University of Louisville School of Medicine, Louisville, KY, USA.
Am Fam Physician. 2017 Nov 15;96(10):648-654.
Glucose management in hospitalized patients poses challenges to physicians, including identifying blood glucose targets, judicious use of oral diabetes mellitus medications, and implementing appropriate insulin regimens. Uncontrolled blood glucose levels can lead to deleterious effects on wound healing, increased risk of infection, and delays in surgical procedures or discharge from the hospital. Previously recommended strict blood glucose targets for hospitalized patients result in more cases of hypoglycemia without improvement in patient outcomes. The current target is 140 to 180 mg per dL. Use of oral diabetes medications, particularly metformin, in hospitalized patients is controversial. Multiple guidelines recommend stopping these medications at admission because of inpatient factors that can increase the risk of renal or hepatic failure. However, oral diabetes medications have important nonglycemic benefits and reduce the risk of widely fluctuating blood glucose levels. There is no proven risk of lactic acidosis from metformin in patients with normal kidney function, and it can be used safely in many hospitalized patients with diabetes. Insulin dosing depends on the patient's previous experience with insulin, baseline diabetes control, and renal function. Other considerations include the patient's current oral intake, comorbidities, and other medications. Many patients can be managed using only a basal insulin dose, whereas others benefit from additional short-acting premeal doses. Historically, sliding scale insulin regimens have been used, but they have no proven benefit, increase the risk of hypoglycemia and large fluctuations in blood glucose levels, and are not recommended. Discharge planning is an important opportunity to address diabetes control, medication adherence, and outpatient follow-up.
住院患者的血糖管理对医生提出了挑战，包括确定血糖目标、合理使用口服糖尿病药物以及实施适当的胰岛素治疗方案。血糖控制不佳可导致伤口愈合不良、感染风险增加以及手术延迟或出院。先前推荐的住院患者严格血糖目标导致更多的低血糖病例，但并未改善患者结局。目前的目标是 140 至 180mg/dL。住院患者使用口服糖尿病药物，特别是二甲双胍，存在争议。多项指南建议在入院时停止这些药物，因为住院因素会增加肾功能衰竭或肝功能衰竭的风险。然而，口服糖尿病药物具有重要的非血糖益处，并降低血糖广泛波动的风险。在肾功能正常的患者中，二甲双胍不会导致乳酸酸中毒，且在许多患有糖尿病的住院患者中可以安全使用。胰岛素剂量取决于患者之前的胰岛素使用经验、基线糖尿病控制情况和肾功能。其他考虑因素包括患者当前的口服摄入量、合并症和其他药物。许多患者仅使用基础胰岛素剂量即可得到控制，而其他患者则受益于额外的餐时短效胰岛素剂量。传统上，使用了胰岛素滑动量表治疗方案，但没有证据表明其有益，反而增加了低血糖和血糖水平大幅波动的风险，因此不推荐使用。出院计划是解决糖尿病控制、药物依从性和门诊随访的重要机会。
