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

Key points

• Glucose targets for non-critically ill hospitalized adults are 100-180 mg/dL (5.6-10.0 mmol/L); scheduled insulin is suggested over non-insulin therapies for most patients with hyperglycemia.
• In patients with insulin-treated diabetes at high risk of hypoglycemia, real-time continuous glucose monitoring (CGM) with confirmatory point-of-care glucose testing is suggested where resources and training are available.
• Glucocorticoid-associated hyperglycemia can be managed with NPH-based or basal-bolus insulin; the same applies to enteral nutrition.
• Patients on insulin pumps may continue them in hospitals with pump expertise.
• Before elective surgery, the suggested targets are hemoglobin A1c below 8% and blood glucose of 100-180 mg/dL.

Overview

This Endocrine Society guideline, co-sponsored by AACE, ADA, ADCES, the Diabetes Technology Society and the European Society of Endocrinology, gives 15 recommendations on 10 common questions about hyperglycemia in non-critically ill hospitalized adults with diabetes or newly recognized or stress-induced hyperglycemia. It emphasizes emerging diabetes technology, insulin therapy and inpatient diabetes self-management education.

Monitoring and technology

High hypoglycemia risk includes age 65 years or older, body mass index 27 kg/m2 or less, total daily insulin of 0.6 units/kg or more, stage 3 or higher chronic kidney disease, prior hypoglycemia and impaired hypoglycemia awareness. CGM is not appropriate with extensive skin infections, hypoperfusion, hypovolemia or vasoactive therapy, and some drugs (for example acetaminophen above 4 g/day) can distort readings. Pump users should continue the pump where expertise exists; otherwise, those expected to stay more than 1-2 days should switch to scheduled subcutaneous basal-bolus insulin before the pump is stopped. Impaired consciousness, critical illness, diabetic ketoacidosis or hyperosmolar hyperglycemic state exclude inpatient pump use.

Insulin and non-insulin therapy

In adults without prior diabetes and with glucose above 140 mg/dL (7.8 mmol/L), initial correctional insulin is suggested, with scheduled insulin added if 2 or more readings are 180 mg/dL or higher within 24 hours. Patients on diet or non-insulin drugs may start with correctional or scheduled insulin, and scheduled insulin is suggested if admission glucose is confirmed at 180 mg/dL or higher. For insulin-treated diabetes, the scheduled regimen should be continued and adjusted for nutrition and illness severity (strong recommendation); basal-heavy regimens may need a 10-20% basal dose reduction. In select patients with mild hyperglycemia and type 2 diabetes (recent HbA1c below 7.5%, glucose below 180 mg/dL), a DPP4 inhibitor with correction insulin is an option.

Surgery, nutrition and education

If an HbA1c below 8% is not feasible before elective surgery, glucose of 100-180 mg/dL 1-4 hours before surgery is the target. Carbohydrate-containing oral fluids are not suggested preoperatively. Carbohydrate counting is not suggested for prandial dosing in non-insulin-treated type 2 diabetes, whereas patients with type 1 or insulin-treated type 2 diabetes may use it or fixed prandial doses. Inpatient diabetes education is suggested as part of discharge planning.

Frequently asked questions

What glucose range is targeted in the hospital?

100-180 mg/dL (5.6-10.0 mmol/L) for non-critically ill adults.

Can oral diabetes drugs be used in hospital?

Scheduled insulin is preferred for most patients, but a DPP4 inhibitor with correction insulin is an option in select patients with mild hyperglycemia and type 2 diabetes.

Should patients keep their insulin pump on admission?

Yes, if the hospital has pump expertise and the patient can safely self-manage the device.

Source

Korytkowski MT, Muniyappa R, Antinori-Lent K, Donihi AC, Drincic AT, Hirsch IB, et al. Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2022;107(8):2101. doi:10.1210/clinem/dgac278. This summary was prepared by Medpresso from the original publication and is not a substitute for the full text or medical advice.