With new technology and new drugs changing diabetes treatment at an unprecedented pace, the Endocrine Society’s “Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Guideline” looks through the latest evidence on glycemic control for the most comprehensive guidance on selecting the optimal approach in hospitalized patients.
The practice of medicine changes quickly, and the treatment of diabetes has changed dramatically with the advent of innovative technology like continuous glucose monitors and insulin pumps as well as new pharmacological approaches. In the 10 years since the Endocrine Society published its previous clinical guideline on the management of hyperglycemia in hospitalized patients in non-critical care settings, clinical experience and studies have amassed at a fast pace.
“Many of the recommendations in the earlier guideline were based on consensus of panel members without systematic reviews,” says Mary T. Korytkowski, MD, professor of medicine at the University of Pittsburgh Medical Center and chair of the committee that recently published an update of the hyperglycemia guideline. “There was a lot of mixed-messaging about how to care for these patients — including what their glycemic goals should be and how to best go about achieving those goals.”
So, the guideline committee members had their work cut out for them in wading through the recent literature. The task was so large that they took a novel approach — rather than trying to cover all the ground of the previous guideline, the update poses 10 key clinical questions and uses the best available evidence to answer them.
- Recent experience has shown that devices such as continuous glucose monitors can facilitate effective goal-directed glycemic management in hospitalized patients.
- Hospitalizations offer an opportunity to provide diabetes self-management education that can improve glucose management following discharge and reduce the risk of readmission.
- The question of when to choose between correctional insulin used alone or in combination with scheduled insulin requires an individualized approach, and a new Endocrine Society guideline provides guidance on selecting the optimal approach in hospitalized patients.
Monitors and Pumps
One of the areas foremost on the minds of the committee members was the dramatic changes wrought by advances in the technology of diabetes management with the widespread use of continuous glucose monitors and insulin pumps in the outpatient setting. The use of CGM in hospitals received a big boost early in the COVID-19 pandemic when the Food and Drug Administration gave permission (but not approval) to use the devices in hospitalized patients. “This guidance from the FDA opened the door to use these technologies in the inpatient setting as many hospitals adopted their use as one way of minimizing the amount of direct contact healthcare personnel had with COVID-19 patients early in the pandemic when supplies of personal protective equipment were not always sufficient,” Korytkowski says.
The success that many hospitals experienced in implementing CGM led to the guideline suggestion that hospitals should consider using real-time CGM with point-of-care blood glucose tests in adults with insulin-treated diabetes who are at high risk of hypoglycemia where adequate resources and training are available. Hospitals that lack these resources can continue using point-of-care blood glucose monitoring.
Guideline committee co-chair Ranganath Muniyappa, MD, PhD, hopes that the FDA will recognize this success and formally approve the use of CGM “in hospitalized patients with diabetes who are at high risk for hypoglycemia with guidance and consideration for safe implementation of these devices.” Muniyappa is a senior research physician at the National Institute of Diabetes and Digestive and Kidney Diseases.
As to another popular diabetes technology, the guideline suggests that patients who were using insulin pumps prior to their admission be allowed to continue using these devices provided they have the physical and mental capacity to do so rather than being changed to subcutaneous insulin therapy.
Importance of Education
Korytkowski says that the guideline also answers a question about the effectiveness of diabetes education in hospitalized patients. She notes that although education on diabetes self-management is often viewed as an outpatient issue, many patients never receive it. The evidence shows that “providing patients with education before they are discharged from the hospital reduces their risk for hospital readmissions and improves their glycemic control at three and six months following hospital discharge.”
Decisions on Therapies
Hospital caregivers need to be aware that commonly used therapies such as glucocorticoids or enteral nutrition can exacerbate hyperglycemia in patients with established diabetes or cause hyperglycemia in patients with no prior history of diabetes, Korytkowski says, so the guideline includes several recommendations for these situations, and reviews therapies that may be most appropriate.
For example, in patients receiving glucocorticoids, the guideline suggests glycemic management using either neutral protamine Hagedorn (NPH)-based insulin or basal-bolus insulin (BBI) regimens. Hospitalized patients receiving enteral nutrition frequently experience hyperglycemia, and the committee’s literature review suggested that either NPH-based or BBI regimens would be appropriate for these patients.
The guideline also suggests that insulin therapy be used for glycemic management instead of non-insulin therapies for most patients with diabetes or hyperglycemia.
Another area that has been a subject of controversy in recent years is the role of correctional insulin — usually a short- or rapid-acting insulin — used alone versus scheduled insulin to maintain glucose targets in hospitalized patients. “The guideline identifies patients for whom correctional insulin used alone might be a reasonable approach and patients for whom this would not a reasonable approach,” Korytkowski says.
For example, the guideline suggests that correctional insulin be used as the initial therapy in patients with no prior history of diabetes who experience hyperglycemia or those with type 2 diabetes treated with non-insulin therapy prior to admission to maintain blood glucose levels between 100–180 mg/dL (5.6–10.0 mmol/L). Scheduled insulin therapy is recommended when blood glucose values consistently exceed 180 mg/dl (10 mmol/L).
“Many of the recommendations in the earlier guideline were based on consensus of panel members without systematic reviews. There was a lot of mixed-messaging about how to care for these patients — including what their glycemic goals should be and how to best go about achieving those goals.”Mary T. Korytkowski, MD, professor of medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa.
For patients with insulin-treated diabetes prior to admission, the guideline recommends continuing their scheduled insulin regimen, while modifying it for their nutritional status and illness severity.
Another complex area the guideline tackles is the use of carbohydrate counting for calculating prandial insulin dosing. For patients with type 1 diabetes or insulin-treated type 2 diabetes, the guideline suggests use of either carbohydrate counting or fixed prandial insulin dosing. The guideline suggests against carbohydrate counting in patients with type 2 diabetes receiving non-insulin therapies or who are receiving insulin therapy only when hospitalized.
Although it does not concern patients already admitted to hospitals, Korytkowski says the guideline committee considered it important to review the literature examining glycemic measures prior to elective surgery and postoperative outcomes in patients with diabetes because of the great variability among surgeons on this issue: “Some surgeons will operate independent of a patient’s level of glycemic control. Other surgeons will recommend a hemoglobin A1c that may not be realistic for some patients before they will operate.”
“We found that being under reasonably good glucose control — that is, an HbA1c of less than 8% — before an elective surgical procedure reduces the risk for surgical complications,” Korytkowski says. For patients who can or cannot achieve this HbA1c level, a pre-operative blood glucose < 180 mg/dl (10 mmol/L) in the time immediately preceding elective surgery is suggested to reduce risk postoperative complications.
Another guideline suggestion for patients with diabetes preparing for surgical procedures is that they not be given carbohydrate-containing oral fluids preoperatively to avoid any exacerbation of hyperglycemia.
“Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Guideline” was published online on June 13 and will appear in the August 2022 print edition of The Journal of Clinical Endocrinology & Metabolism. It was co-sponsored 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.
SEABORG IS A FREELANCE WRITER BASED IN CHARLOTTESVILLE, VA. IN THE MAY ISSUE, HE PROVIDED AN ENDO 2022 PREVIEW OF THE SESSION “ENDOCRINE DEBATE: LOW RISK THYROID CANCER.”