ATLANTA — Goal-directed glycemic management — which may include new technologies for glucose monitoring — for non-critically ill hospitalized patients who have diabetes or newly recognized hyperglycemia can improve outcomes, according to a new practice guideline from the Endocrine Society.
Even though roughly 35% of hospitalized patients have diabetes or newly discovered hyperglycemia, there is “wide variability in glycemic management in clinical practice,” writing panel chair Mary Korytkowski, MD, from the University of Pittsburgh, Pittsburgh, Pennsylvania, said during a press briefing at ENDO 2022.
“These patients get admitted to every patient service in the hospital, meaning that every clinical service will encounter this group of patients, and their glycemic management can have a major effect on their outcomes. Both short term and long term.”
This guideline provides strategies “to achieve previously recommended glycemic goals while also reducing the risk for hypoglycemia, and this includes inpatient use of insulin pump therapy or continuous glucose monitoring (CGM) devices, among others,” she said.
It also includes “recommendations for preoperative glycemic goals as well as when the use of correctional insulin — well known as sliding scale insulin — may be appropriate” and when it is not.
The document, which replaces a 2012 guideline, will be formally presented at the meeting here on Monday and is simultaneously published online in the Journal of Clinical Endocrinology & Metabolism.
A multidisciplinary panel developed the document over the last 3 years to answer 10 clinical practice questions related to management of non-critically ill hospitalized patients with diabetes or newly discovered hyperglycemia.
Use of CGM Devices in Hospital
The first recommendation is:
“In adults with insulin-treated diabetes hospitalized for noncritical illness who are at high risk of hypoglycemia, we suggest the use of real-time [CGM] with confirmatory bedside point-of-care blood glucose, monitoring for adjustments in insulin dosing rather than point-of-care blood glucose, rather than testing alone in hospital settings where resources and training are available.” (Conditional recommendation. Low certainty of evidence).
“We were actually very careful in terms of looking at the data” for use of CGMs, Korytkowski told Medscape Medical News.
Although CGMs are approved by the US Food and Drug Administration (FDA) in the outpatient setting, and that’s becoming the standard of care there, they are not yet approved for in-hospital use.
However, as previously reported, the FDA granted an emergency allowance for use of CGMs in hospitals during the COVID-19 pandemic.
That was “when everyone was scrambling for what to do,” Korytkowski noted. “There was a shortage of personal protective equipment and a real interest in trying to limit the amount of exposure of healthcare personnel in some of these really critically ill patients for whom intravenous insulin therapy was used to control their glucose level.”
On March 1, the FDA granted Breakthrough Devices Designation for Dexcom CGM use in the hospital setting.
The new guideline suggests CGM be used to detect trends in glycemic management, with insulin dosing decisions made with point-of-care glucose measure (the standard of care).
To implement CGM for glycemic management in hospitals, Korytkowski said, would require “extensive staff and nursing education to have people with expertise available to provide support to nursing personnel who are both placing these devices, changing these devices, looking at trends, and then knowing when to remove them for certain procedures such as MRI or radiologic procedures.”
“We know that not all hospitals may be readily available to use these devices,” she said. “It is an area of active research. But the use of these devices during the pandemic, in both critical care and non-critical care setting has really provided us with a lot of information that was used to formulate this suggestion in the guideline.”
The document addresses the following areas: CGM, continuous subcutaneous insulin infusion (CSII) pump therapy, inpatient diabetes education, prespecified preoperative glycemic targets, use of neutral protamine Hagedorn (NPH) insulin for glucocorticoid or enteral nutrition-associated hyperglycemia, noninsulin therapies, preoperative carbohydrate-containing oral fluids, carbohydrate counting for prandial (mealtime) insulin dosing, and correctional and scheduled (basal or basal bolus) insulin therapies.
Nine Key Recommendations
Korytkowski identified nine key recommendations:
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Continuous glucose monitoring systems can help guide glycemic management with reduced risk for hypoglycemia.
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Patients experiencing glucocorticoid- or enteral nutrition-associated hyperglycemia require scheduled insulin therapy to address anticipated glucose excursions.
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Selected patients using insulin pump therapy prior to a hospital admission can continue to use these devices in the hospital if they have the mental and physical capacity to do so with knowledgeable hospital personnel.
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Diabetes self-management education provided to hospitalized patients can promote improved glycemic control following discharge with reductions in the risk for hospital readmission. “We know that is recommended for patients in the outpatient setting but often they do not get this,” she said. “We were able to observe that this can also impact long-term outcomes “
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Patients with diabetes scheduled for elective surgery may have improved postoperative outcomes when preoperative A1c is ≤ 8% and preoperative blood glucose < 180 mg/dL. “This recommendation answers the question ‘Where should glycemic goals be for people who are undergoing surgery?’ “
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Providing preoperative carbohydrate-containing beverages to patients with known diabetes is not recommended.
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Patients with newly recognized hyperglycemia or well-managed diabetes on noninsulin therapy may be treated with correctional insulin alone as initial therapy at hospital admission.
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Some noninsulin diabetes therapies can be used in combination with correction insulin for patients with type 2 diabetes who have mild hyperglycemia.
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Correctional insulin — “otherwise known as sliding scale insulin” — can be used as initial therapy for patients with newly recognized hyperglycemia or type 2 diabetes treated with noninsulin therapy prior to hospital admission.
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Scheduled insulin therapy is preferred for patients experiencing persistent blood glucose values > 180 mg/dL and is recommended for patients using insulin therapy prior to admission.
The Guideline Writers’ Hopes
“We hope that this guideline will resolve debates” about appropriate preoperative glycemic management and when sliding insulin can be used and should not be used, said Korytkowski.
The authors also hope that “it will stimulate research funding for this very important aspect of diabetes care, and that hospitals will recognize the importance of having access to knowledgeable diabetes care and education specialists who can provide staff education regarding inpatient glycemic management, provide oversight for patients using insulin pump therapy or CGM devices, and empower hospital nurses to provide diabetes [self-management] education prior to patient discharge.”
Claire Pegg, the patient representative on the panel, hopes “that this guideline serves 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 need additional assistance.”
Development of the guideline was funded by the Endocrine Society. Korytkowski has reported no relevant financial disclosures. The disclosures of the other authors are listed with the original article.
J Clin Endocrinol Metab. Published online June 12, 2022. Full text
Annual Meeting of the Endocrine Society #ENDO2022. To be presented
June 13 during guideline session G01.
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