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s t o p p e da ss o o na sp o s s i b l ei nt h e first\ntrimester to avoid second and third tri-mester fetopathy (128). Antihypertensivedrugs known to be effective and safe in\npregnancy include methyldopa, nifedi-\npine, labetalol, diltiazem, clonidine, andprazosin. Atenolol is not recommended,but other b-blockers may... | [
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necessary. Chronic diuretic use duringpregnancy is not recommended as it hasbeen associated with restricted maternalplasma volume, which may reduce ute-roplacental perfusion (129). On the basis\nof available evidence, statins should also\nbe avoided in pregnancy (130).\nSee pregnancy and antihypertensive\nmedications i... | [
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medications in Section 10, “Cardiovascular\nDisease and Risk Management,” for more\ninformation on managing blood pressurein pregnancy.\nPOSTPARTUM CARE\nRecommendations\n15.23 Insulin resistance decreases\ndramatically immediately postpartum,diabetesjournals.org/care Management of Diabetes in Pregnancy S289\n©American... | [
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and insulin requirements need to be\nevaluated and adjusted as they are\noften roughly half the prepregnancy\nrequirements for the initial few dayspostpartum. C\n15.24 A contraceptive plan should\nbe discussed and implemented with\nall people with diabetes of childbear-\ning potential. A\n15.25 Screen individuals with ... | [
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ing potential. A\n15.25 Screen individuals with a recent\nhistory of GDM at 4 –12 weeks post-\npartum, using the 75-g oral glucosetolerance test and clinically appropri-\nate nonpregnancy diagnostic criteria. B\n15.26 Individuals with overweight/\nobesity and a history of GDM found | [
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15.26 Individuals with overweight/\nobesity and a history of GDM found\nto have prediabetes should receiveintensive lifestyle interventions and/ormetformin to prevent diabetes. A\n15.27 Breastfeeding efforts are rec-\nommended for all individuals withdiabetes. ABreastfeeding is recom- | [
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ommended for all individuals withdiabetes. ABreastfeeding is recom-\nmended for individuals with a his-tory of GDM for multiple bene fits,A\nincluding a reduced risk for type 2diabetes later in life. B\n15.28 Individuals with a history of\nGDM should have lifelong screeningfor the development of type 2 diabe-tes or pred... | [
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15.29 Individuals with a history of\nGDM should seek preconceptionscreening for diabetes and precon-ception care to identify and treat hy-perglycemia and prevent congenitalmalformations. E\n15.30 Postpartum care should include\npsychosocial assessment and supportfor self-care. E\nGestational Diabetes Mellitus\nPostpart... | [
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Gestational Diabetes Mellitus\nPostpartum Care\nBecause GDM often represents previ-\nously undiagnosed prediabetes, type 2diabetes, maturity-onset diabetes of theyoung, or even developing type 1 diabe-tes, individuals with GDM should be\ntested for persistent diabetes or predia-\nbetes at 4 –12 weeks postpartum with a | [
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betes at 4 –12 weeks postpartum with a\nfasting 75-g OGTT using nonpregnancycriteria as outlined in Section 2, “Diagnosis\nand Classi fication of Diabetes, ”specifi cally\nTables 2.1 and 2.2. The OGTT is recom-mended over A1C at 4 –12 weeks postpar- | [
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tum because A1C may be persistentlyimpacted (lowered) by the increased redblood cell turnover related to preg-nancy, by blood loss at delivery, or bythe preceding 3-month glucose pro file.\nT h eO G T Ti sm o r es e n s i t i v ea td e t e c t i n g | [
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T h eO G T Ti sm o r es e n s i t i v ea td e t e c t i n g\nglucose intolerance, including both predia-betes and diabetes. In the absence of un-equivocal hyperglycemia, a positive screen\nfor diabetes requires two abnormal val-\nues. If both the fasting plasma glucose($126 mg/dL [ $7.0 mmol/L]) and 2-h\nplasma glucose... | [
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plasma glucose ($200 mg/dL [ $11.1\nmmol/L]) are abnormal in a single screen-ing test, then the diagnosis of diabetes ismade. If only one abnormal value in theOGTT meets diabetes criteria, the test\nshould be repeated to confi rm that the\nabnormality persists. OGTT testing imme- | [
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abnormality persists. OGTT testing imme-\ndiately postpartum, while still hospitalized,has demonstrated improved engagementin testing but also variably reduced sensi-\ntivity to the diagnosis of impaired fasting\nglucose, impaired glucose tolerance, andtype 2 diabetes (131,132).\nIndividuals with a history of GDM shoul... | [
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Individuals with a history of GDM should\nhave ongoing screening for prediabetes or\ntype 2 diabetes every 1 –3y e a r s ,e v e ni f\nthe results of the initial 4 –12 week post-\npartum 75-g OGTT are normal. Ongoing\nevaluation may be performed with any rec-\nommended glycemic test (e.g., annual A1C, | [
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ommended glycemic test (e.g., annual A1C,\nannual fasting plasma glucose, or triennial75-g OGTT using thresholds for nonpreg-nant individuals).\nIndividuals with a history of GDM\nhave an increased lifetime maternalrisk for diabetes estimated at 50 –60%\n(133,134), and those with GDM havea 10-fold increased risk of dev... | [
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type 2 diabetes compared with those\nwithout GDM (133). Absolute risk ofdeveloping type 2 diabetes after GDMincreases linearly through a person ’s\nlifetime, being approximately 20% at\n10 years, 30% at 20 years, 40% at 30 years,\n50% at 40 years, and 60% at 50 years(134). In the prospective Nurses ’Health\nStudy II (N... | [
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Study II (NHS II), subsequent diabetes\nrisk after a history of GDM was signi fi-\ncantly lower in those who followed\nhealthy eating patterns (135). Adjustingfor BMI attenuated this association mod-\nerately, but not completely. Interpreg- | [
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erately, but not completely. Interpreg-\nnancy weight gain is associated withincreased risk of adverse pregnancy out-comes (136) and higher risk of GDM,while in people with BMI >25 kg/m\n2,\nweight loss is associated with lower riskof developing GDM in the subsequentpregnancy (137). Development of type 2diabetes is 18%... | [
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increase from prepregnancy BMI at\nfollow-up, highlighting the importance ofeffective weight management after GDM(138). In addition, postdelivery lifestyle in-terventions are effective in reducing risk oftype 2 diabetes (139).\nBoth metformin and intensive life- | [
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Both metformin and intensive life-\nstyle intervention prevent or delay pro-gression to diabetes in individuals withprediabetes and a history of GDM. Onlyfive to six individuals with prediabetes | [
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and a history of GDM need to be treatedwith either intervention to prevent onecase of diabetes over 3 years (140). Inthese individuals, lifestyle intervention\nand metformin reduced progression to di-\nabetes by 35% and 40%, respectively,over 10 years compared with placebo(141). If the pregnancy has motivated the | [
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adoption of healthy nutrition, building on\nthese gains to support weight loss is rec-ommended in the postpartum period.(See Section 3, “Prevention or Delay of\nDiabetes and Associated Comorbidities. ”)\nIndividuals with prediabetes or a his-\ntory of GDM will need preconceptionevaluation for as long as they have child... | [
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Preexisting Type 1 and Type 2\nDiabetes Postpartum Care\nInsulin sensitivity increases dramatically\nwith the delivery of the placenta. In one\nstudy, insulin requirements in the imme-\ndiate postpartum period are roughly34% lower than prepregnancy insulin re-quirements (142). Insulin sensitivity then\nreturns to prepr... | [
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returns to prepregnancy levels over the\nfollowing 1 –2 weeks. For individuals tak-\ning insulin, particular attention shouldbe directed to hypoglycemia prevention\nin the setting of breastfeeding and er-\nratic sleep and eating schedules (143).\nLactation\nConsidering the immediate nutritional andimmunological bene fit... | [
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for the baby, all mothers, including thosewith diabetes, should be supported in at-tempts to breastfeed. An analysis of 28systematic reviews and meta-analyses of\nassociations between breastfeeding and\noutcomes in children found that breast-feeding was associated with numeroushealth bene fits for children such as re- | [
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duced infant mortality due to infectiousdiseases at <6m o n t h so fa g e( o d d sr a t i o\n[OR] 0.22 –0.59 across studies), reduced\nrespiratory infections in children aged\n<2 years, and reduced asthma or wheez-\ni n gi nc h i l d r e na g e d5 –18 years (OR 0.91, | [
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i n gi nc h i l d r e na g e d5 –18 years (OR 0.91,\n0.85– 0.98) (144). The same analysis foundS290 Management of Diabetes in Pregnancy Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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that breastfeeding was associated with\nimproved maternal health outcomes in-cluding reduced risks of breast cancer\n(OR 0.81 [95% CI 0.77 –0.86]), ovarian\nc a n c e r( O R0 . 7 0[ 9 5 %C I0 . 6 4 –0.75]), and\ntype 2 diabetes (OR 0.68 [95% CI 0.57 –\n0.82]). Breastfeeding may also confer\nlonger-term metabolic bene fi... | [
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longer-term metabolic bene fits to both\nmother (145) and offspring (146). Breast-feeding reduces the risk of developing\ntype 2 diabetes in mothers with previous\nGDM (145). It may improve the metabolicrisk factors of offspring, but more studies\nare needed (147). However, lactation can\nincrease the risk of overnight ... | [
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increase the risk of overnight hypoglyce-\nmia, and insulin dosing may need to be\nadjusted.\nContraception\nA major barrier to effective preconcep-tion care is the fact that the majority\nof pregnancies are unplanned. Planning\npregnancy is critical in individuals with\npreexisting diabetes to achieve the opti- | [
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preexisting diabetes to achieve the opti-\nmal glycemic goals necessary to preventcongenital malformations and reduce\nthe risk of other complications. There-\nfore, all individuals with diabetes of\nchildbearing potential should have fam-\nily planning options reviewed at regularintervals to make sure that effective | [
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contraception is implemented and main-\ntained. This applies to individuals in the\nimmediate postpartum period. Individu-\nals with diabetes have the same contra-ception options and recommendations as\nthose without diabetes. Long-acting, re-\nversible contraception may be ideal for\nindividuals with diabetes and chil... | [
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0.06934545934200287,
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0.03738771006464958,
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0.004167633596807718,
0.10332851111888885,
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-0.0415712... |
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0.014624254778027534,
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16. Diabetes Care in the Hospital:\nStandards of Care in Diabetes—\n2024\nDiabetes Care 2024;47(Suppl. 1):S295 –S306 |https://doi.org/10.2337/dc24-S016American Diabetes Association\nProfessional Practice Committee *\nThe American Diabetes Association (ADA) “Standards of Care in Diabetes ”includes | [
0.010850194841623306,
0.02899003028869629,
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0.045990217477083206,
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0.02734426222741604,
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0.054066918790340424,
-0.0884341225028038,
-0.00722... |
the ADA ’s current clinical practice recommendations and is intended to provide the\ncomponents of diabetes care, general treatment goals and guidelines, and tools to | [
-0.04139997065067291,
0.0067419796250760555,
-0.08455739915370941,
0.06411178410053253,
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0.022022750228643417,
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0.04925420135259628,
-0.11957837641239166,
0.03734... |
evaluate quality of care. Members of the ADA Professional Practice Committee, aninterprofessional expert committee, are responsible for updating the Standards ofCare annually, or more frequently as warranted. For a detailed description ofADA standards, statements, and reports, as well as the evidence-grading systemfor ... | [
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0.07729093730449677,
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0.020894693210721016,
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as well as the evidence-grading systemfor ADA ’s clinical practice recommendations and a full list of Professional Prac- | [
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tice Committee members, please refer to Introduction and Methodology. Read-ers who wish to comment on the Standards of Care are invited to do so atprofessional.diabetes.org/SOC.\nAmong hospitalized individuals, hyperglycemia, hypoglycemia, and glucose variability | [
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are associated with adverse outcomes, including increased morbidity and mortality(1). Identi fication and careful management of people with diabetes and dysglycemia\nduring hospitalization has direct and immediate bene fits. Diabetes management in\nthe inpatient setting is facilitated by identi fication and treatment of h... | [
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prior to elective procedures, a dedicated inpatient diabetes management service ap-\nplying validated standards of care, and a proactive transition plan for outpatient dia-\nbetes care with timely prearranged follow-up appointments. These steps canimprove outcomes, shorten hospital stays, and reduce the need for readmi... | [
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emergency department visits. For older hospitalized individuals or for people with di-\nabetes in long-term care facilities, please see Section 13, “Older Adults. ”\nHOSPITAL CARE DELIVERY STANDARDS\nRecommendations\n16.1 Perform an A1C test on all people with diabetes or hyperglycemia (random | [
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blood glucose >140 mg/dL [ >7.8 mmol/L]) admitted to the hospital if no A1C test\nresult is available from the prior 3 months. B\n16.2 Institutions should implement protocols using validated written or comput-\nerized provider order entry sets for management of dysglycemia in the hospital | [
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(including emergency department, intensive care unit [ICU] and non-ICU wards,gynecology-obstetrics/delivery units, dialysis suites, and behavioral health units)that allow for a personalized approach, including glucose monitoring, insulin and/or noninsulin therapy, hypoglycemia management, diabetes self-management educa... | [
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management, diabetes self-management educa-tion, nutrition recommendations, and transitions of care. B | [
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Considerations on Admission\nHigh-quality hospital care for diabetes requires standards for care delivery, which are\nbest implemented using structured order sets and quality improvement strategies for*A complete list of members of the American\nDiabetes Association Professional Practice Committeecan be found at https:... | [
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Duality of interest information for each author is\navailable at https://doi.org/10.2337/dc24-SDIS.\nSuggested citation: American Diabetes Association\nProfessional Practice Committee. 16. Diabetes carein the hospital: Standards of Care in Diabetes —\n2024. Diabetes Care 2024;47(Suppl. 1):S295 –S306 | [
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2024. Diabetes Care 2024;47(Suppl. 1):S295 –S306\n© 2023 by the American Diabetes Association.Readers may use this article as long as thework is properly cited, the use is educationaland not for pro fit, and the work is not altered. | [
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More information is available at https://www.diabetesjournals.org/journals/pages/license.16. DIABETES CARE IN THE HOSPITALDiabetes Care Volume 47, Supplement 1, January 2024 S295\n©AmericanDiabetesAssociation | [
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process improvement. Unfortunately, “best\npractice ”protocols, reviews, and guidelines\nare inconsistently implemented within hos-\npitals (2). To correct this, medical centersstriving for optimal inpatient diabetestreatment should establish protocols andstructured order sets, which include com-\nputerized provider or... | [
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puterized provider order entry (CPOE).\nInstitutions are encouraged to performaudits regularly to monitor proper use andinstitute educational/training programs tokeep staff up to date.\nInitial evaluation should state the type\nof diabetes (i.e., type 1, type 2, gesta-tional, pancreatogenic, drug related, or\nnutrition... | [
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nutrition related) when it is known. Be-\ncause inpatient treatment and dischargeplanning are more effective when pread-mission glycemia is considered, A1Cshould be measured for all people withdiabetes or dysglycemia admitted to the\nhospital if no A1C test result is available\nfrom the previous 3 months (3 –6). In | [
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from the previous 3 months (3 –6). In\naddition, diabetes self-managementknowledge and behaviors should be as-sessed on admission, and diabetes self-management education provided (if\navailable), especially if a new treatment | [
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available), especially if a new treatment\nplan is being considered. Diabetes self-management education should includeknowledge and survival skills needed af-ter discharge, such as medication dosingand administration, glucose monitoring,and recognition and treatment of hypo-\nglycemia (7). Evidence supports pread- | [
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glycemia (7). Evidence supports pread-\nmission treatment of hyperglycemia inpeople scheduled for elective surgery as aneffective means of reducing adverse out-comes (8 –11).\nThe National Academy of Medicine rec-\nommends CPOE to prevent medication-\nrelated errors and to increase medication\nadministration ef ficiency... | [
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administration ef ficiency (12). Systematic\nreviews of randomized controlled trialsusing computerized advice to improveglycemic outcomes in the hospital foundsignificant improvement in the percent-\nage of time individuals spent in the gly-\ncemic goal range, lower mean blood | [
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cemic goal range, lower mean blood\nglucose levels, and no increase in hypo-glycemia (13). Where feasible, thereshould be structured order sets that pro-vide computerized guidance for glycemicmanagement. Insulin dosing algorithms\nusing machine learning and data in the | [
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using machine learning and data in the\nelectronic health record (EHR) currentlyin development show promise for pre-dicting insulin requirements duringhospitalization (14).Diabetes Care Specialists in the\nHospital\nRecommendation\n16.3 When caring for hospitalized peo-\nple with diabetes (with an existing or | [
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ple with diabetes (with an existing or\nnew diagnosis) or stress hyperglycemia,consult with a specialized diabetes orglucose management team when ac-cessible. B\nCare provided by appropriately trained\nspecialists or specialty teams may reduce | [
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the length of stay and improve glycemicand other clinical outcomes (15,16). In ad-dition, the increased risk of 30-day read-mission following hospitalization that hasbeen attributed to diabetes can be re-duced, and costs saved, when inpatientcare is provided by a specialized diabetesmanagement team (15,17,18). In a cro... | [
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team (15,17,18). In a cross-sectional study comparing usual care to | [
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specialists reviewing diabetes cases and\nmaking recommendations virtually throughthe EHR, rates of both hyperglycemia andhypoglycemia were reduced by 30 –40% | [
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(19). Providing inpatient diabetes self-management education and developing adiabetes discharge plan that includes con-tinued access to diabetes medicationsand supplies and ongoing education andsupport are key strategies to improve out-comes (20,21). Details of diabetes careteam composition and other resourcesare avail... | [
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careteam composition and other resourcesare available from the Joint Commission | [
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accreditation program for the hospital\ncare of diabetes, from the Society of Hos-pital Medicine workbook, and from theJoint British Diabetes Societies (JBDS) forInpatient Care Group (22 –24).\nGLYCEMIC GOALS IN\nHOSPITALIZED ADULTS\nRecommendations\n16.4 Insulin Aand/or other therapies\nBshould be initiated or intensi... | [
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Bshould be initiated or intensi fied for\ntreatment of persistent hyperglycemia\nstarting at a threshold of $180 mg/dL\n($10.0 mmol/L) (con firmed on two\noccasions within 24 h) for noncritically\nill (non-ICU) individuals. A\n16.5a Once therapy is initiated, a\nglycemic goal of 140 –180 mg/dL\n(7.8–10.0 mmol/L) is recom... | [
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glycemic goal of 140 –180 mg/dL\n(7.8–10.0 mmol/L) is recommended\nfor most critically ill (ICU) individuals\nwith hyperglycemia. A\n16.5b More stringent glycemic goals, such\nas 110 –140 mg/dL (6.1– 7.8 mmol/L),\nmay be appropriate for selectedcritically ill individuals and are accept-\nable if they can be achieved wi... | [
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able if they can be achieved withoutsignificant hypoglycemia. B\nStandard Defi nitions of Glucose\nAbnormalities\nHyperglycemia in hospitalized individuals isdefined as blood glucose levels >140 mg/dL\n(>7.8 mmol/L) (2). An admission A1C value\n$6.5% ( $48 mmol/mol) suggests that | [
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$6.5% ( $48 mmol/mol) suggests that\nthe onset of diabetes preceded hospitali-zation (see Section 2, “Diagnosis and\nClassifi cation of Diabetes ”). Level 1 hypo-\nglycemia is de fined as a glucose concen-\ntration of 54 –69 mg/dL (3.0 –3.8 mmol/L).\nLevel 2 hypoglycemia is de fined as\na glucose concentration <54 mg/dL | [
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Level 2 hypoglycemia is de fined as\na glucose concentration <54 mg/dL\n(<3.0 mmol/L), which is typically the\nthreshold for neuroglycopenic symptoms.Level 3 hypoglycemia is de fined as a clini-\ncal event characterized by altered mental\nand/or physical functioning that requires | [
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and/or physical functioning that requires\nassistance from another person for recov-ery ( Table 6.4 ) (25,26). Levels 2 and 3\nrequire immediate intervention and cor-rection of low blood glucose. Prompt\ntreatment of level 1 hypoglycemia is\nrecommended as an effort to preventprogression to more signi ficant level 2\nan... | [
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and level 3 hypoglycemia.\nGlycemic Goals\nIn a landmark clinical trial conducted in asurgical intensive care unit (ICU), Vanden Berghe et al. (27) demonstrated that\nan intensive intravenous insulin protocol\nwith a glycemic goal of 80 –110 mg/dL\n(4.4–6.1 mmol/L) reduced mortality by | [
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(4.4–6.1 mmol/L) reduced mortality by\n40% compared with a standard approachof a glycemic goal of 180 –215 mg/dL\n(10–12 mmol/L) in critically ill hospitalized\nindividuals with recent surgery. This studyprovided evidence that active treatmentto lower blood glucose in hospitalized in-dividuals could have immediate bene... | [
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However, a large, multicenter follow-up\nstudy in critically ill hospitalized individu-\nals, the Normoglycemia in Intensive CareEvaluation and Survival Using GlucoseAlgorithm Regulation (NICE-SUGAR) trial(28), led to a reconsideration of the opti-\nmal glucose lowering goal in critical illness. | [
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0.04628... |
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