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Reviews/Commentaries/Position Statements
T E C H N I C A L R E V I E W

Management of Diabetes and Hyperglycemia in Hospitals
STEPHEN CLEMENT MD, CDE1 SUSAN S. BRAITHWAITE, MD2 MICHELLE F. MAGEE, MD, CDE3 ANDREW AHMANN, MD4 ELIZABETH P. SMITH, RN, MS, CANP, CDE1 REBECCA G. SCHAFER, MS, RD, CDE5 IRL B. HIRSCH, MD6 ON BEHALF OF THE DIABETES IN HOSPITALS WRITING COMMITTEE
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iabetesincreases the risk for disorders that predispose individuals to hospitalization, including coronary artery, cerebrovascular and peripheral vascular disease, nephropathy, infection, and lower-extremity amputations. The management of diabetes in the hospital is generally considered secondary in importance compared with the condition that prompted admission. Recent studies (1,2) have focused attention tothe possibility that hyperglycemia in the hospital is not necessarily a benign condition and that aggressive treatment of diabetes and hyperglycemia results in reduced mortality and morbidity. The purpose of this technical review is to evaluate the evidence relating to the management of hypergly-

cemia in hospitals, with particular focus on the issue of glycemic control and its possible impacton hospital outcomes. The scope of this review encompasses adult nonpregnant patients who do not have diabetic ketoacidosis or hyperglycemic crises. For the purposes of this review, the following terms are defined (adapted from the American Diabetes Association [ADA] Expert Committee on the Diagnosis and Classification of Diabetes Mellitus) (3):
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Unrecognized diabetes: hyperglycemia(fasting blood glucose 126 mg/dl or random blood glucose 200 mg/dl) occurring during hospitalization and confirmed as diabetes after hospitalization by standard diagnostic criteria, but unrecognized as diabetes by the treating physician during hospitalization. Hospital-related hyperglycemia: hyperglycemia (fasting blood glucose 126 mg/dl or random blood glucose 200 mg/dl) occurring during thehospitalization that reverts to normal after hospital discharge.

Medical history of diabetes: diabetes has been previously diagnosed and acknowledged by the patient’s treating physician.

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From the 1Georgetown University Hospital, Washington, DC; the 2University of North Carolina, Chapel Hill, NorthCarolina; 3Medstar Research Institute at Washington Hospital Center, Washington, DC; the 4Oregon Health and Science University, Portland, Oregon; the 5VA Medical Center, Bay Pines, Florida; and the 6 University of Washington, Seattle, Washington. Address correspondence and reprint requests to Dr. Stephen Clement, MD, Georgetown University Hospital, Department of Endocrinology, Bldg. D, Rm. 232, 4000Reservoir Rd., NW, Washington, DC 20007. E-mail: clements@gunet.georgetown.edu.. Received and accepted for publication 1 August 2003. S.C. has received honoraria from Aventis and Pfizer. S.S.B. has received honoraria from Aventis and research support from BMS. M.F.M. has been on advisory panels for Aventis; has received honoraria from Aventis, Pfizer, Bristol Myers Squibb, Takeda, and Lilly; and hasreceived grant support from Aventis, Pfizer, Lilly, Takeda, Novo Nordisk, Bayer, GlaxoSmithKline, and Hewlett Packard. A.A. has received honoraria from Aventis, Bayer, BMS, GlaxoSmithKline, Johnson & Johnson, Lilly, Novo Nordisk, Pfizer, and Takeda and research support from Aventis, BMS, GlaxoSmithKline, Johnson & Johnson, Lilly, Novo Nordisk, Pfizer, Roche, and Takeda. E.P.S. holds stock in Aventis.I.B.H. has received consulting fees from Eli Lilly, Aventis, Novo Nordisk, and Becton Dickinson and grant support from Novo Nordisk. Additional information for this article can be found in two online appendixes at http:// care.diabetesjournals.org. Abbreviations: ADA, American Diabetes Association; AMI, acute myocardial infarction; CDE, certified diabetes educator; CHF, congestive heart failure;...