Q&A: Mary Korytkowski, MD, and Ranganath Muniyappa, MD, PhD

ENDO_2022_4C

Ahead of their ENDO 2022 session on Monday June 13 from 11:00 a.m. to 12:30 p.m., Endocrine News talks with Mary Korytkowski, MD, and Ranganath Muniyappa, MD, PhD, chairs of the guideline development panel that created the latest Endocrine Society Clinical Practice Guideline on treating adult patients with hyperglycemia in a hospital setting.

This month, the Endocrine Society plans to issue a Clinical Practice Guideline on treating hospitalized patients with hyperglycemia. Titled “Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline.” This guideline serves as an update to the last guideline addressing glycemic management in a hospital setting from 2012. The guideline was published online June 13 and will appear in the August 2022 print issue of The Journal of Clinical Endocrinology & Metabolism.

Mary Korytkowski, MD, professor of medicine, Division of Endocrinology, University of Pittsburgh Medical Center, Pittsburgh, Pa., and Ranganath Muniyappa, MD, PhD, senior research physician, Clinical Endocrinology Section, Diabetes, Endocrinology, and Obesity Branch; director, Inter-Institute Endocrinology Fellowship Program, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesday, Md., are the chairs of the guideline development panel that authored the guideline. They shared their thoughts with Endocrine News about how they hope this guideline will aid healthcare professionals who treat hospitalized adult patients with hyperglycemia as well as prove to be a vital resource for professionals in other specialties.

Endocrine News: What were the main reasons for the publication of the inpatient hyperglycemia guideline – what drove the decision and why now?

Mary Korytkowski:

  • Management of inpatient hyperglycemia is an important aspect of patient care that contributes to clinical outcomes. There is wide variability in the attention provided to inpatient glycemic management in many hospital settings.
  • There are ongoing developments in technologies for diabetes care in the outpatient setting that have relevance to inpatient glycemic management. There are increasing numbers of patients who use continuous glucose monitoring (CGM) devices and continuous subcutaneous insulin infusion (CSII) devices (i.e. insulin pumps) either alone or in combination who are admitted to the hospital with these devices in place. In addition, CGM is being investigated for guiding glucose lowering therapies in hospitalized patients with hyperglycemia who were not using this prior to hospital admission.   
  • There are many questions regarding the use of non-insulin therapies in the inpatient setting.
  • The last Endocrine Society Clinical Guideline addressing glycemic management in non-critically ill hospitalized patients was published in 2012. Many of the recommendations in this earlier guideline were based on consensus of panel members without systematic reviews.

Ranganath Muniyappa, MD, PhD

“The guideline also acknowledges that hospitalization provides an opportunity for providing self-management education to patients, many of whom do not have access to this education in the outpatient setting. The practice of providing this information to patients can help improve glycemic measures following hospital discharge and reduce need for readmissions.”

Ranganath Muniyappa, MD, PhD, senior research physician, Clinical Endocrinology Section, Diabetes, Endocrinology, and Obesity Branch; director, Inter-Institute Endocrinology Fellowship Program, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md.

Endocrine News: What are your hopes for the impact of the guideline on endocrine performed standards of care for hospitalized patients in non-critical care setting with hyperglycemia?

Ranganath Muniyappa: There are several:

  • That the use of CGM in hospitalized patients with diabetes who are at high risk for hypoglycemia will receive approval by the FDA with guidance and consideration for safe implementation of these devices by hospitals.
  • That pre-operative glycemic management and targets for elective surgical procedures will be more consistent
  • That hospitals will acknowledge the importance of hiring knowledgeable DCES (either certified or eligible for certification) to:
    • Provide ongoing staff education regarding many of the recommendations for inpatient use of DM technologies (CGM CSII)
    • Provide oversight for patients using technologies for glycemic management in the hospital
    • Empower/ educate staff nurses to provide standardized diabetes self-management education to patients prior to discharge as a way of minimizing risk for hospital readmission
  • Resolve the debate regarding appropriate and inappropriate use of correctional insulin therapy (previously referred to as SSI) for inpatient glycemic management
  • Stimulate funding for research protocols for aspects of inpatient glycemic management for which there is little or no data available to guide clinical practice (e.g. use of metformin / SGLT2is / other emerging therapies in the hospital setting)

EN: How do you expect other medical specialties to be affected by the Guideline Development Panel’s recommendations?

MK: Patients with diabetes are admitted to every service in a hospital setting which means that all medical specialties will encounter this group of patients. It is important that all medical specialties be aware of the importance of glycemic management as a contributor to either positive or negative clinical outcomes. We do not anticipate that all medical specialties will have the expertise necessary for safe glycemic management, but that awareness of this will serve as an incentive for hospitals to provide personnel (MDS, CRNPs, PA’s, CDCES, pharmacists) who are knowledgeable in this practice.

There are several therapies that are commonly used in the hospital setting, including use of glucocorticoids or enteral nutrition, which can either exacerbate hyperglycemia in patients with established diabetes or cause hyperglycemia in patients with no prior history of diabetes. These patients are at higher risk for adverse outcomes when glycemic management in not addressed.

Examples of settings where this guideline may affect patient care include surgical subspecialties, some of which recommend tight glycemic control prior to elective surgical procedures, and others for which there is little of no thought given to pre-operative glycemic control.  Together with surgeons, another group that may be affected are anesthesiologists who are most likely to make decisions regarding use of pre-operative ingestion of oral carbohydrates, a practice that can exacerbate risk for hyperglycemia in some patients.

EN: What are the key take home messages for patients in this guideline?

RM: A patient representative served as a contributing member of the writing panel providing important insights to each of the questions addressed 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 these guidelines will serve as the beginning of a conversation that will allow inpatient caregivers to provide individualized care to patients some of whom may be self-sufficient with their glycemic management and others who may need additional assistance. The importance of these conversations cannot be overstated.

Having a patient voice for each of the recommendations represents a change in the way recommendations for clinical care were made in the pasts.

Mary Korytkowski, MD

“There are several therapies that are commonly used in the hospital setting, including use of glucocorticoids or enteral nutrition, which can either exacerbate hyperglycemia in patients with established diabetes or cause hyperglycemia in patients with no prior history of diabetes. These patients are at higher risk for adverse outcomes when glycemic management in not addressed.”

Mary Korytkowski, MD, professor of medicine, Division of Endocrinology, University of Pittsburgh Medical Center, Pittsburgh, Pa.

This guideline will help to empower patients with diabetes prior to admission to discuss continuation of technologies such as CGM or CSII that they were using prior to admission while in the hospital. The guideline places an emphasis on targeted glycemic management strategies that avoid both hypoglycemia and hyperglycemia in the hospital setting. This includes specific guidance as to when it is either appropriate or inappropriate to discontinue or modify glucose lowering therapies used prior to admission. Clear guidance is provided regarding use of correctional insulin previously referred to as sliding scale insulin.

Patients may be relieved to know specific glycemic targets prior to surgical procedures that can help avoid canceling surgical procedures due to hyperglycemia.

The guideline also acknowledges that hospitalization provides an opportunity for providing self-management education to patients, many of whom do not have access to this education in the outpatient setting. The practice of providing this information to patients can help improve glycemic measures following hospital discharge and reduce need for readmissions.                       

Editor’s Note: This article could not have happened without Andrea Hickman, the Endocrine Society’s manager of clinical practice guidelines, who coordinated and created this entire Q&A.

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