Inpatient Hyperglycemia Guideline Resources

May 13, 2022

Full Guideline: Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline
JCEM | XXXX 2022 (online June 2022)

Mary T. Korytkowski (Chair), Ranganath Muniyappa (Co-Chair), Kellie Antinori-Lent, Amy C. Donihi, Andjela T. Drincic, Irl B. Hirsch, Anton Luger, Marie E. McDonnell, M. Hassan Murad, Craig Nielsen, Claire Pegg, Robert J. Rushakoff, Nancy Santesso, Guillermo E. Umpierrez

The 2022 guideline on management of hyperglycemia in hospitalized adult patients in non-critical care settings:

  • Focuses on the treatment of hyperglycemia in non-critically ill hospitalized adult patients with diabetes and/or with newly recognized or stress-induced hyperglycemia.
  • Emphasizes the use of emerging diabetes technology and insulin therapy for glycemic management and inpatient diabetes self-management education.

A systematic review supporting the Endocrine Society clinical practice guideline: Management of inpatient hyperglycemia (link to be provided before/on the date of publication)


Resources

  • Clinician Education Presentation (Free CME) | Endocrine Society
  • Patient Resources | ENDOCares (link to be provided before/on the date of publication)
  • Guidelines Pocket Card | Guideline Central
  • Interview with the Chair | Endocrine News

Essential Points

  • Continuous glucose monitoring systems can effectively achieve glycemic targets and reduce hypoglycemia in hospitalized patients.
  • Patients receiving glucocorticoid therapy or enteral nutrition 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 with oversight by hospital personnel.
  • Diabetes self-management education to hospitalized patients can promote improved glycemic control with reductions in the risk for hospital readmission.
  • Patients with diabetes scheduled for elective surgery may have improved postoperative outcomes when pre-operative hemoglobin A1c (HbA1c) is ≤8% and when blood glucose (BG) 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.
  • 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.

List of Recommendations

Recommendation 1.1:

In adults with insulin-treated diabetes hospitalized for non-critical illness who are at high risk of hypoglycemia, we suggest the use of real time continuous glucose monitoring (CGM) with confirmatory bedside point-of-care blood glucose (POC-BG) monitoring for adjustments in insulin dosing rather than POC-BG testing alone in hospital settings where resources and training are available. (2⊕⊕◯◯)

Remarks:

  • In hospitals where CGM is not available, monitoring of blood glucose (BG) levels can be continued with POC-BG testing as an alternative option.
  • Patients identified as being at high risk for hypoglycemia include but are not limited to the following criteria: age ≥65 years; body mass index (BMI) ≤27 kg/m2; total daily dose of insulin ≥0.6 units/kg; history of Stage 3 or higher chronic kidney disease (eGFR < 60 mL/min/1.73m2), liver failure, cerebrovascular accident, active malignancy, pancreatic disorders, congestive heart failure, or infection; or history of preadmission hypoglycemia or hypoglycemia occurring during a recent or current hospitalization; or impaired awareness of hypoglycemia.
  • This recommendation does not apply to situations in which CGM may not be accurate, including in patients with extensive skin infections, hypoperfusion, or hypovolemia or those receiving vasoactive or pressor therapy. In addition, some medications can cause inaccurate CGM readings (e.g., acetaminophen >4 g/day, dopamine, vitamin C, hydroxyurea).

Recommendation 2.1:

In adult patients who are hospitalized for non-critical illness and experience hyperglycemia while receiving glucocorticoids (GCs), we suggest glycemic management with either neutral protamine Hagedorn (NPH)-based insulin or basal-bolus insulin (BBI) regimens. (2⊕⊕◯◯)

Remarks:

  • An NPH-based regimen may consist of NPH (with or without prandial insulin) given in divided doses depending on the timing, pharmacokinetics and frequency of the specific GC being administered. NPH insulin may be added to BBI, if the patient is already on this regimen.
  • Management of patients with GC-associated hyperglycemia requires ongoing BG monitoring with adjustment of insulin dosing. All therapies require safeguards to avoid hypoglycemia when doses of GCs are tapered or abruptly discontinued.

Recommendation 3.1:

In adult patients using insulin pump therapy for diabetes management prior to admission for non-critical illness, we suggest that these patients continue insulin pump therapy rather than changing to subcutaneous (SC) BBI therapy in hospitals with access to personnel with expertise in insulin pump therapy. Where expertise is not accessible, we suggest that patients with anticipated hospital length of stay (LOS) of more than 1-2 days be transitioned to scheduled SC BBI before discontinuation of an insulin pump. (2⊕⊕◯◯)

Remarks: 

  • Patients with an impaired level of consciousness, inability to appropriately adjust pump settings, critical illness (intensive care unit [ICU] care), diabetic ketoacidosis, or hyperosmolar hyperglycemic state are not candidates for inpatient use of the insulin pump. Any change in a patient’s condition that would interfere with their ability to safely self-manage the insulin pump device requires removal and transition to SC therapy (Table 3). Availability of supplies (provided by the patient or patient’s family) over the course of the hospitalization is necessary. Adaptation of the basal rate might be needed at time of admission.
  • Patients using hybrid closed loop insulin pump therapy may be able to continue this at time of admission if they meet criteria similar to that for patients using insulin pump therapy independently of a CGM device as long as the CGM and insulin pump are able to function without interference with hospital care.  If CGM fails or is removed from the patient, the insulin pump can be reverted to manual mode as long as basic criteria for pump use in hospital are still met.
  • Hospitals need to have policies, procedures including patients’ informed consent, and standardized order sets in place as well as expertise from a health care professional who is knowledgeable in insulin pump therapy. These policies and procedures should include information for management of insulin pump devices during magnetic resonance imaging, computed tomography, or other imaging studies, in addition to any surgical procedures.

Recommendation 4.1:

In adult patients with diabetes who are hospitalized for non-critical illness, we suggest providing inpatient diabetes education as part of a comprehensive diabetes discharge-planning process, rather than not providing inpatient diabetes education. (2⊕⊕⊕◯)

Remarks:

  • Inpatient diabetes education is best provided by diabetes care and education specialists (DCESs).  Where availability of DCESs is limited, DCESs can serve as a resource to healthcare providers specifically tasked to provide inpatient diabetes education (e.g., staff nurses, pharmacists, dieticians, etc.) by providing training and support.
  • Ideally, the DCESs should be Certified Diabetes Care and Education Specialists (CDCESs) and/or hold the Board Certified-Advanced Diabetes Management (BC-ADM) credential or be working toward one of these certifications.
  • A comprehensive diabetes discharge-planning process includes education on and validation of diabetes survival skills, referral for outpatient DSMES, scheduling diabetes care follow-up appointments, and ensuring access to the medications and supplies required for diabetes self-management following discharge.
  • In the case of limited personnel, healthcare providers providing diabetes education could prioritize education for patients at high risk for hospital readmission, those admitted for diabetes-related issues, and those newly diagnosed with diabetes or newly starting insulin.

Recommendations:

Recommendation 5.1: For adult patients with diabetes undergoing elective surgical procedures, we suggest targeting preoperative hemoglobin A1c (HbA1c) levels <8% (63.9 mmol/mol) and BG concentrations 100-180 mg/dL (5.6-10 mmol/L). (2⊕◯◯◯)

Recommendation 5.2: For adult patients with diabetes undergoing elective surgical procedures when targeting HbA1c to <8% (63.9 mmol/mol) is not feasible, we suggest targeting preoperative BG concentrations 100-180 mg/dL (5.6-10 mmol/L). (2⊕◯◯◯)

Remarks: 

  • These recommendations apply only to patients who are scheduled for elective surgical procedures for whom it would be reasonable to allow time for implementation of therapies that target either a preoperative HbA1c or BG level.
  • BG concentrations should be within the targeted range of 100-180 mg/dL (5.6-10 mmol/L) 1-4 hours prior to surgery.
  • Factors that may affect HbA1c levels such as anemia, hemoglobinopathies, chronic renal failure, alcoholism, drugs and large BG variations should be taken into account.

Recommendation 6.1:

In adult patients hospitalized for non-critical illness who are receiving enteral nutrition with diabetes- specific and non-specific formulations, we suggest using NPH-based or basal bolus regimens. (2⊕◯◯◯)

Recommendations: 

Recommendation 7.1: In most adult patients with hyperglycemia (with or without known type 2 diabetes [T2D]) hospitalized for a non-critical illness, we suggest that scheduled insulin therapy be used instead of non-insulin therapies for glycemic management. (2⊕⊕◯◯) 

Remarks:

  • Dipeptidyl peptidase-4 inhibitors (DPP4is) may be appropriate in select patients with T2D (see Recommendation 7.2), including those with established non-insulin–requiring diabetes nearing hospital discharge. 
  • It may be reasonable to begin other non-insulin therapies in stable patients prior to discharge as a part of a coordinated transition plan.

Recommendation 7.2: In select adult patients with mild hyperglycemia and T2D hospitalized for a non-critical illness, we suggest using either DPP4i with correction insulin or scheduled insulin therapy. (2⊕⊕◯◯)

Remarks:

  • Select patients include those with T2D that is moderately well-managed as reflected by a recent HbA1c <7.5% (9.4 mmol/L); BG <180 mg/dL (10 mmol/L); and, if on insulin therapy before hospitalization, to have a total daily insulin dose <0.6 units/kg/day; this recommendation applies both to patients taking the DPP4i before admission and those who are not.
  • Patients who develop persistently elevated BG (e.g., >180 mg/dL [10 mmol/L]) on DPP4i therapy should be managed with scheduled insulin therapy; this recommendation does not apply to patients with (type 1 diabetes) T1D or other forms of insulin-dependent diabetes.
  • As with all new therapies started in the hospital, a discussion with the patient about cost and overall acceptability is suggested if there are plans to continue the medication after discharge.

Recommendation 8.1:

In adult patients with T1D, T2D, and other forms of diabetes undergoing surgical procedures, we suggest not administering carbohydrate (CHO)-containing oral fluids preoperatively. (2⊕◯◯◯) 

 

Recommendations:

Recommendation 9.1: In adult patients with non-insulin treated T2D hospitalized for non-critical illness who require prandial insulin therapy, we suggest not carbohydrate counting (CC) for calculating prandial insulin doses. (2⊕◯◯◯) 

Recommendation 9.2: In adult patients with T1D, insulin-treated T2D hospitalized for non-critical illness, we suggest either CC or no CC with fixed prandial insulin dosing. (2⊕◯◯◯) 

Remarks:

  • Patients who perform CC in the outpatient setting, including those with insulin-treated T2D, may prefer to continue this method of calculating prandial insulin doses during hospitalization. An insulin to carbohydrate ratio (ICR) is used to calculate the prandial dose of insulin when using CC.
  • A policy to guide CC for calculating prandial insulin dosing in the hospital is necessary for safe implementation, as is expertise from a health care professional knowledgeable in diabetes management.
  • In hospitals where expertise, resources, and training are available, either CC or fixed prandial insulin dosing can be implemented
  • Adjustments to the ICR may be needed in the hospital setting to address the impact of illness or treatments on insulin requirements (e.g.,  glucose-interfering medications, infection, surgery, insulin resistance).

Recommendations:

Recommendation 10.1: In adults with no prior history of diabetes hospitalized for non-critical illness with hyperglycemia (defined as BG > 140 mg/dL [7.8 mmol/L]) during hospitalization, we suggest initial therapy with correctional insulin over scheduled insulin therapy (defined as usual basal  or basal/bolus) to maintain glucose targets in the range of 100-180 mg/dL (5.6-10.0 mmol/L). For patients with persistent hyperglycemia (≥2 POC-BG measurements ≥180 mg/dL [>10.0 mmol/L] in a 24-hour period on correctional insulin), we suggest the addition of scheduled insulin therapy. (2⊕OOO)

Recommendation 10.2: In adults with diabetes treated with diet or non-insulin diabetes medications prior to admission, we suggest initial therapy with correctional insulin or scheduled insulin therapy to maintain glucose targets in the range of 100-180 mg/dL (5.6-10.0 mmol/L). For hospitalized adults started on correctional insulin alone and with persistent hyperglycemia (≥2 POC-BG measurements ≥180 mg/dL in a 24-hour period [>10.0 mmol/L]), we suggest addition of scheduled insulin therapy. We suggest initiation of scheduled insulin therapy for patients with confirmed admission BG >180 mg/dL (>10.0 mmol/L). (2⊕OOO)

Recommendation 10.3: In adults with insulin-treated diabetes prior to admission who are hospitalized for non-critical illness, we recommend continuation of the scheduled insulin regimen modified for nutritional status and severity of illness to maintain glucose targets in the range of 100-180 mg/dL (5.6-10.0 mmol/L). (1⊕⊕OO)

Remarks: 

  • Reductions in the dose of basal insulin (by 10-20%) at time of hospitalization may be required for patients on basal heavy insulin regimens (defined as doses of basal insulin ≥0.6-1.0 units/kg/day), in which basal insulin is being used inappropriately to cover meal-related excursions in BG.
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