CGM use, education focus of managing hyperglycemia in hospitalized adults with diabetes
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Use of continuous glucose monitoring for glycemic management and inpatient diabetes education before discharge may improve outcomes for hospitalized adults with diabetes at risk for hyperglycemia, according to clinical practice guidelines.
In an article published in The Journal of Clinical Endocrinology & Metabolism, the Endocrine Society released an updated clinical practice guideline for managing hyperglycemia in hospitalized patients in noncritical care settings. Last updated in 2012, the new guideline was drafted using an updated methodology adhering to the Institute of Medicine standards for formulating recommendations and for the first time, included a patient representative on the panel of clinician experts.
“This updated guideline addresses evolving strategies for inpatient glycemic management that facilitate the ability to achieve desired glycemic goals while also reducing risk for hypoglycemia, and provides guidance for areas where there is wide variability in how these patients are currently managed in the hospital setting,” Mary Korytkowski, MD, emeritus professor of medicine in the division of endocrinology and metabolism at the University of Pittsburgh, told Healio.
The expert panel developed the guideline by identifying and answering 10 clinical questions related to the inpatient management of patients with diabetes or newly recognized hyperglycemia. Systematic reviews of studies pertaining to each question were performed. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method to assess the strength of the research.
Diabetes device use, inpatient education essential
The guideline includes 15 recommendations. The first focuses on using real-time CGM alongside point-of-care blood glucose testing instead of point-of-care testing alone. The use of CGM is suggested for insulin treated adults hospitalized with noncritical illness who are at high risk for hypoglycemia. The guideline emphasizes the importance of implementing CGM at hospitals where resources and training in use of these devices are available.
For adults using an insulin pump prior to admission, the researchers recommend continuing insulin pump therapy in patients who are assessed as having the physical and mental capacity to do so instead of changing to subcutaneous basal-bolus insulin therapy as long as the hospital has access to personnel with expertise in using insulin pumps.
“Patients using hybrid closed-loop insulin pump therapy may be able to continue this at time of admission if they meet criteria similar to that for patients using insulin pump therapy independently of a CGM device as long as the CGM and insulin pump are able to function without interference of hospital care,” the researchers wrote. “If CGM fails or is removed from the patient, the insulin pump can be reverted to manual mode as long as basic criteria for pump use in hospital are still met.”
The researchers also recommend that hospitals provide inpatient diabetes education as part of a comprehensive discharge-planning process. The process should include education on diabetes survival skills, referral for outpatient diabetes self-management education, diabetes care follow-up appointments, and access to the medications and supplies required for diabetes self-management after discharge.
“Education is preferably given by diabetes care and education specialists as a way of reducing risk for hospital readmission and improving glycemic measures over the next 6 months,” Korytkowski said.
HbA1c, glucose targets for elective surgery
For adults with diabetes who are preparing for an elective surgical procedure, the guideline suggests a pre-operative HbA1c of less than 8%. If reaching that target is not feasible, targeting a blood glucose concentration of less than 180 mg/dL in the immediate preoperative period is suggested. The recommendation applies only to patients who have a reasonable amount of time to implement therapies to reach the HbA1c or blood glucose target before the procedure.
The guideline also clarifies circumstances for use of correctional insulin, which is often referred to as sliding scale insulin. Correctional insulin can be used as initial therapy for patients with newly recognized hyperglycemia, those with type 2 diabetes treated with non-insulin therapy prior to admission, or in combination with a DPP-IV inhibitor in selected adults with moderately well-managed type 2 diabetes with a recent HbA1c of less than 7.5%. All patients treated with insulin prior to admission as well as adults with persistent hyperglycemia defined as blood glucose values greater than 180 mg/dL require scheduled insulin therapy instead of noninsulin therapy for glycemic management.
“As with all new therapies started in the hospital, a discussion with the patient about cost and overall acceptability is suggested if there are plans to continue the medication after discharge,” the researchers wrote.
For more information:
Mary Korytkowski, MD, can be reached at mtk7@pitt.edu.
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