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Nisa Maruthur, M.D., M.H.S.
02-03-2011
- Acute changes in medical condition that can cause both hyperglycemia (including diabetic ketoacidosis [DKA] and hyperosmolar hyperglycemic state [HHS]) and hypoglycemia.
- Hyperglycemia may be due to stress of illness, failure to take adequate insulin or other diabetic medication, dehydration or excess sweet liquid intake.
- Hypoglycemia may be caused by: decreased oral caloric intake, decreased endogenous glucose production (e.g. adrenal crisis or liver failure), increased glucose utilization (e.g. infection), decreased insulin clearance (e.g. renal failure).
- Infection is the most common cause of DKA and HHS.
- Other important acute changes in medical condition that can cause hyperglycemic states include trauma, stroke, myocardial infarction, alcohol abuse, and pancreatitis.
- Patients with diabetes (DM) are more likely to require hospitalization for acute illnesses such as infections.
- Glucose should be monitored more frequently with any acute illness.
- Evaluation of urine or blood for ketones should be considered in patients considered at risk for DKA.
- Consider medications used to treat acute illness (corticosteroids, thiazide diuretics, sympathomimetics, and atypical antipsychotic agents) which can also precipitate hyperglycemia.
- Certain antibiotics (e.g. quinolones) can cause both hyper- and hypoglycemia.
- Pronounced hyperglycemia may require a change in outpatient treatment plan, such as increased short-acting insulin.
- Inability to maintain oral intake, vomiting, or alteration of mental status: refer to an emergency department for evaluation for DKA and HHS.
- In general, diabetes medications (including insulin) should be continued during acute illness but dosage may need adjustment.
- Monitor blood glucose every 4 hours during acute illness, and adjust medications based on results.
- Encourage patients to call their health care provider early when ill.
- Short- or rapid- acting insulin can be substituted for long-acting during acute illness.
- Encourage antipyretics for fever.
- Maintain oral intake as much as possible and supplement with caloric beverages and salt.
- Self-monitoring of urine and blood ketones is available and can be used in conjunction with frequent blood glucose monitoring during acute illness.
- Alteration in outpatient treatment plan due to hyperglycemia or hypoglycemia is individualized based on patient's history of response to illness (e.g., history of ketosis) and current regimen (e.g. diet or insulin).
- Timely outpatient or emergency department visits may be necessary to address glycemic control and avoid ketoacidosis both during and after acute illness.
- Physicians should have a lower threshold for referral to the emergency department for potential hospitalization for patients with diabetes and acute illness.
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