Managing diabetes in hospitalized patients: Endocrine Society releases new guideline
USA: The Endocrine Society has released an updated guideline for the management of hospitalized patients with diabetes or stress-induced hyperglycemia.
The guideline is an updated version of the Society's inpatient hyperglycemia guideline and addresses emerging areas specific to non-critically ill hospitalized patients with diabetes or newly recognized or stress-induced hyperglycemia. Hyperglycemia is the technical term for high blood sugar. High blood sugar happens when the body has too little insulin or when the body cannot use insulin properly.
Over 30% of noncritically ill hospitalized patients are comprised of adult patients with diabetes or newly recognized hyperglycemia. These patients are at increased risk for adverse clinical outcomes in the absence of defined approaches to glycemic management.
The Clinical Practice Guideline, published in The Journal of Clinical Endocrinology & Metabolism, states that hospitalized patients with diabetes or hyperglycemia who receive goal-directed glycemic management may have better outcomes and less likelihood of readmission. Goal-directed glycemic management includes new technologies for glucose monitoring and pre-discharge diabetes self-management education.
"This guideline addresses several important aspects of care specific to inpatient management of non-critically ill patients with diabetes or newly recognized hyperglycemia that have the potential to improve clinical outcomes in the hospital as well as the following discharge," said Mary Korytkowski, M.D., of the University of Pittsburgh in Pittsburgh, Pa. Korytkowski is the chair of the panel that wrote the guideline.
The guideline, using an updated methodology that adheres to the Institute of Medicine (IOM) Standards, addresses, and updates some of the standards of care for glycemic management for non-critically ill-hospitalized adult patients with diabetes.
Updates to the 2012 guideline include consideration of monitoring blood sugar levels using continuous glucose monitoring devices in combination with point-of-care blood glucose measures for patients at high risk for hypoglycemia and providing inpatient diabetes education as part of a comprehensive diabetes discharge-planning process. In addition, new topics include recommendations for inpatient use of insulin pump therapy, management of hyperglycemia in patients receiving glucocorticoids or enteral nutrition, use of non-insulin glucose-lowering therapies, and preoperative blood glucose targets for patients undergoing elective surgical procedures, and specific recommendations for scheduled insulin therapy.
Key recommendations from the guideline include:
- Continuous glucose monitoring systems can guide effective glycemic management that reduces risk for hypoglycemia in hospitalized patients.
- Patients receiving glucocorticoid therapy or enteral nutrition—liquid nutrition delivered directly to the digestive system—are at high risk for hyperglycemia and require scheduled insulin therapy in the hospital.
- Patients using insulin pump therapy before hospital admission may self-manage these devices if they have the mental and physical capacity to do so with oversight by hospital personnel.
- Diabetes self-management education provided to hospitalized patients can promote improved glycemic control following discharge with reductions in the risk for hospital readmission.
- Patients with diabetes scheduled for elective surgery may have improved postoperative outcomes when pre-operative HbA1c is ≤ 8% and when blood glucose values in the immediate pre-operative period are < 180 mg/dL.
- Providing pre-operative carbohydrate-containing beverages to patients with known diabetes is not recommended.
- Patients with newly recognized hyperglycemia or well-managed diabetes on non-insulin therapy may be treated with correctional insulin alone as initial therapy at hospital admission.
- Scheduled insulin therapy is preferred for patients experiencing persistent blood glucose values > 180 mg/dL and is recommended for patients using insulin therapy prior to admission.
- Dipeptidyl peptidase inhibitors can be used in combination with correction insulin in selected patients with type 2 diabetes who have milder degrees of hyperglycemia provided there are no contraindications to the use of these agents.
"The recommendations are based on the consideration of important outcomes, practicality, feasibility, and patient values and preferences," the writing committee wrote in their guideline. "These recommendations can be used to inform system improvement and clinical practice for this frequently encountered inpatient population."
Reference:
Korytkowski MT, Muniyappa R, Antinori-Lent K, Donihi AC, Drincic AT, Hirsch IB, Luger A, McDonnell ME, Murad MH, Nielsen C, Pegg C, Rushakoff RJ, Santesso N, Umpierrez GE. Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2022 Jun 12:dgac278. doi: 10.1210/clinem/dgac278. Epub ahead of print. PMID: 35690958.
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