Management of Hyperglycemia in Hospitalized Adult

Patients in Non-Critical Care Settings: An Endocrine

Society Clinical Practice Guideline
The Journal of Clinical Endocrinology & Metabolism, 30, April, 2022

Mary T. Korytkowski,1, Ranganath Muniyappa,2 Kellie Antinori-Lent,3 Amy C. Donihi,4

Andjela T. Drincic,5 Irl B. Hirsch,6 Anton Luger,7 Marie E. McDonnell,8, M. Hassan Murad,9
Craig Nielsen, 10 Claire Pegg, 11 Robert J. Rushakoff, 12 Nancy Santesso, 13 and
Guillermo E. Umpierrez14
Definition of Terms Used:
1. Sliding scale insulin (SSI):
• A rapid-acting insulin analogue or regular insulin is administered for an elevated BG level often
without regard to timing of food, the presence or absence of preexisting insulin administration, or
individualization of the patient’s sensitivity to insulin.
• Doses range from 0 units to a prespecified maximum dose for BG levels below and above a
defined level.
2. Correction insulin therapy:
• Administration of a rapid-acting analogue or regular insulin based on POC-BG readings obtained
prior to a meal in patients who are eating or at 4- to 6-hour intervals in patients who are nil per
os.
• Correction insulin can be used alone in specific situations or in combination with scheduled
insulin therapy.

3. Scheduled insulin therapy:

• A combination of an intermediate- or long-acting basal insulin with prandial administration of a
rapid- or short-acting insulin prior to meals or as a combination of basal insulin with correction
insulin administered every 4-6 hours based on POC-BG levels.
4. Basal bolus insulin (BBI) therapy:
• An approach to scheduled insulin therapy that combines
A. basal insulin administered once or twice a day with
B. prandial insulin in combination with correction insulin.

5. Carbohydrate counting (CC):

• A method used to calculate prandial insulin doses based on the anticipated amount of CHO to be
consumed as part of a meal.
Question 1:
• Should CGM (with confirmatory point-of-care blood glucose monitoring for adjustments in insulin
dosing) vs bedside capillary blood glucose monitoring be used for adults with diabetes
hospitalized for noncritical illness?

Recommendation 1.1:
• We suggest the use of real-time CGM with confirmatory bedside  point-of-care blood glucose
(POC-BG) monitoring for adjustments in insulin dosing rather than  point-of-care blood glucose
(POC-BG) testing alone in hospital settings where resources and training are available.
(2⊕⊕◯◯)
Remarks:
• Patients at high risk for hypoglycemia include:
 Age ≥ 65 years
 BMI ≤ 27 kg/m2
 Total daily dose of insulin ≥ 0.6 units/kg
 History  of stage ≥3 chronic kidney disease (estimated glomerular filtration rate < 60 mL/min/1.73
m2), liver failure, CVA, active malignancy, pancreatic disorders, CHF, or infection
 History of preadmission hypoglycemia or hypoglycemia during a recent or current hospitalization;
or impaired awareness of hypoglycemia.
• This recommendation does not apply to situations in which CGM may not be accurate, including
in patients with extensive skin infections, hypoperfusion, or hypovolemia or those receiving
vasoactive or pressor therapy.
• Some medications can cause inaccurate CGM readings (eg, acetaminophen > 4 g/day, dopamine,
vitamin C, hydroxyurea).
• In hospitals where  CGM is not available, monitoring of blood glucose (BG) levels can be
continued with POC-BG testing as an alternative option.
Other evidence to decision criteria and considerations:
• Panel members placed a high value on the moderate benefits that may occur with CGM use,
including early detection and avoidance of hypoglycemia, and less on the trivial undesired effects.
• The majority of patients included in studies comparing CGM with POC-BG had type 2 diabetes.
• The baseline risk of hypoglycemia may be similar in insulin treated patients with T2D to what
occurs with type 1 diabetes, suggesting that hospitalized patients with T1D would derive similar
benefits with CGM use.
• Hospitals will need to consider costs associated with CGM devices, training of personnel who will
be using these devices, and increased costs that could occur with repeated sensor malfunctions
or need for replacement in patients undergoing MRIor other radiologic procedures.
• The accuracy of CGM devices when compared to POC-BG measures in the inpatient setting has
been demonstrated as moderate to good in several RCT and non-RCT studies in the inpatient
setting.
• The lower accuracy of CGM for BG < 70 mg/dL (<3.9 mmol/L) raises some concern for
overtreating low BG; however, the benefit of avoiding significant hypoglycemia outweighs this
concern.
• The lower accuracy at higher BG levels supports recommendations to confirm results with POC-
BG prior to making insulin adjustments.
• Calibration of any CGM device with POC-BG within the first 12 hours following initial placement of
the sensor device is important for validating the reliability or accuracy of glucose readings
obtained using CGM.
• For patients using sensor augmented insulin pump therapy, the pump device can be placed in
manual mode in the event of failure or insufficient supplies to continue to use the patient-owned
CGM.
Question 2:
• Should NPH insulin regimens vs basal bolus insulin regimens be used for adults with
hyperglycemia hospitalized for noncritical illness receiving glucocorticoids?

Recommendation 2.1:
• We suggest glycemic management with either neutral protamine Hagedorn (NPH)-based insulin
or basal bolus insulin (BBI) regimens. (2⊕⊕◯◯)
Remarks:
• NPH insulin may be added to BBI if the patient is already on this regimen.
• All therapies require safeguards to avoid hypoglycaemia when doses of GCs are tapered or
abruptly discontinued.
• Neither regimen demonstrated cost, feasibility, acceptability, or equity advantages.
Question 3:
• Should continuous subcutaneous insulin infusion pump therapy be continued vs transitioning to
scheduled subcutaneous insulin therapy for adults with diabetes on pump therapy who are
hospitalized for noncritical illness?

Recommendation 3.1:
• We suggest that these patients continue insulin pump therapy rather than changing to SC basal
bolus insulin (BBI) therapy in hospitals with access to personnel with expertise in insulin pump
therapy.
• Where expertise is not accessible, we suggest that patients with anticipated hospital length of
stay of more than 1 to 2 days be transitioned to scheduled  subcutaneous (SC) basal bolus insulin
(BBI) before discontinuation of an insulin pump. (2⊕⊕◯◯).

Remarks:
• Patients with an impaired level of consciousness, inability to appropriately adjust pump settings,
critical illness (intensive care unit care), DKA, or HHS are not candidates for inpatient use of the
insulin pump.
• Hospitals need to have policies and procedures including patients’ informed consent and
standardized order sets in place as well as expertise from a healthcare professional who is
knowledgeable in insulin pump therapy.

• These policies and procedures should include information for management of insulin pump
devices during MRI, CT, or other imaging studies, in addition to any surgical procedures.
Question 4:
• Should inpatient diabetes education be provided vs not provided before discharge for adults with
diabetes hospitalized for noncritical illness?

Recommendation 4.1:
• We suggest providing inpatient diabetes education as part of a comprehensive diabetes discharge
planning process, rather than not providing inpatient diabetes education. (2⊕⊕⊕◯)
Remarks:
• A comprehensive diabetes discharge-planning process includes education on and validation of
diabetes survival skills, referral for outpatient diabetes self-management education and support,
scheduling diabetes care follow-up appointments, and ensuring access to the medications and
supplies required for diabetes self-management following discharge.
• In the case of limited personnel, healthcare providers providing diabetes education could
prioritize education for patients at high risk for hospital readmission, those admitted for diabetes-
related issues, and those newly diagnosed with diabetes or newly starting insulin.
Question 5:
• Should prespecified preoperative blood glucose and/or Hb A1c levels be targeted for adults with
diabetes undergoing elective surgical procedures?

Recommendation 5.1:
• For adult patients with diabetes undergoing elective surgical procedures, we suggest targeting
preoperative  hemoglobin A1c (HbA1c) levels < 8% (63.9 mmol/mol) and blood glucose (BG)
concentrations 100 to 180 mg/dL (5.6 to10 mmol/L) (2⊕◯◯◯)
Recommendation 5.2:
• When HbA1c to < 8% is not feasible, we suggest targeting preoperative blood glucose
concentrations 100 to 180 mg/dL (5.6 to 10 mmol/L) (2⊕◯◯◯)

Remarks:
• Factors that may affect HbA1c levels such as anemia, hemoglobinopathies, chronic renal failure,
alcoholism, drugs, and large  BG variations should be taken into account.
Question 6:
• Should basal or BBI vs NPH insulin be used for adults hospitalized for noncritical illness receiving
enteral nutrition with diabetes-specific and nonspecific formulations?

Recommendation 6.1:
• We suggest using neutral protamine Hagedorn (NPH)-based or basal bolus regimens.
(2⊕◯◯◯).
• NPH insulin, due to the shorter half-life and duration of action compared to long-acting insulin
preparations, may be appropriate for patients on enteral nutrition.
Question 7:
• Should noninsulin therapies vs scheduled insulin therapies be used for adults with hyperglycemia
[with and without known type 2 diabetes] hospitalized for noncritical illness?

Recommendation 7.1:
• We suggest that scheduled insulin therapy be used instead of noninsulin therapies for glycemic
management (2⊕⊕◯◯)
• Several retrospective analyses identified SU use as a risk factor for hypoglycemia in the hospital,
indicating more harm than benefit.
• Since interrupted nutrition and other hypoglycemia risk factors are common in hospitalized
patients, SUs are generally not advisable for inpatient use.
• Theoretical concerns derived from the use of some noninsulin glucose-lowering therapies in the
outpatient setting, including rare and known adverse events, were considered as being more
likely to occur in the acute care setting.
• These include lactic acidosis (MET), euglycemic ketoacidosis, and acute kidney injury especially in
the perioperative setting (SGLT2is) and acute heart failure (TZDs).
Recommendation 7.2:
• In select adult patients with mild hyperglycemia and type 2 diabetes (T2D) hospitalized for a
noncritical illness, we suggest using either dipeptidyl peptidase-4 inhibitor (DPP4i) with correction
insulin or scheduled insulin therapy (2⊕⊕◯◯)
• Select patients include those with T2D with a recent HbA1c < 7.5% , BG < 180 mg/dL, and, if on
insulin therapy before hospitalization, to have a total daily insulin dose < 0.6 units/kg/day.
• This recommendation applies both to patients taking the DPP4i before admission and those who
are not.
• Patients who develop persistently elevated BG [eg, >180 mg/dL (10 mmol/L)] on DPP4i therapy
should be managed with scheduled insulin therapy
• This recommendation does not apply to patients with T1D or other forms of insulin-dependent
diabetes.

Remarks:
• It may be reasonable to begin other noninsulin therapies in stable patients prior to discharge as a
part of a coordinated transition plan.
• DPP4is are approved for use and considered safe in patients with any degree of kidney disease
(Note that dose adjustment for renal dysfunction is required for select DPP4is).
Question 8:
• Should caloric carbohydrate containing oral fluids vs noncaloric beverages be used preoperatively
for adults with diabetes undergoing planned elective surgical procedures?

Recommendation 8.1:
• We suggest not administering carbohydrate (CHO) containing oral fluids preoperatively
(2⊕◯◯◯)
• One of the components has been to optimize perioperative nutrition with administration of CHO
containing beverages within a few hours before surgery.
• This practice is based on a hypothesis that the insulin resistance and muscle catabolism induced
by surgical stress can be dampened by preoperative oral CHO administration.
• The potential benefits, such as decreased insulin resistance, would not be expected in patients
with diabetes who have insulin resistance and/or insulinopenia.
• There are also potential harms associated with administration of CHO-containing beverages to
patients with diabetes, such as hyperglycemia with potential cancellation of scheduled
procedures.
Question 9:
• Should carbohydrate counting for prandial insulin dosing vs no carbohydrate counting be used for
adults with diabetes hospitalized for noncritical illness?
Recommendation 9.1:
• In adult patients with noninsulin-treated T2D hospitalized for noncritical illness who require
prandial insulin therapy, we suggest not using carbohydrate counting (CC) for calculating prandial
insulin doses (2⊕◯◯◯)
Recommendation 9.2:
• In adult patients with type 1 diabetes (T1D) or insulin-treated type 2 diabetes (T2D) hospitalized
for noncritical illness, we suggest either carbohydrate counting (CC) or no carbohydrate counting
(CC) with fixed prandial insulin dosing (2⊕◯◯◯)
• CC is a strategy used for calculating prandial doses of insulin often used by nonhospitalized
patients with T1D or T2D receiving multiple daily insulin injections or insulin pump therapy.
• This method calculates doses of premeal rapid- or short acting insulin based on the anticipated
CHO content of the food to be consumed.
• This offers more flexibility in insulin dosing and improved postprandial glycemic excursions when
compared to fixed premeal dosing.
• CC is used less frequently in the inpatient setting in part due to the few studies evaluating this
approach in hospitalized patients.
Remarks:
• Patients who perform CC in the outpatient setting, including those with insulin-treated T2D, may
prefer to continue this during hospitalization.
• An insulin to-carbohydrate ratio (ICR) is used to calculate the prandial dose of insulin when using
CC.
• Adjustments to the ICR may be needed in the hospital setting to address the impact of illness or
treatments on insulin requirements (eg, glucose-interfering medications, infection, surgery,
insulin resistance).
• Successful implementation of CC requires the prerequisite of nutrition and nursing education,
development of menus that include information regarding the CHO content of foods, and
development of protocols. to guide this approach.
Question 10:
• Should correctional insulin vs correctional insulin and scheduled insulin therapy (as basal bolus
insulin or basal insulin with correctional insulin) be used for adults with hyperglycemia (with and
without known diabetes) hospitalized for noncritical illness?
Recommendation 10.1:
• In adults with no prior history of diabetes hospitalized for noncritical illness with hyperglycemia
[defined as blood glucose (BG) > 140 mg/dL during hospitalization, we suggest initial therapy with
correctional insulin over scheduled insulin therapy to maintain glucose targets in the range of 100
to 180 mg/dL.
• For patients with persistent hyperglycemia [≥2 point-of-care blood glucose (POC-BG)
measurements ≥ 180 mg/dL in a 24-hour period on correctional insulin alone], we suggest the
addition of scheduled insulin therapy. (2⊕OOO).
Recommendation 10.2:
• In adults with diabetes treated with diet or noninsulin diabetes medications prior to admission,
we suggest initial therapy with correctional insulin or scheduled insulin therapy to maintain
glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L).
• For hospitalized adults started on correctional insulin alone and with persistent hyperglycemia [≥2
pointof-care blood glucose (POC-BG) measurements ≥ 180 mg/dL in a 24-hour period
(≥10.0 mmol/L)], we suggest addition of scheduled insulin therapy.
• We suggest initiation of scheduled insulin therapy for patients with confirmed admission blood
glucose (BG) ≥ 180 mg/dL (≥10.0 mmol/L) (2⊕OOO)
Recommendation 10.3:
• In adults with insulin-treated diabetes prior to admission who are hospitalized for noncritical
illness, we recommend continuation of the scheduled insulin regimen modified for nutritional
status and severity of illness to maintain glucose targets in the range of 100 to 180 mg/dL
(1⊕⊕OO).
Remarks:
• Reductions in the dose of basal insulin (by 10% to 20%) at time of hospitalization may be required
for patients on basal heavy insulin regimens (defined as doses of basal insulin ≥ 0.6 to 1.0
units/kg/day).
• Overall glycemic differences between the 2 strategies (correctional insulin vs scheduled insulin
therapy) for patients with newly recognized hyperglycemia or with T2D may be small.
• There was general but not unanimous agreement that premix insulin preparations (eg, 70/30,
50/50, 75/25) not be considered as BBI.
THANK YOU