The Endocrine Society Updates the Clinical Guideline for Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings

This article was written by Mary T. Korytkowski, MD, Kellie Antinori-Lent, MSN, RN, and Amy C. Donihi, PharmD, BCPS, BC-ADM, FCCP.

Introduction

Patients with diabetes account for more than 25% of all hospitalized patients. Another 12% of hospitalized patients experience hyperglycemia due to previously undiagnosed diabetes, illness associated dysglycemia, or as a complication of therapies such as glucocorticoid administration or use of enteral or parenteral nutrition. Goal directed management of inpatient hyperglycemia is an important aspect of patient care that contributes to favorable clinical outcomes. Currently, there is wide variability in the attention provided to inpatient glycemic management in many hospital settings. In addition, the emerging use of technologies such as continuous glucose monitoring devices and insulin pump therapy, to facilitate glycemic management in the outpatient setting, has led to questions regarding the safe use of these therapies in the inpatient setting. To address the observed variability in management of inpatient hyperglycemia, the Endocrine Society convened a writing panel in 2019 to review and update the previous 2012 guideline that provided recommendations for glycemic management in non-critically ill-hospitalized patients.^1,2 The writing panel identified and addressed 10 frequently encountered clinical questions relating to inpatient glycemic management across a wide range of hospital settings.

Systematic reviews of relevant studies pertaining to each clinical question were performed prior to the development of a list of recommendations to assess the strength of the available research.³ This guideline employed an updated methodology adhering to the Institute of Medicine standards for formulating recommendations and, for the first time, included a patient representative on the panel of clinician experts.⁴ The results of these systematic reviews are published in the August 2022 issue of the Journal of Clinical Endocrinology and Metabolism. ¹

Summary of Recommendations

The updated guideline addresses evolving strategies for inpatient glycemic management that facilitate the ability to achieve desired glycemic goals, defined as blood glucose levels between 100 and 180 mg/dl, while also reducing risk for hypoglycemia that is recognized as a major barrier to the ability to achieve these goals. The following specific areas of glycemic management are addressed:

• Use of continuous glucose monitoring devices in combination with point-of-care blood glucose measures for monitoring blood glucose levels in patients at risk for hypoglycemia.
• Managing hyperglycemia in patients receiving glucocorticoids or enteral nutrition.
• Allowing continuation of insulin pump therapy for selected patients using these devices prior to hospitalization.
• Providing inpatient diabetes education as part of a comprehensive diabetes discharge-planning process to improve post-discharge glycemic measures and reduce risk for hospital readmission.
• Defining preoperative glycemic targets for patients undergoing elective surgical procedures to reduce risk for postoperative complications.
• Avoiding routine use of preoperative carbohydrate containing beverages for patients with diabetes undergoing elective surgical procedures.
• Using non-insulin glucose lowering therapies in selected patients with type 2 diabetes.
• Comparing carbohydrate counting with other methods for determining prandial insulin dosing.
• Identifying patient populations for whom correctional insulin (often referred to as sliding scale insulin) can be safely used as an initial glycemic management strategy.
• Defining patient populations for whom scheduled insulin therapy with basal and bolus insulin is essential.

Commentary

The guideline panel recognized that not all providers in the hospital have the knowledge and expertise necessary for implementing safe and effective glycemic management strategies. In addition, due to equity issues, not all hospitals have the resources necessary for implementation of potentially expensive technologies such as continuous glucose monitoring systems. Emphasis was placed on the need for hospital systems to have access to personnel who are knowledgeable in glycemic management strategies and familiar with use of newer technologies, including insulin pumps and continuous glucose monitoring systems to serve as a resource for clinicians and patients. This could be physicians, certified registered nurse practitioners, physician assistants, pharmacists, or diabetes care and education specialists. For example, patients who continue to use their personal insulin pumps or continuous glucose monitoring devices while in the hospital, require daily assessment of their physical and mental capacity to continue to use these devices with oversight by hospital personnel knowledgeable in these therapies. Implementation of a program of continuous glucose monitoring for patients at risk for hypoglycemia requires initial and ongoing staff education regarding placement of these devices, interpretation of the glycemic data, knowledge of interfering substances that result in erroneous information, and when to remove these devices (e.g., in preparation of radiologic procedures). The guideline addresses recommendations for pre-operative glycemic measures as this is an area where there has been much debate. Some surgeons recommend tight glycemic control prior to elective surgical procedures, while others will operate independent of glycemic measures. The systematic review conducted to address this question identified that patients with HbA1c values <8% and blood glucose values >< 180 mg/dl prior to surgery have fewer postoperative complications than those with higher values. To avoid preoperative hyperglycemia in patients with known diabetes, a recommendation was made against routine preoperative ingestion of oral carbohydrates.

Another important issue addressed in this guideline was the use of correctional insulin alone in the inpatient setting. Despite frequent concerns raised that use of correctional insulin alone would result in untoward glycemic excursions, a review of the literature suggests that there are selected patients for whom this may be a reasonable initial strategy. This includes patients with newly recognized hyperglycemia and patients with type 2 diabetes treated only with non-insulin therapies prior to admission. The panel recommended that patients who are treated with correctional insulin alone and who experience persistent hyperglycemia, defined as blood glucose levels > 180 mg/dl, be transitioned to scheduled insulin therapy with a basal bolus or basal only insulin regimen depending on patient circumstances, such as nutritional status. However, any patient treated with scheduled insulin therapy prior to admission will require continuation of this in the hospital, usually in combination with correctional insulin.

The use of non-insulin therapies for glycemic management in selected patients with type 2 diabetes or newly recognized hyperglycemia in the hospital is also addressed in the guideline. A review of the literature revealed only six studies addressing the safety and efficacy of these therapies in the hospital setting. The agents studied included glucagon like peptide 1 receptor agonists (GLP1RA) and dipeptidyl peptidase 4 inhibitors (DPP4i). It is important to note that these studies of non-insulin therapies included correctional insulin as part of the glycemic regimen. Based on the available data, the panel recommended against use of GLP1RA based on evidence of more nausea and increased patient dropouts with the short acting agent exenatide and limited information with other agents in this class. A conditional recommendation was made for use of DPP4i 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. Despite enthusiasm for hospital use of sodium glucose cotransporter 2 inhibitors (SGLT2i) for patients with heart failure, these agents have not been investigated for glycemic management of hospitalized patients. Given concerns for risk of urogenital infections and euglycemic DKA with SGLT2i, no recommendations could be made for their inpatient use as a glycemic management strategy.

Summary

Many of the recommendations in this updated 2022 guideline were made based on low or moderate quality evidence. However, it is hoped that this guideline will help resolve debates regarding appropriate preoperative glycemic targets, as well as appropriate use of correctional and scheduled insulin therapies. It is also hoped that this guideline will stimulate research funding for this important aspect of diabetes care, including use of non-insulin therapies, and that hospitals will recognize the importance of having access to diabetes care and education specialists whose direct and indirect involvement can lead to reductions in hospital readmissions, as well as improvements in glycemic control that persist well after hospital discharge. As described earlier, the patient representative on the guideline panel provided important insights regarding issues of patient satisfaction and preferences, as well as equity of glycemic management strategies during hospitalization and at time of hospital discharge. This representative expressed the hope that this guideline will encourage clinicians to engage in conversations as a way of ensuring individualized care. Many patients with diabetes may be well educated and self-sufficient with their glycemic management while others may need additional assistance.

References

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2. Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, Seley JJ, Van den Berghe G. Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology and Metabolism. 2012; 97:16-38.

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