A Systematic Review Supporting the Endocrine Society Clinical Practice Guideline for the Management of Hyperglycemia in Adults Hospitalized for Noncritical Illness or Undergoing Elective Surgical Procedures

Abstract

Context Individuals with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. Management of hyperglycemia in these patients is challenging. Objective To support development of the Endocrine Society Clinical Practice Guideline for management of hyperglycemia in adults hospitalized for noncritical illness or undergoing elective surgical procedures. Methods We searched several databases for studies addressing 10 questions provided by a guideline panel from the Endocrine Society. Meta-analysis was conducted when feasible. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess certainty of evidence. Results We included 94 studies reporting on 135 553 patients. Compared with capillary blood glucose, continuous glucose monitoring increased the number of patients identified with hypoglycemia and decreased mean daily blood glucose (BG) (very low certainty). Data on continuation of insulin pump therapy in hospitalized adults were sparse. In hospitalized patients receiving glucocorticoids, combination neutral protamine hagedorn (NPH) and basal-bolus insulin was associated with lower mean BG compared to basal-bolus insulin alone (very low certainty). Data on NPH insulin vs basal-bolus insulin in hospitalized adults receiving enteral nutrition were inconclusive. Inpatient diabetes education was associated with lower HbA1c at 3 and 6 months after discharge (moderate certainty) and reduced hospital readmissions (very low certainty). Preoperative HbA1c level < 7% was associated with shorter length of stay, lower postoperative BG and a lower number of neurological complications and infections, but a higher number of reoperations (very low certainty). Treatment with glucagon-like peptide-1 agonists or dipeptidyl peptidase-4 inhibitors in hospitalized patients with type 2 diabetes and mild hyperglycemia was associated with lower frequency of hypoglycemic events than insulin therapy (low certainty). Caloric oral fluids before surgery in adults with diabetes undergoing surgical procedures did not affect outcomes (very low certainty). Counting carbohydrates for prandial insulin dosing did not affect outcomes (very low certainty). Compared with scheduled insulin (basal-bolus or basal insulin + correctional insulin), correctional insulin was associated with higher mean daily BG and fewer hypoglycemic events (low certainty). Conclusion The certainty of evidence supporting many hyperglycemia management decisions is low, emphasizing importance of shared decision-making and consideration of other decisional factors.

Gaps in our knowledge of managing inpatient dysglycaemia and diabetes in non‐critically ill adults: A call for further research

“…The focus for funding on diabetes research has, for several decades essentially ignored the needs of this vulnerable population. The Endocrine Society in the USA has recently updated its guidance on the management of hyperglycaemia in hospitalised individuals and has an accompanying systematic review which gives the reasons for their recommendations, and the strength of the evidence 17,19 . However, they only cover 10 questions.…”

“…The Endocrine Society in the USA has recently updated its guidance on the management of hyperglycaemia in hospitalised individuals and has an accompanying systematic review which gives the reasons for their recommendations, and the strength of the evidence. 17 , 19 However, they only cover 10 questions. Resources are needed to enable such systematic reviews of the available evidence to identify the many other gaps in our knowledge for the whole of the patient journey and in all circumstances and facilities for which a person with diabetes may be admitted.…”

“…The American Diabetes Association (ADA) and the American Association Clinical Endocrinology (AACE), and the Endocrine Society have also produced guidelines and recommendations but, unlike the JBDS documents, their emphasis is often not on specific aspects of inpatient care 15–18 . They have also produced a systematic review of the evidence behind some of their recommendations 19 . All of these documents have been produced by a multidisciplinary team of interested professionals 20 .…”

“… 15 , 16 , 17 , 18 They have also produced a systematic review of the evidence behind some of their recommendations. 19 All of these documents have been produced by a multidisciplinary team of interested professionals. 20 However, the authors of these documents freely admit that whilst many of the recommendations are based on the available evidence from randomized controlled trials and observational studies, a lot of the guidance is based on consensus, driven by expert opinion.…”

Improving inpatient hyperglycaemia in non-critically ill adults in resident wards through audit and feedback

“…The Endocrine Society and American Diabetes Association (ADA)/American Association of Clinical Endocrinologists (AACE) Practice Guidelines in 2022 were published to update the previous 2012 guidelines for the management of hyperglycaemia in hospitalised non-critical care settings. They recommend that most non-critically ill patients receiving insulin treatment maintain a premeal glucose level below 140 mg/dL and a random glucose level below 180 mg/dL 5 6. Per recommendation 7.1, ‘in most adult patients with hyperglycaemia hospitalised for a non-critical illness, we suggest that scheduled insulin therapy be used instead of non-insulin therapies for glycaemic management’ 7.…”