Hyperglycemia
Olivia C. Welter, PharmD
Hyperglycemia is a common occurrence in hospitalized patients whether they have diabetes or not. Patients with diabetes account for nearly 25% of inpatients, and up to an additional 25% of patients without diabetes may experience hyperglycemia while admitted to the hospital. Hyperglycemia is associated with complications for patients and longer hospital stays.
In June 2022, the Endocrine Society released a new clinical practice guideline to help health care teams with the latest glycemic management protocols. The guideline, published in the Journal of Clinical Endocrinology and Metabolism, is an update to the Endocrine Society’s previous decade-old guideline.
A team of clinicians, expert reviewers, and a patient representative identified 10 key questions related to hyperglycemic care for noncritically ill adult patients and provided 15 recommendations, summarized below, in response to these questions.
Continuous glucose monitoring
As medical device technology has advanced, continuous glucose monitoring (CGM) has become a mainstay of diabetes management for many patients.
While bedside capillary blood glucose monitoring is a standard practice for patients with diabetes, the new guideline recommends real-time CGM use partnered with bedside confirmatory blood glucose testing for insulin-treated patients who are at high risk for hypoglycemia.
Insulin use
The first insulin-related recommendation in the guideline specifically focuses on patients who are hyperglycemic and concurrently on glucocorticoid therapy.
Regardless of diabetes status, the patient’s glycemic management should include either an NPH-based insulin regimen or a basal bolus insulin regimen.
The guideline also recommends that, if a patient who was using an insulin pump prior to admission has access to a provider with expertise on insulin pumps, the patient should not be transitioned to subcutaneous insulin dosing. Contrarily, if no providers have adequate knowledge on insulin pumps, the patient should be transferred to scheduled subcutaneous basal bolus insulin dosing if their anticipated length of stay exceeds 2 days.
If a patient taking insulin is receiving enteral nutrition, the guideline recommends using either a basal bolus insulin regimen or an NPH-based insulin regimen.
Appropriateness of noninsulin therapies is also considered, and the guideline ultimately recommends that hyperglycemic patients receive scheduled insulin therapy rather than non-insulin therapies for glycemic management. However, in specific cases which are outlined in the guideline, a dipeptidyl peptidase 4–inhibitor may be used in addition to scheduled or correctional insulin.
When considering correctional insulin and prandial insulin regimens, the guideline breaks down recommendations by hyperglycemic patient type prior to admission: patients without diabetes, patients with diabetes managed with noninsulin therapies, and patients with diabetes managed with insulin.
The guideline suggests that patients without diabetes receive correctional insulin only, unless the patient is persistently hyperglycemic, in which case scheduled insulin should be added. Carbohydrate counting to dose prandial insulin is not necessary for these patients.
Patients with diabetes who do not manage their diabetes with insulin can be initiated on either a scheduled or correctional insulin regimen. Carbohydrate counting to dose prandial insulin is not necessary for these patients.
Insulin-managed patients with diabetes should continue their home regimen while hospitalized, although adjustments might be made to account for severity of disease and nutritional status. Carbohydrate counting to dose prandial insulin or implementing a fixed prandial dose without counting carbohydrates is recommended for these patients.
Inpatient diabetes education
Education is an important part of the care plan for inpatient patients with diabetes preparing for discharge. The guideline recommends that inpatient diabetes education be provided to all adult patients with diabetes to ensure the discharge planning process is as comprehensive as possible.
Preoperative practices
Since a planned, elective surgical procedure is not an emergency, there is time for patients to longitudinally correct their hemoglobin A1C to ensure the procedure is completed safely. The guideline recommends that patients with diabetes attain an A1C of < 8% prior to surgery and aim for their blood glucose to be in the 100–180 mg/dL range. ■