A clinical practice guideline from the Endocrine Society recommends that all non-critically ill inpatients be tested for elevated blood glucose levels in an effort to identify individuals with diabetes earlier in the course of the disease.
Research suggests that approximately one-third of patients admitted to hospitals in the United States have a blood glucose level greater than 180 mg/dL. The CDC estimates that admissions for patients with diabetes increased from 2.8 million in 1990 to 5.5 million in 2009. These are conservative estimates that do not account for patients who experience a transient increase in blood glucose during stress or illness.
Previous guidelines have addressed the care of hospital patients with hyperglycemia, but these recommendations focus mostly on individuals in the ICU. “We’re still missing many individuals because most hospital patients aren’t admitted to the ICU,” explains Guillermo Umpierrez, MD. “Studies have shown that hyperglycemia is associated with an increased number of complications in general medical and surgical patients. More recently, data suggest that treating these patients can decrease the number of complications they experience and improve glucose control.”
Addressing the Issue
In 2012, the Endocrine Society collaborated with five other medical associations to release a consensus guideline on the management of hyperglycemia in non-critically ill hospitalized patients. The guidelines are divided into eight areas, beginning with diagnosis and recognition of hyperglycemia and diabetes (Table 1). “In agreement with previous guidelines, hyperglycemia is defined as a fasting or pre-meal blood glucose level greater than 140 mg/dL in hospitalized patients with and without a history of diabetes,” says Dr. Umpierrez, who was the lead author of the guidelines. “Patients with elevated blood glucose are recommended to undergo an A1C test in the hospital because it can assess the level of glucose control they have at home and guide therapy when patients are being prepared for discharge. The A1C test can also help clinicians recognize hyperglycemia when it would otherwise go undetected.” The guidelines also note that a patient with elevated glucose values and an A1C greater than 6.5% be considered diabetic.
According to the guidelines, testing for hyperglycemia is recommended for all patients admitted to the hospital. Those who are diagnosed as hyperglycemic but with no history of diabetes should undergo continuous testing in the hospital for the following 24 to 48 hours. Those with persistently elevated blood glucose are recommended to undergo an A1C test to make a potential diabetes diagnosis. “Several studies have shown that glucose control in the hospital is cost-effective,” explains Dr. Umpierrez. “That’s because it can decrease complications, length of stay, and possibly the number of procedures to be performed on patients. By identifying these patients early, the hope is that earlier treatment will pay off in the long run.”
Managing Patients with Hyperglycemia
The guidelines also provide treatment recommendations for when hyperglycemia is diagnosed. Fasting glucose levels should be less than 140 mg/dL and random blood glucose should be less than 180 mg/dL for most hospitalized patients. “Some patients may have multiple complications and/or terminal illness,” Dr. Umpierrez says. “In these cases, keeping blood glucose levels below 200 mg/dL should be sufficient. Physicians must also be careful to avoid hypoglycemia, as it has been associated with an increased rate of complications and in-hospital mortality.” To keep patients at desired blood glucose levels, the guideline recommendations provide management strategies that go beyond pharmacologic treatment. They provide guidance on addressing patients’ diet while they are in the hospital and how to optimize transitions to and from the hospital (Table 2).
“Insulin is recommended as the preferred method for achieving glucose control in hospitalized patients with diabetes,” says Dr. Umpierrez. “Oral anti-diabetic agents should be stopped during hospitalization because of a lack of data to support the safety and efficacy of these therapies in hospital settings.” For patients with type 1 or type 2 diabetes, a basal bolus insulin protocol is the preferred method because it helps avoid swings in blood glucose levels that come with short-acting insulin.
Looking Ahead on Managing Patients
Future research will focus on how to simplify the management of patients experiencing hyperglycemia in the hospital, according to Dr. Umpierrez. “We need to better establish if a ‘one-size-fits-all’ approach can be appropriate or if there are conditions or disorders that we need to treat more aggressively than others. We also need more studies on how to manage patients during the transition from hospital to home. Additionally, comparisons are needed in which insulin types are evaluated in a large number of hospitalized patients. In the meantime, clinicians can refer to the current guidelines for information on the best practices and protocols for addressing hyperglycemia in non-critical hospitalized patients.”
View and print an example of a Basal Bolus Insulin Regimen. Click Here.