’, Dr Ellis warned.
Ageing and type 2 diabetes
Dr Sophia Rauff
The physiological changes of ageing and
the pathology of diabetes are cumulative.
Dr Sophia Rauff, an endocrinologist and
currently a specialist in the Department of
Geriatrics, University of KwaZulu-Natal,
noted that type 2 diabetes is a growing
problem in older patients (defined by the
World Health Organisation as those over
the age of 60 years).
The need to individualise therapy to
each older patient was stressed. In the
case of the frail older patient, particu-
larly when targeting glucose control, one
should seek to avoid hypoglycaemia, and
a target HbA
1c
level of 8% would be
acceptable. It was noted that in the older
patient, angiography frequently shows
worse atherosclerotic disease than the
duration and severity of diabetes may
suggest. Emphasis was placed on the
early introduction of primary preventive
measures.
With regard to blood pressure meas-
urement in the older person, there is
clinical value in using the standing blood
pressure rather than sitting blood pres-
sure, as orthostatic hypotension can lead
to damaging falls in the elderly.
The HYVET trial,
4
using a low-dose
diuretic (inadapamide sustained release
1.5 mg daily) and perindopril (2–4
mg) achieved excellent results with an
on-treatment reduction in mortality. Of
interest is that the open-label extension
of the HYVET trial has recently been
published and the benefits of reduction
in total and cardiovascular mortality were
retained
5
in patients on sustained thera-
py (achieved blood pressure of 146/76
mmHg).
The results of this study of blood
pressure control in the active, free-living
