Wypis ze szpitala
W celu uniknięcia błędów związanych ze stosowaniem leków oraz zmniejszenia częstości ponownych hospitalizacji przygotowania do przejścia od leczenia szpitalnego do ambulatoryjnego powinny rozpoczynać się już w momencie przyjęcia pacjenta do szpitala.117 Opierając się na niedawnym oznaczeniu stężenia HbA1C, u pacjentów, u których cukrzyca była uprzednio dobrze kontrolowana za pomocą leków doustnych (stężenie HbA1C <7%), rozsądne jest, aby w momencie wypisu powrócić do uprzednio stosowanego leczenia. Natomiast pacjenci z większym stężeniem HbA1C będą często wymagali intensyfikacji dotychczasowego leczenia ambulatoryjnego lub kontynuacji szpitalnego leczenia insuliną.5
Pacjenci, u których podczas hospitalizacji rozpoczęto leczenie insuliną, wymagają dokładnej edukacji diabetologicznej przed wypisem ze szpitala. Chociaż w wytycznych American Diabetes Association zalecono, aby u pacjentów prowadzić edukację w zakresie podstawowych informacji na temat cukrzycy w celu zapewnienia bezpiecznego leczenia po powrocie do domu,118 nie wiadomo, czy te zalecenia są realizowane ani czy pacjenci, u których taka edukacja zostanie przeprowadzona, potrafią wykorzystać te informacje po wypisie ze szpitala. Dostępne są jedynie ograniczone informacje na temat tego, co dzieje się z chorymi na cukrzycę po wypisie ze szpitala, i nie przeprowadzono niemal żadnych badań dotyczących poprawy jakości opieki w momencie przejścia od leczenia szpitalnego do ambulatoryjnego. W obecnych wytycznych zachęca się jednak, aby w momencie wypisu ze szpitala pacjenci i członkowie ich rodzin lub opiekunowie otrzymywali zarówno pisemne, jak i ustne instrukcje dotyczące zaleconego schematu leczenia cukrzycy.5 Zasadnicze znaczenie dla zapewnienia bezpiecznego i skutecznego przejścia do leczenia hipoglikemizującego w warunkach ambulatoryjnych ma również sprawna komunikacja ze świadczeniodawcami prowadzącymi leczenie ambulatoryjne.6
Wnioski
Hiperglikemia u pacjentów szpitalnych jest częsta i wiąże się ze zwiększonym ryzykiem powikłań zarówno u chorych na cukrzycę, jak i u pacjentów bez uprzednio rozpoznanej cukrzycy. Wykazano, że korygowanie hiperglikemii przez podawanie insuliny poprawia kliniczne wyniki leczenia,5,6 a dostępne dane kliniczne przemawiają za tym, aby w celu uzyskania i utrzymania kontroli glikemii u hospitalizowanych stosować insulinę, a nie inne leki przeciwcukrzycowe. Wykazano, że leczenie insuliną podstawową i bolusami poprawia kontrolę glikemii i zmniejsza częstość występowania powikłań okołooperacyjnych u internistycznych i chirurgicznych pacjentów z cukrzycą.12,30 Hipoglikemia jest najczęstszym działaniem niepożądanym i czynnikiem ograniczającym uzyskiwanie kontroli glikemii w warunkach szpitalnych. Mimo że w niedawnych badaniach stwierdzono związek między hipoglikemią a zwiększoną umieralnością w szpitalu, pozostaje niejasne, czy hipoglikemia jest bezpośrednim mediatorem niepomyślnych wyników leczenia i zgonów, czy też jedynie biomarkerem obciążenia chorobą oraz jej ciężkości.
Coraz więcej wstępnych danych wskazuje na to, że leki inkretynowe stwarzają możliwość poprawy kontroli glikemii z małym ryzykiem hipoglikemii. Potrzeba jednak więcej prospektywnych badań w celu określenia bezpieczeństwa i skuteczności tych leków w warunkach szpitalnych. Pozostałe dostępne leki przeciwcukrzycowe odgrywają ograniczoną rolę w szpitalu ze względu na potencjał poważnych działań niepożądanych, w tym ryzyko kwasicy mleczanowej w przypadku metforminy, hipoglikemii w przypadku pochodnych sulfonylomocznika i glinidów, obrzęków i niewydolności serca z powodu stosowania pioglitazonu, a także odwodnienia oraz zakażeń układu moczowego i dróg rodnych w przypadku inhibitorów SGLT-2.
Copyright 2014 American Diabetes Association. From Diabetes Spectrum, Vol. 27, No. 3, 2014, p. 180. Pharmacotherapy for hyperglycemia in noncritically ill hospitalized patients. Reprinted with permission from The American Diabetes Association.
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