10 priority areas for glycaemic management in the hospital

The Endocrine Society’s new guidelines on the management of hyperglycaemia in non-critical adult inpatients recognises the increased role of diabetes technology such as CGM over the last decade.

The guidelines, launched at ENDO 22 and published in the Journal of Clinical Endocrinology and Metabolism, comprise 15 recommendations on the 10 most frequently encountered areas specific to glycaemic management in the hospital

“The increasing use of CGM devices in the outpatient setting has led to significant improvements in glycemic measures and variability. Emerging data have led to increasing interest in incorporating CGM in the hospital setting,” it said.

Recommendations include:

  • The prioritisation of real-time CGM with confirmatory bedside point-of-care blood glucose (POC-BG) monitoring rather than POC-BG alone for insulin adjustments. It noted that CGM may not be accurate in patients with extensive skin infections, hypoperfusion or hypovolaemia and that some medications such as acetaminophen >4g/day can cause inaccurate readings.
  • Patients using insulin pump therapy for diabetes management prior to admission should continue insulin pump therapy rather than changing to subcutaneous (SC) basal bolus insulin (BBI) therapy in hospitals with expertise in insulin pump therapy.
  • Patients using hybrid closed-loop insulin pump therapy may also be able to continue this as long as the CGM and insulin pump are able to function without interference with hospital care.

In some of the other recommendations:

  • Patients who experience hyperglycaemia while receiving glucocorticoids (GC) can be managed with either neutral protamine Hagedorn (NPH)-based insulin or BBI regimens. Ongoing BG monitoring with adjustment of insulin dosing is required through GC tapering and discontinuation.
  • Patients with diabetes scheduled for elective surgery may have improved postoperative outcomes with preoperative targets of HbA1c levels < 8% (63.9 mmol/mol) and BG concentrations 5.6 to 10 mmol/L.
  • In adult patients hospitalised for noncritical illness who are receiving enteral nutrition with diabetes-specific and nonspecific formulations, use NPH-based or basal bolus regimens.
  • In most adult patients with hyperglycaemia (with or without known type 2 diabetes) hospitalised for a noncritical illness, scheduled insulin therapy should be used instead of noninsulin therapies for glycemic management.
  • DPP-4 inhibitors can be used in combination with correction insulin in selected patients with type 2 diabetes who have milder degrees of hyperglycaemia provided there are no contraindications to the use of these agents.

The guidelines were co-sponsored by the American Association of Clinical Endocrinologists, American Diabetes Association, Association of Diabetes Care and Education Specialists, Diabetes Technology Society, European Society of Endocrinology.

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