All patients admitted to the hospital in noncritical care settings should have their blood glucose tested, according to a new clinical practice guideline from the Endocrine Society.
The guideline, published in the Journal of Clinical Endocrinology and Metabolism, is designed to complement previous recommendations that focused more on glucose targets, based largely on data from studies conducted in intensive/critical care settings (most recently Diabetes Care [2009;32:1119-31]). This new guideline is focused specifically on glucose management in noncritical settings, with special emphasis on systemic issues such as patient transition between hospital units and from inpatient to outpatient settings, as well as detailed guidance for hospitals on how to create systems and protocols that will ensure optimal patient management and safety (J. Clin. Endocrinol. Metab. 2012;97:16-38).
"This paper is different. It was viewed from the start as something that would be complementary to some of the earlier papers. It was a piece that hadn’t really been focused on. Your patients are more likely not to be in the ICU than in the ICU, so what about glycemic control at all the other times? That’s what a great deal of this statement is about," coauthor Dr. Richard Hellman said in an interview.
"Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline" was developed by an eight-member panel with representatives from the American Diabetes Association, American Heart Association, American Association of Diabetes Educators, European Society of Endocrinology, and the Society of Hospital Medicine. The lead author was Dr. Guillermo E. Umpierrez, professor of medicine at Emory University, and chief of diabetes and endocrinology at Grady Memorial Hospital, both in Atlanta. It was published Jan. 5.
It comprises eight sections, all focused on the noncritical hospital setting: diagnosis and recognition of hyperglycemia and diabetes; monitoring glycemia; glycemic targets; management of hyperglycemia; special situations; recognition and management of hypoglycemia; implementation of a glycemic control program; and patient and professional education. Strong recommendations are given as "we recommend," and weaker ones as "we suggest."
In the first section, assessment of all patients for a history of diabetes on admission is "recommended," while laboratory blood glucose testing on admission for all patients, regardless of prior diagnosis of diabetes, is "suggested." Still, there is strong rationale for it. "There’s abundant data to show that a very large number of people in hospitals have high blood sugars, and that correlates with poorer outcomes. The recommendation to check the glucose is extremely important because it isn’t just for people with a prior diagnosis of diabetes. Some come in with undiagnosed diabetes and people also develop stress hyperglycemia," noted Dr. Hellman, an endocrinologist who is a clinical professor of medicine at the University of Missouri–Kansas City.
Bedside capillary point-of-care (POC) glucose testing is recommended, using monitors that have demonstrated accuracy in acutely ill patients. Despite the acknowledged less-than-optimal accuracy of hand-held devices, the recommendation is based on the need for such testing in order to time glucose measures to match the patient’s nutritional intake and medication regimens. The patients’ personal glucose meters should not be used, and continuous glucose monitors, while "promising," have not been adequately tested in acute care and therefore can’t be recommended for hospital use at this time, Dr. Umpierrez and his associates wrote.
Recommended glycemic targets are the same as in the 2009 guideline: less than 140 mg/dL premeal and less than 180 mg/dL random for the majority of hospitalized patients with noncritical illness, with suggested modification according to clinical status. Lower targets might be considered among those who are able to achieve them without hypoglycemia, while higher targets might be appropriate for those at high risk for hypoglycemia or a limited life expectancy.
Medical nutrition therapy is recommended as a component of the glycemic management program for all hospitalized patients with diabetes and hyperglycemia. Meals with consistent amounts of carbohydrate are suggested, to help coordinate doses of rapid-acting insulin to carbohydrate ingestion.
Insulin therapy is recommended as the preferred method for achieving glycemic control in all hospitalized patients with diabetes and hyperglycemia, with the suggestion that oral hypoglycemic agents be discontinued and insulin therapy initiated in patients with type 2 diabetes at the time of admission for acute illness. That advice is based in part on the fact that contraindications to use of many oral agents are present in a high percentage of hospitalized patients. Such contraindications include use of metformin in patients with decompensated heart failure, renal insufficiency, hypoperfusion, or chronic pulmonary disease, and in any patient given intravenous contrast dye, the authors noted.