The Endocrine Society has updated their guideline for the management of hospitalized patients with diabetes or stress-induced hyperglycemia. Adult patients with diabetes or newly recognized hyperglycemia account for greater than 30% of noncritically ill hospitalized patients. These patients are at increased risk for “adverse clinical outcomes in the absence of defined approaches to glycemic management,” as described in Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline, which was published online in The Journal of Clinical Endocrinology & Metabolism.1

The guideline replaces the Society’s 2012 inpatient hyperglycemia guideline. Hospitalized patients who received steroid therapy or enteral nutrition are at high risk for hyperglycemia. The guidelines update some of the standards of care for glycemic management for non-critically ill-hospitalized adult patients with diabetes using an updated methodology that adheres to the Institute of Medicine (IOM) Standards, noted the society in a press release.2

The Endocrine Society guideline writing committee identified 10 frequently encountered areas specific to glycemic management in the hospital and made recommendations. Updates to the 2012 guideline include hospital use of continuous glucose monitoring and insulin pump therapy for patients at high risk for hypoglycemia, and providing inpatient diabetes education as part of a comprehensive diabetes discharge-planning process, according to the society (Table). In addition, the following new topics were included: 

  • Inpatient use of insulin pump therapy
  • Management of hyperglycemia in patients receiving glucocorticoids or enteral nutrition
  • Use of noninsulin glucose-lowering therapies
  • Preoperative blood glucose targets for patients undergoing elective surgical procedures
  • Specific recommendations for scheduled insulin therapy

“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 following discharge,” said Mary Korytkowski, MD, of the University of Pittsburgh in Pittsburgh, Pennsylvania. Dr Korytkowski is chair of the panel that wrote the guideline.2


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Table. Key Recommendations for Management of Hyperglycemia in Hospitalized Patients

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 preoperative HbA1c is ≤8% and when blood glucose values in the immediate preoperative period are <180 mg/dL
When targeting hemoglobin HbA1c to <8% is not feasible, clinicians should target preoperative blood glucose concentrations at 100 to 180 mg/dL (5.6 to 10 mmol/L)
Providing preoperative 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 writing committee that developed the guideline included members from the National Institutes of Health in Bethesda; national and international diabetes experts, and a member from the Diabetes Patient Advocacy Coalition. The guideline was cosponsored by the American Association of Clinical Endocrinologists, American Diabetes Association, Association of Diabetes Care and Education Specialists, Diabetes Technology Society, and European Society of Endocrinology.

References

1.  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. J Clin Endocrinol Metab. 2022;dgac278. Online ahead of print. doi:10.1210/clinem/dgac278

2. Endocrine Society’s clinical practice guideline offers recommendations for hospitalized patients with diabetes. News release. The Endocrine Society. June 12, 2022. Accessed June 13, 2022. https://www.endocrine.org/news-and-advocacy/news-room/2022/endocrine-societys-clinical-practice-guideline-offers-recommendations