Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline

Abstract

Background Adult patients with diabetes or newly recognized hyperglycemia account for over 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. Objective To review and update the 2012 Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline and to address emerging areas specific to the target population of noncritically ill hospitalized patients with diabetes or newly recognized or stress-induced hyperglycemia. Methods A multidisciplinary panel of clinician experts, together with a patient representative and experts in systematic reviews and guideline development, identified and prioritized 10 clinical questions related to inpatient management of patients with diabetes and/or hyperglycemia. The systematic reviews queried electronic databases for studies relevant to the selected questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations. Results The panel agreed on 10 frequently encountered areas specific to glycemic management in the hospital for which 15 recommendations were made. The guideline includes conditional recommendations for hospital use of emerging diabetes technologies including continuous glucose monitoring and insulin pump therapy; insulin regimens for prandial insulin dosing, glucocorticoid, and enteral nutrition–associated hyperglycemia; and use of noninsulin therapies. Recommendations were also made for issues relating to preoperative glycemic measures, appropriate use of correctional insulin, and diabetes self-management education in the hospital. A conditional recommendation was made against preoperative use of caloric beverages in patients with diabetes. Conclusion The recommendations are based on the consideration of important outcomes, practicality, feasibility, and patient values and preferences. These recommendations can be used to inform system improvement and clinical practice for this frequently encountered inpatient population.

SGLT-2 inhibitor associated euglycaemic diabetic ketoacidosis in an orthopaedic trauma patient

“…In the postoperative period, in all patients admitted with SGLT-2 inhibitors, blood ketones should continue to be monitored, even in the context of normal blood glucose 18 38. The Endocrine Society recommends all patients with type 2 diabetes mellitus who miss more than one meal should be started on a variable-rate insulin infusion 41. Treatment with SGLT-2 inhibitors can be restarted once the patient is medically stable,18 38 eating and drinking normally,18 38 has normal ketones18 38 and had any volume depletion corrected 38.…”

Diabetes technology: A primer highlighting the role of the pharmacist

“…Recently, the Endocrine Society released guidelines related to hyperglycemia management in hospitalized patients. 55 Specific delineation pertaining to the continued use of both CGM and insulin pump therapy within noncritical care patients are described within these guidelines. The use of CGMs for hospitalized patients is currently not FDA approved; however, they have allowed use of CGM to reduce the need for personal protective equipment in the acute care setting and access to remote monitoring during the coronavirus pandemic.…”

“…Professional organizations, including the Endocrine Society, advocate for continuation of insulin pumps in appropriate hospitalized people with diabetes in the noncritical care setting. 1,3,55 Yet, many limitations exist and may affect hospital policies surrounding continuing use of technology during the hospital stay. Guidance for continuation or removal of insulin pumps while hospitalized is summarized in Table 14.…”

“…The use of diabetes technology in the inpatient setting is evolving. Recently, the Endocrine Society released guidelines related to hyperglycemia management in hospitalized patients 55 . Specific delineation pertaining to the continued use of both CGM and insulin pump therapy within noncritical care patients are described within these guidelines.…”

“…Studies also have demonstrated improved detection of hypo‐ and hyperglycemic events in both critically ill and noncritically ill patients 57,60‐62 . The Endocrine Society recommends the use of CGM monitoring in noncritical care patients at risk for hypoglycemia, coupled with confirmatory point of care testing, when dosing insulin in hospitalized patients 55 . Use of CGM in the hospital setting requires trained health care staff available to assist people wearing devices and assess data received.…”