An updated Endocrine Society clinical practice guideline for the treatment of hospitalized patients with newly recognized or stress-induced diabetes or hyperglycemia was published online June 12 in the Journal of Clinical Endocrinology & Metabolism to coincide with presentation at the annual meeting. of the Endocrine Society, held from June 11 to 14 in Atlanta.
Mary T. Korytkowski, MD, of the University of Pittsburgh, and colleagues reviewed and updated the 2012 guidelines for the management of hyperglycemia in patients hospitalized in noncritical care settings. A multidisciplinary panel identified and prioritized 10 clinical questions related to the in-hospital management of patients with diabetes and/or hyperglycemia.
The panel made 15 recommendations related to 10 specific common areas of hospital glycemic management. These include conditional recommendations for the use of emerging diabetes technologies in the hospital, such as continuous glucose monitoring and insulin pump therapies; insulin regimens for prandial insulin dosing, hyperglycemia associated with glucocorticoids and associated with enteral nutrition; and use of non-insulin therapy. Recommendations were also made for issues related to preoperative glycemic measurements, appropriate use of corrective insulin, and in-hospital diabetes self-management education.
"This guideline addresses several important aspects of care specific to the in-hospital treatment of non-critically ill patients with newly recognized diabetes or hyperglycemia that have the potential to improve clinical outcomes in the hospital as well as after discharge," Korytkowski said in a statement. .
| Background |
Adult patients with newly recognized diabetes or hyperglycemia represent more than 30% of hospitalized patients who are not critically ill. These patients are at increased risk for adverse clinical outcomes in the absence of defined approaches to glycemic management.
| Aim |
Review and update the Endocrine Society ’s 2012 Management of Hyperglycemia in Hospitalized Patients in Noncritical Care Settings: A Clinical Practice Guideline and address emerging areas specific to the target population of noncritically ill hospitalized patients with diabetes or newly recognized or hyperglycemia. stress induced.
| Methods |
A multidisciplinary panel of clinical experts, along with a patient representative and experts in systematic reviews and guideline development, identified and prioritized 10 clinical questions related to the in-hospital management of patients with diabetes and/or hyperglycemia.
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 the evidence and make recommendations.
| Results |
The panel agreed on 10 specific areas of frequently encountered hospital glycemic management, for which 15 recommendations were made. The guideline includes conditional recommendations for hospital use of emerging diabetes technologies, such as continuous glucose monitoring and insulin pump therapy; insulin regimens for prandial dosing of insulin, glucocorticoids, and hyperglycemia associated with enteral nutrition; and the use of non-insulin therapies.
Recommendations were also made on issues related to preoperative glycemic measurements, appropriate use of corrective insulin, and in-hospital diabetes self-management education. A conditional recommendation was made against the preoperative use of caloric beverages in patients with diabetes.
| Conclusion |
Recommendations are based on 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.
| RECOMMENDATIONS |
> Recommendation 1 In adults with insulin -treated diabetes hospitalized for a non-critical illness who are at high risk of hypoglycemia , we suggest the use of real-time continuous glucose monitoring (CGM) with point-of-care blood glucose monitoring (POC-BG). ) confirmatory for insulin dosing adjustments instead of point-of-care blood glucose (POC-BG) testing only in hospital settings where resources and training are available. > Recommendation 2 In adult patients who are hospitalized for a noncritical illness and experience hyperglycemia while receiving glucocorticoids (GC), we suggest glycemic control with Hagedorn neutral protamine-based insulin (NPH) or basal-bolus insulin (BBI) regimens. > Recommendation 3 In adult patients using insulin pump therapy for diabetes control prior to admission for non-critical illness, we suggest that these patients continue insulin pump therapy rather than switching to basal-bolus insulin therapy. (BBI) subcutaneous (SC) in hospitals with access to staff experienced in insulin pump therapy. When experience is not accessible, we suggest that patients with an anticipated hospital stay (LOS) of more than 1 to 2 days transition to scheduled subcutaneous (SC) basal bolus insulin (BBI) before discontinuing an insulin pump. > Recommendation 4 In adult patients with diabetes who are hospitalized for a noncritical illness, we suggest providing inpatient diabetes education as part of a comprehensive diabetes discharge planning process, rather than not providing inpatient diabetes education. > Recommendation 5 For adult patients with diabetes undergoing elective surgical procedures , we suggest targeting preoperative hemoglobin A1c (HbA1c) levels < 8% (63.9 mmol/mol) and blood glucose (BG) concentrations of 100 to 180 mg /dL (5.6 to 10 mmol/L). > Recommendation 6 For adult patients with diabetes undergoing elective surgical procedures, when targeting hemoglobin A1c (HbA1c) at < 8% (63.9 mmol/mol) is not feasible , we suggest targeting preoperative blood glucose concentrations ( GS) from 100 to 180 mg/dl (5.6 to 10mmol/L). > Recommendation 7 In adult patients hospitalized for non-critical illness receiving enteral nutrition with diabetes-specific and non-diabetes-specific formulations, we suggest the use of basal bolus or neutral protamine Hagedorn (NPH)-based regimens. > Recommendation 8 In most adult patients with hyperglycemia (with or without known type 2 diabetes (T2D)) hospitalized for a noncritical illness, we suggest that scheduled insulin therapy be used instead of noninsulin therapies for glycemic control. > Recommendation 9 In selected adult patients with mild hyperglycemia and type 2 diabetes (T2D) hospitalized for non-critical illness, we suggest using a dipeptidyl peptidase-4 inhibitor (DPP4i) with correction insulin or scheduled insulin therapy. > Recommendation 10 In adult patients with type 1 diabetes (T1D), type 2 diabetes (T2D), or other forms of diabetes undergoing surgical procedures , we suggest not administering oral fluids containing carbohydrates (CHO) preoperatively. > Recommendation 11 In insulin-naive adult patients with type 2 diabetes (T2D) hospitalized for a non-critical illness requiring prandial insulin therapy, we suggest not using carbohydrate counting (CC) to calculate prandial insulin doses. > Recommendation 12 In adult patients with type 1 diabetes (T1D) or insulin-treated type 2 diabetes (T2D) hospitalized for a non-critical illness, we suggest carbohydrate counting (CC) or no carbohydrate counting (CC) with fixed doses of prandial insulin. > Recommendation 13 In adults without a history of diabetes hospitalized for a non-critical illness with hyperglycemia [defined as blood glucose (BG) > 140 mg/dL (7.8 mmol/L)] during hospitalization, we suggest initial corrective insulin therapy over scheduled insulin therapy (defined as basal or basal/bolus insulin) to maintain glucose goals in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For patients with persistent hyperglycemia [≥2 point-of-care blood glucose (POC-BG) measurements ≥180 mg/dL (≥10.0 mmol/L) in a 24-hour period with corrective insulin alone], we suggest add scheduled insulin therapy. > Recommendation 14 In adults with diabetes treated with diet or non-insulin diabetes medications before admission, we suggest initial therapy with correctional insulin or scheduled insulin therapy to maintain glucose goals in the range of 100 to 180 mg/dL (5, 6 to 10.0 mmol/L). For hospitalized adults started on corrective insulin alone and with persistent hyperglycemia [≥2 point-of-care blood glucose (POC-BG) measurements ≥180 mg/dL in a 24-hour period (≥10.0 mmol/L )], we suggest addition of scheduled insulin therapy. We suggest initiation of scheduled insulin therapy for patients with confirmed admission blood glucose (BG) ≥180 mg/dL (≥10.0 mmol/L). > Recommendation 15 In adults with diabetes treated with insulin before admission who are hospitalized for a noncritical illness, we recommend continuation of the modified scheduled insulin regimen based on nutritional status and disease severity to maintain glucose goals in the range of 100 at 180 mg/dl (5.6 to 10.0 mmol/L). |
* Access the full text of the Guide (PDF in English) here
