Managing hyperglycemia in hospitalized adults

The 2012 Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline recommendations can be used for system improvement and clinical practice in adult patients with diabetes or newly recognized hyperglycemia, according to a recent review.

Without defined approaches to glycemic management, patients with diabetes or hyperglycemia are at an increased risk of adverse clinical outcomes such as increased incidence of complications, extended hospital stay, and disability after hospital discharge. 

Continuous glucose monitoring (CGM), the standard treatment for patients with insulin-treated diabetes, has the potential to be used for facilitating glycemic management and avoiding hypoglycemia in hospitalized patients. New data and technologies led to a need for reviewing the 2012 guideline.

The 2012 guidelinewas reviewed with focus on recommendations for managing noncritically ill hospitalized patients with diabetes or hyperglycemia.A Guideline Development Panel of clinician experts used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method to evaluate the recommendations. 

Fifteen guidelines from 10 areas of glycemic management were assessed. These areas were CGM, continuous subcutaneous insulin infusion (CSII), pump therapy, inpatient diabetes education, prespecified preoperative glycemic targets, and use neutral protamine Hagedorn (NPH) insulin for glucocorticoid (GC) or enteral nutritionassociated hyperglycemia.

Further areas included noninsulin therapies, preoperative carbohydrate (CHO)containing oral fluids, carbohydrate counting (CC) for prandial insulin dosing, and correctional and scheduled insulin therapies.

The first recommendation was to use real-time CGM for adjustments in insulin dosing. Data has indicated this may increase the detection of hypoglycemic events. It is preferred to point-of-care blood glucose (POC-BG) testing alone.

The second recommendation was to use glycemic management with either NPH-based insulin or basal bolus insulin (BBI) regimens in adult patients hospitalized for noncritical illness with hyperglycemia experiences. This has been associated with lower blood glucose (BG) with low-certainty evidence.

The third recommendation was to continue insulin pump therapy in patients with diabetes rather than switching subcutaneous (SC) BBI therapy. Data has indicated insulin pump therapy to be safe and not increasing risk of hypoglycemia or diabetic ketoacidosis.

The fourth recommendation was to provide inpatient diabetes education to patients hospitalized for noncritical illness. This has been shown to decrease hemoglobin A1c(HbA1c) by 1.25% at 3 months after discharge, along with reducing readmission rates.

The fifth recommendation was to target preoperative HbA1c levels and BG concentrations in diabetic adult patients undergoing elective surgical procedures, and to target BG concentration when targeting HbA1c to under 8% is not feasible. This reduces the risk of respiratory complications, neurologic complications, postoperative renal failure, and cardiac complications.

The sixth recommendation was to use NPH-based or basal bolus regimens in adult patients hospitalized for noncritical illness receiving enteral nutrition with diabetes-specific and nonspecific formulations. This may reduce hospital length of stay, but evidence is uncertain.

The seventh recommendation was to use insulin therapy rather than noninsulin therapy in patients hospitalized for a noncritical illness with hyperglycemia. The panel considered it favorable to use noninsulin therapy over insulin therapy in patients without a defined insulin requirement.

The 8 recommendation was to not preoperatively administer CHO-containing oral fluids in diabetic patients undergoing surgery. However, studies did not find significant evidence for changed hyperglycemia, BG, or hospital length of stay after this method.

The ninth recommendation was to not use CC to calculate prandial insulin dose in adult patient with noninsulin-treated type 2 diabetes hospitalized for noncritical illness, and to use CC or no CC with fixed prandial insulin dosing in adult patients with type 1 diabetes hospitalized for noncritical illness. This may lower average daily BG levels.

The final recommendation involved initial therapy for hospitalized adults. Those with no prior history of adolescents hospitalized for noncritical illness with hyperglycemia should be treated with correctional insulin over scheduled insulin therapy.

Adults with diabetes treated with noninsulin or diet medication before admission should receive correctional insulin or scheduled insulin therapy. Those with insulin-treated diabetes hospitalized for noncritical illness should receive continuation of schedule insulin medication. These treatments will maintain proper glucose levels in patients.

Reference

Korytkowski MT, Muniyappa R, Antinori-Lent K, et al. Management of hyperglycemia in hospitalized adult patients in non-critical care settings: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. 2022;107:2101–2128. doi:10.1210/clinem/dgac278