inpatient hyperglycemia in non-critical care setting

Clinical Guidelines for the Clinical Guidelines for the Management of Hyperglycemia Management of Hyperglycemia in Hospitalized Patients in a in Hospitalized Patients in a Non-Critical Care SettingNon-Critical Care Setting Work in Work in ProgressProgress

The Endocrine Society, The Endocrine Society, European Endo Society, European Endo Society, American Heart Association, American Heart Association, American Diabetes Association, American Diabetes Association, Society of Hospitalist Medicine, Society of Hospitalist Medicine, American Association of Diabetes American Association of Diabetes Educators Educators

Inpatient Hyperglycemia in non-Inpatient Hyperglycemia in non-critical care settingcritical care setting

1.1. What is the frequency of hyperglycemia What is the frequency of hyperglycemia and diabetes? and diabetes?

2.2. What diagnosis criteria should we use?What diagnosis criteria should we use?

3.3. What is the association between What is the association between hyperglycemia and outcomes?hyperglycemia and outcomes?

4.4. How should we manage hyperglycemia in How should we manage hyperglycemia in non-ICU setting?non-ICU setting?

Hyperglycemia: Scope of the ProblemHyperglycemia: Scope of the Problem

Kosiborod M, et al. J Am Coll Cardiol. 2007;49(9):1018-183:283A-284A.

No Diabetes

26%

Diabetes 50

40

30

20

10

0<110110-140

50

40

30

20

10

0<110110-140 140-170170-200>200

78%

140-170170-200>200

Mean BG, mg/dL

Pati

en

ts,

%

Hyperglycemia*: A Common Hyperglycemia*: A Common Comorbidity in Medical-Surgical Comorbidity in Medical-Surgical Patients in a Community HospitalPatients in a Community Hospital

62%62%

12%12%

26%26%

NormoglycemiaNormoglycemia

Known DiabetesKnown Diabetes

New HyperglycemiaNew Hyperglycemia

Umpierrez G et al, J Clin Endocrinol Metabol 87:978, 2002Umpierrez G et al, J Clin Endocrinol Metabol 87:978, 2002

n = 2,020n = 2,020

* Hyperglycemia: Fasting BG * Hyperglycemia: Fasting BG 126 mg/dl 126 mg/dl or Random BG or Random BG 200 mg/dl X 2 200 mg/dl X 2

New and Stress hyperglycemiaNew and Stress hyperglycemia

Patients with hyperglycemia without a previous history of diabetes should be tested with a hemoglobin A1C during the hospital stay or with an oral glucose tolerance test after discharge to confirm the diagnosis of diabetes.

Less than 35% of patients had normal glucose tolerance after 3 to 12 months of follow-up.

Norhammar et al. Lancet 2002; 359(9324): 2140-4.Arora et al. Endocr Pract 2009; 15(5): 425-30.Greci et al. Diabetes Care 2003; 26(4): 1064-8.

IGT and Undiagnosed T2DM are IGT and Undiagnosed T2DM are Common in Acute MI and StrokeCommon in Acute MI and Stroke

Norhammar A, et al. Lancet 2002;359:2140−4.Matz K, et al. Diabetes Care 2006;792−7.

2-hour OGTT

70

60

50

40

30

20

10

0

Norhammar(n=181)

Matz(n=238)

Pati

ents

(%

)

66

39

Myocardial infarction

Stroke

IGT Undiagnosed T2DM

3523

31

16

Epidemiology of Inpatient Epidemiology of Inpatient Hyperglycemia in non-critical care Hyperglycemia in non-critical care settingsetting1.1. What is the frequency of hyperglycemia What is the frequency of hyperglycemia

and diabetes? and diabetes?




NORMAL IFG or IGT PREDIABETES

DIABETES

FPG < 100 mg/dl FPG > 100 - 125 mg/dl (IFG)

FPG > 126 mg/dl

2-h PG < 140 mg/dl

2-h PG > 140 - 199 mg/dl (IGT)

2-h PG > 200 mgRandom PG > 200 + symptoms

A1C 5.7% to 6.4% ≥ 6.5%

ADA 2010 - Categories of Increased Risk for Diabetes*

ADA Clinical Practice Recommendations, January 2019

A1C for Diagnosis of Diabetes in A1C for Diagnosis of Diabetes in the Hospitalthe Hospital

Inhospital hyperglycemia is defined as an Inhospital hyperglycemia is defined as an admission or inhospital BG > greater 140 admission or inhospital BG > greater 140 mg/dl. mg/dl.

HbA1c > 6.5% can be identified as having HbA1c > 6.5% can be identified as having diabetes, and patients with A1C 5.7%-6.4% diabetes, and patients with A1C 5.7%-6.4% can be considered as being at risk for can be considered as being at risk for diabetes. diabetes.

Implementation of A1C testing can be Implementation of A1C testing can be useful:useful: assess glycemic control prior to admissionassess glycemic control prior to admission assist with differentiation of newly diagnosed assist with differentiation of newly diagnosed

diabetes from stress hyperglycemiadiabetes from stress hyperglycemia designing an optimal regimen at the time of designing an optimal regimen at the time of

dischargedischarge

Comparison of sensitivity and specificity achieved for the diagnosis of diabetes based on FPG, at various levels of HbA1c, from NHANES III and 1999–2004 NHANES

J Clin Endocrinol Metab, July 2008, 93(7):2447–2453

Factors influencing A1cFactors influencing A1c

Hyperglycemia and Pneumonia Hyperglycemia and Pneumonia OutcomesOutcomes

0

5

1 0

1 5

2 0

2 5

3 0

M o r ta l it y

H o s p ita lC o m p lic a t io n s

BG (mg/dl) < 110 110 - <198 198 - <250 ≥250

* *

* *

* p: < 0.05 vs BG < 198 mg/dl (11 mmol/L)

Admission glucose (mg/dl)

%

McAllister et al, Diabetes Crae 28:810-815, 2005McAllister et al, Diabetes Crae 28:810-815, 2005

N= 2,471 patients with CAP

Community Acquired Pneumonia Community Acquired Pneumonia Outcomes in Patients with DiabetesOutcomes in Patients with Diabetes

0

20

40

60

80

100

%

Hospitalization Mortality Pleural Effusion Concomitant IllnessesP: < 0.001

N= 660 (DM: 106 & non-DM: 554)No differences in microorganisms and bacteremia rates

Falguera et al, Chest 128:3233-3239, 2005Falguera et al, Chest 128:3233-3239, 2005

*

*

*

*

93

817

78

31

18

53

40*

Diabetes

No Diabetes

A case control study of 108,593 patients who underwent noncardiac surgery.

*Odds ratio for perioperative mortality is 1.19 (95% CI 1.1–1.3) per mmol/l increase of glucose level

http://www.eje-online.org/content/vol156/issue1/images/large/137F3.jpeg

Thirty Day Mortality and Inhospital Complications in diabetic and non-diabetic subjects

†p = 0.1 * p= 0.001 #p=0.017

†

*

**

*#

*

%

A Frisch et al. Diabetes Care, May 2010

Hyperglycemia and mortalityHyperglycemia and mortality

Mean POSTSURGERY blood glucose and ODDS RATIOS for 30 day mortality in diabetic and non diabetic patients

0

10

20

30

40

50

60

50 100 150 200 250 300Odds

ratio

for 3

0-d

ay m

orta

lity

Mean blood glucose after surgery (mg/dl)

All patients Diabetics non-Diabetics

A Frisch et al. Diabetes 58 (suppl 1) A27, 2009

Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes

Total In-patient MortalityTotal In-patient Mortality

NormoglycemiaNormoglycemia Known Known New New DiabetesDiabetes Hyperglycemia Hyperglycemia

1.7%1.7% 3.0%3.0%

16.0% 16.0% **

Mort

alit

y (

%)

Mort

alit

y (

%)

* P < 0.01* P < 0.01

Umpierrez GE et al, J Clin Endocrinol Metabol 87:978, 2002Umpierrez GE et al, J Clin Endocrinol Metabol 87:978, 2002

AACE/ADA Target Glucose Levels AACE/ADA Target Glucose Levels in Nonin Non––ICU PatientsICU Patients

Glucose Target in nonGlucose Target in non––ICU setting:ICU setting: Premeal glucose targets <140 mg/dL Premeal glucose targets <140 mg/dL Random BG <180 mg/dLRandom BG <180 mg/dL To avoid hypoglycemia, reassess insulin To avoid hypoglycemia, reassess insulin

regimen if BG levels fall below 100 mg/dLregimen if BG levels fall below 100 mg/dL Occasional patients may be maintained with a Occasional patients may be maintained with a

glucose range below and/or above these cut-glucose range below and/or above these cut-points points

Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4). http://www.aace.com/pub/pdf/guidelines/InpatientGlycemicControlConsensusStatement.pdf

1.ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care. 2006 & 20092.Diabetes Care. 2009;31(suppl 1):S1-S110..

Antihyperglycemic Therapy

Insulin Recommended

OADs Not Generally

Recommended

IV Insulin

Critically ill patients in the ICU

SC Insulin

Non-critically ill patients

Recommendations for Managing Patients With Diabetes in the Hospital Setting

AACE/ADA Consensus StatementAACE/ADA Consensus Statement Non-insulin therapies in the Non-insulin therapies in the hospital?hospital?Sulfonylureas are a major cause of Sulfonylureas are a major cause of

hypoglycemiahypoglycemiaMetformin contraindicated in setting of decrease Metformin contraindicated in setting of decrease

renal blood flow and with use of iodinated renal blood flow and with use of iodinated contrast dyecontrast dye

Thiazolidinediones associated with edema and Thiazolidinediones associated with edema and CHFCHF

αα glucosidase inhibitors are weak glucose glucosidase inhibitors are weak glucose lowering agentslowering agents

Pramlintide and GLP1-directed therapies can Pramlintide and GLP1-directed therapies can cause nausea and have a greater effect on cause nausea and have a greater effect on postprandial glucose postprandial glucose

Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009

Management of Hyperglycemia Management of Hyperglycemia and Diabetes in non-ICU Settingand Diabetes in non-ICU Setting

Non-ICUNon-ICU

Sliding Scale Short-Acting Insulin Sliding Scale Short-Acting Insulin

Basal/bolus therapy (MDI)Basal/bolus therapy (MDI)• NPH and Regular insulinNPH and Regular insulin• Long-acting and rapid-acting insulinLong-acting and rapid-acting insulin

Premix insulinPremix insulin

Study Type: Prospective, multicenter, randomized, open-label trial

Patient Population: 130 subjects with DM2 Diet and/or oral hypoglycemic agents

Umpierrez et al, Diabetes Care 30:2181–2186, 2007

D/C oral antidiabetic drugs on admissionD/C oral antidiabetic drugs on admission

Starting total daily dose (TDD): Starting total daily dose (TDD): 0.4 U/kg/d x BG between 140-200 mg/dL0.4 U/kg/d x BG between 140-200 mg/dL 0.5 U/kg/d x BG between 201-400 mg/dL 0.5 U/kg/d x BG between 201-400 mg/dL

Half of TDD as insulin glargine and half as Half of TDD as insulin glargine and half as rapid-acting insulin (lispro, aspart, rapid-acting insulin (lispro, aspart, glulisine)glulisine) Insulin glargine - once daily, at the same Insulin glargine - once daily, at the same

time/day. time/day. Rapid-acting insulin- three equally divided Rapid-acting insulin- three equally divided

doses (AC)doses (AC)

RaRandomized ndomized BBasal asal BBolus versus Sliding Scale olus versus Sliding Scale Regular Regular IInsulin in patients with nsulin in patients with ttype ype 22 Diabetes Diabetes

MellitusMellitus(RABBIT-2 Trial)(RABBIT-2 Trial)

Umpierrez et al, Diabetes Care 30:2181–2186, 2007

Umpierrez GE et al. Diabetes Care. 2007;30:2181-2186.

• Before meal: Supplemental Sliding Scale Insulin (number of units)

– Add to scheduled insulin dose

• Bedtime: Give half of Supplemental Sliding Scale InsulinBlood Glucose

(mg/dL) Insulin Sensitive Usual Insulin Resistant

>141-180 2 4 6

181-220 4 6 8

221-260 6 8 10

261-300 8 10 12

301-350 10 12 14

351-400 12 14 16

>400 14 16 18

Sliding Scale Insulin Regimen

Rabbit 2 Trial: Changes in Glucose Levels Rabbit 2 Trial: Changes in Glucose Levels With Basal-Bolus vs. Sliding Scale InsulinWith Basal-Bolus vs. Sliding Scale Insulin

Umpierrez GE, et al. Diabetes Care. 2007;30(9):2181-2186.

Days of Therapy

BG

, m

g/d

L

100

120

140

160

180

200

220

240

Admit 1

Sliding-scale

Basal-bolus

bP<.05.

aa a

b bb

b

2 3 4 5 6 7 8 9 10

aP<.05.

• Sliding scale regular insulin (SSRI) was given 4 times daily • Basal-bolus regimen: glargine was given once daily; glulisine was given before meals.0.4 U/kg/d x BG between 140-200 mg/dL0.5 U/kg/d x BG between 201-400 mg/dL

Persistent hyperglycemia (BG>240 Persistent hyperglycemia (BG>240 mg/dl) is common (15%) during SSI mg/dl) is common (15%) during SSI therapytherapy

Days of Therapy

BG

, m

g/d

L

100120140160180200220240

Admit1

Sliding-scale

Basal-bolus

260280300

3 3 4 5 6 72 4 21

Rabbit 2 Trial: Treatment Success With Basal-Bolus vs. Sliding Scale

Insulin

Hypoglycemia Hypoglycemia rate:rate:

Basal Bolus Group: BG < 60 mg/dL: 3% BG < 40 mg/dL:

none

SSRI: BG < 60 mg/dL: 3% BG < 40 mg/dL: none

Umpierrez GE, et al. Diabetes Care. 2007;30(9):2181-2186.

Study Type: Prospective, randomized, open-label trial

Patient Population: 130 subjects with DM2 Oral hypoglycemic agents or insulin therapy

Study Sites: Grady Memorial Hospital, Atlanta, GARush University Medical Center, Chicago, IL

Umpierrez et al, J Clin Endocrinol Metab 94: 564–569, 2009

Detemir–Aspart Insulin Regimen

• D/C oral antidiabetic drugs on admission

• Starting total daily dose (TDD): – 0.4 U/kg/d x BG between 140-200 mg/dL– 0.5 U/kg/d x BG between 201-400 mg/dL

• Half of TDD as insulin detemir and half as aspart– Insulin detemir - once daily, at the same time

of the day. – Insulin aspart - three equally divided doses

(AC)


NPH–Regular Split-Mixed Regimen

• D/C oral antidiabetic drugs on admission

• Starting total daily dose (TDD): – 0.4 U/kg/d x BG between 140-200 mg/dL– 0.5 U/kg/d x BG between 201-400 mg/dL

• Three-fifth of TDD as insulin NPH and two-fifth as regular– NPH insulin– twice daily, 2/3 before breakfast,

1/3 before dinner – Regular insulin- twice daily, 2/3 before

breakfast, 1/3 before dinner


DEAN Trial: Changes in Mean Daily DEAN Trial: Changes in Mean Daily Blood Glucose ConcentrationBlood Glucose Concentration

BG

, m

g/d

L

Duration of Therapy, d

Data are means SEM.

Detemir + aspartNPH + regular

Basal-bolus regimen: detemir was given once daily; aspart was given before meals.NPH/regular regimen: NPH and regular insulin were given twice daily, two thirds in AM, one third in PM.Umpierrez GE, et al. J Clin Endocrinol Metab. 2009;94(2):564-569.

P=NS

100

120

140

160

180

200

220

240

Pre-RxBG

0 1 2 3 4 5 6-10

120

140

160

180

200

Breakfast Lunch Dinner Bedtime

Blo

od

glu

cose

(m

g/d

L)

Detemir + NovologNPH + Regular

DEAN-Trial

NPH/Regular BG < 40 mg/dl: 1.6% BG < 60 mg/dl: 25.4%

Detemir/Aspart BG < 40 mg/dl: 4.5% BG < 40 mg/dl: 32.8%


DEAN Trial: Hypoglycemia

To determine risk factors for

hypoglycemic events during SC insulin therapy

p-value*

variable BG < 60 mg/dl BG < 70 mg/dl

AGE 0.036 0.001

wt 0.027 0.001

A1C 0.521 0.658

Creatinine 0.011 0.002

Enrollment BG 0.166 0.319

Previous treatment 0.005 <.001Previous insulin Rx <0.001 <.001

Treatment group <0.001 <.001*p-values are from Wilcoxon Two-Sample Test

Summary of Univariate Analyses

Umpierrez et al, ADA Scientific Meeting, Poster #516, 2009

RAndomized Study of Basal Bolus RAndomized Study of Basal Bolus Insulin Therapy in the Inpatient Insulin Therapy in the Inpatient Management of Patients with Type 2 Management of Patients with Type 2 Diabetes Undergoing General Diabetes Undergoing General Surgery: RABBIT Surgery TrialSurgery: RABBIT Surgery Trial

Guillermo E Umpierrez, Dawn Smiley, Sol Guillermo E Umpierrez, Dawn Smiley, Sol Jacobs, Limin Peng, Angel Temponi, Jacobs, Limin Peng, Angel Temponi, Christopher Newton, Denise Umpierrez, Christopher Newton, Denise Umpierrez, Patrick Mulligan, Darin Olson, Jana MacLeod, Patrick Mulligan, Darin Olson, Jana MacLeod, Monica Rizzo. Monica Rizzo.

Umpierrez et al, Preliminary data- ADA Scientific Session 2010

Research Design and MethodsResearch Design and Methods

Study Type: Multi-center, prospective, open-label randomized clinical trial

Patient Population: Patients with type 2 DM admitted to general surgery services

Study Sites: Grady Memorial Hospital, Veterans Affairs Medical Center and Emory University Hospital, Atlanta, GA

Treatment Groups: Group 1: basal/bolus regimen with glargine once

daily and glulisine before meals Group 2: sliding scale regular insulin (SSRI) four

times daily

Umpierrez et al, Preliminary data- Abstract submitted to ADA Scientific Session 2010

Primary outcome: • Differences between groups in mean daily BG

concentration

• Composite of hospital complications including: postoperative wound infection, pneumonia, respiratory failure, acute renal failure, and bacteremia.

Secondary outcome:

Differences between groups in any of the following measures:

•Mean fasting and pre-meal BG, number of hypoglycemic (BG < 70 mg/dL and < 40 mg/dL) and hyperglycemic (BG > 200 mg/dL) events , length of hospital stay, need for ICU care, and rate of complications including wound infection, pneumonia, acute renal failure, and mortality.

211 Patients with type 2 DM that underwent general surgery

Glargine + Glulisine(Gla+Glu)N= 104

Group 1: 0.5 U/kg

Half as glargine once daily Half as glulisine before meals

Sliding scale insulin (SSRI) N= 107

OPEN-LABELED RANDOMIZATION

Group 2: 4 times/day for BG >140 mg/dl

RABBIT SURGERY TRIAL

RABBIT 2 SURGERY

Umpierrez et al, Preliminary data- Abstract to be submitted_ADA Scientific Session 2010

120

140

160

180

200

220

0 1 2 3 4 5 6 7 8 9 10 11

Bloo

d Gl

ucos

e (m

g/dL

)

*† ‡

*

Duration of Treatment (days)

1 2 3 4 5 6 7 8 9 10

† †

Randomi-zation

Rabbit Surgery TrialGlucose levels during Basal Bolus and SSRI

Therapy

* p<0.001 † p: 0.01ŧ p: 0.02

SSIGLA+GLU

Glucose levels Before meals and Bedtime

120

140

160

180

200

220

-0.25 0.75 1.75 2.75

Bloo

d G

luco

se (

mg/

dL)

*

*


Breakfast Lunch Dinner Bedtime

* *SSI

Basal Bolus

Differences in BG Concentration Within TargetDuring Hospital Stay and After 24 Hours of Treatment

Hospital Complications: Primary outcome

Umpierrez et al, Preliminary data- Abstract to be submitted_ADA Scientific Session 2010

Hypoglycemic Events

Treatment with glargine once daily plus glulisine before meals improved glycemic control and reduced hospital complications compared to SSRI in general surgery patients with T2DM.

Our study indicates that basal/bolus insulin regimen is the preferred insulin regimen in the hospital management of general surgery patients with type 2 diabetes.

Summary & Conclusion Summary & Conclusion RABBIT 2 SURGERY

Management RecommendationsManagement Recommendations

All patients with T1DM must receive insulin All patients with T1DM must receive insulin treatment with basal bolus, multi-dose insulin treatment with basal bolus, multi-dose insulin combination of NPH plus regular insulin or combination of NPH plus regular insulin or continuous insulin pump.continuous insulin pump.

Patients treated with insulin at home should be Patients treated with insulin at home should be continued with insulin therapy in the hospital.continued with insulin therapy in the hospital.

Scheduled subcutaneous basal bolus insulin regimen Scheduled subcutaneous basal bolus insulin regimen is preferred for the majority of non-critically ill is preferred for the majority of non-critically ill patients with hyperglycemia. patients with hyperglycemia.

The practice of using sliding scale insulin (SSI) as a The practice of using sliding scale insulin (SSI) as a single form of therapy is undesirable.single form of therapy is undesirable.

Strategies for Preventing Strategies for Preventing HypoglycemiaHypoglycemia

In-service training on new treatment In-service training on new treatment modalities and the actions of new modalities and the actions of new antihyperglycemic agentsantihyperglycemic agents

Braithwaite SS, et al. Endocr Pract. 2004;10(suppl 2):89-99.

Reducing outpatient insulin dose in patients treated with insulin prior to admission

Basal Bolus is preferred over SSRI and NPH/regular combination

D/C oral antidiabetic drugs on admissionD/C oral antidiabetic drugs on admission

Starting total daily dose (TDD): Starting total daily dose (TDD): 0.3 U/kg/d in elderly and renal failure (lean?)0.3 U/kg/d in elderly and renal failure (lean?) 0.4 U/kg/d x BG between 140-200 mg/dL0.4 U/kg/d x BG between 140-200 mg/dL 0.5 U/kg/d x BG between 201-400 mg/dL 0.5 U/kg/d x BG between 201-400 mg/dL

Half of TDD as insulin glargine and half as Half of TDD as insulin glargine and half as rapid-acting insulin (lispro, aspart, rapid-acting insulin (lispro, aspart, glulisine)glulisine)

Decrease outpatient insulin dose by 20-Decrease outpatient insulin dose by 20-25% 25%

Basal Bolus Insulin Regimen in T2DM: SummaryBasal Bolus Insulin Regimen in T2DM: Summary

Umpierrez et al, Diabetes Care 2007; JCEM 2009; Diabetes 2010

120

140

160

180

200

220

0 1 2 3 4 5 6 7 8 9 10 11

Bloo

d Gl

ucos

e (m

g/dL

)

*† ‡

*


1 2 3 4 5 6 7 8 9 10

† †

Randomi-zation

Rabbit Surgery TrialGlucose levels during Basal Bolus and SSRI

Therapy

* p<0.001 † p: 0.01ŧ p: 0.02

Mainly Basal (Glargine) Insulin

4:004:00 16:0016:00 20:00 20:00 24:0024:00 4:004:00 8:008:0012:0012:008:008:00TimeTime

Glargine once daily

0.25 U/kg

Basal-PLUS Insulin RegimenBasal-PLUS Insulin RegimenIn

su

lin

Acti

on

Leahy J. In: Leahy J, Cefalu W, eds. Insulin Therapy. New York: Marcel Dekker; 2002:87; Nathan DM. N Engl J Med. 2002;347:1342

Aspart, Lispro or Apidra before meals per sliding scale

A1C < 7%

Re-start outpatient treatment regimen

(OAD and/or insulin)

A1C 7%-9%

Re-start outpatient oral agents and D/C

on glargine once daily at

50-80% of hospital dose

A1C >9%

D/C on basal bolus at same hospital

dose.

Alternative: re-start oral agents

and D/C on glargine once daily

at 50-80% of hospital dose

Discharge insulin Algorithm

Discharge Treatment

Needed Research StudiesNeeded Research Studies

What is the role of medical nutrition therapy in What is the role of medical nutrition therapy in non-critical care setting? non-critical care setting?

How should glycemia be monitored in non-How should glycemia be monitored in non-critical care setting? critical care setting?

How should hyperglycemia be managed across How should hyperglycemia be managed across transitions in care? transitions in care?

What are the best predictors of hypoglycemia?What are the best predictors of hypoglycemia? What is the financial impact of glycemic What is the financial impact of glycemic

control in non-critical care areas? control in non-critical care areas?

inpatient hyperglycemia in non-critical care setting

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