New guidelines recommend blood-glucose testing for all hospitalized patients

The Endocrine Society recently released new clinical practice guidelines recommending that all patients have their blood-glucose levels tested upon admission to the hospital, even if they haven’t been diagnosed with diabetes. The guidelines were published January 1 in The Journal of Clinical Endocrinology & Metabolism.

The guidelines were developed by a task force appointed by The Clinical Guidelines Subcommittee of The Endocrine Society and chaired by Guillermo Umpierrez, MD, from Emory University in Atlanta. The published recommendations are the consensus of several organizations, including The Endocrine Society, the American Diabetes Association, American Heart Association, American Association of Diabetes Educators, European Society of Endocrinology, and the Society of Hospital Medicine.

According to the article, hyperglycemia affects 32% to 38% of patients in community hospitals and occurs not only in patients with known diabetes, but also in those with previously undiagnosed diabetes. Some patients develop stress hyperglycemia during an acute illness that resolves prior to discharge.

“The association between hyperglycemia in hospitalized patients (with or without diabetes) and increased risk for complications and mortality is well established,” the authors wrote. “This association is observed for both admission glucose and mean BG level during the hospital stay.”

The goal of the task force was to develop practical and safe glycemic goals as well as protocols and procedures for achieving the goals.

Specific recommendations in the society’s guideline include:

All patients, independent of a prior diabetes diagnosis, should undergo laboratory blood-glucose testing on admission. Inpatients with known diabetes or with hyperglycemia (glucose >7.8 mmol/L) should undergo testing of hemoglobin A1c levels if this had not been done in the preceding 2 or 3 months.

For most hospitalized patients with noncritical illness, the recommended premeal glucose target is less than 140 mg/dL and the recommended target for a random blood-glucose level is less than 180 mg/dL. Antidiabetic therapy should be reassessed when blood glucose levels fall below 5.6 mmol/L (100 mg/dL). Modification may be necessary if blood glucose levels fall below 3.9 mmol/L (70 mg/dL).

Glycemic targets should be modified according to clinical status, with tighter control for patients who are not prone to hypoglycemia, and a higher target range (<11.1 mmol/L or 200 mg/dL) for patients with terminal illness or limited life expectancy, or who are at high risk for hypoglycemia.

Patients with diabetes who receive insulin at home should be treated with a scheduled regimen of subcutaneous insulin while they are hospitalized.

Patients with type 1 diabetes and most patients with type 2 diabetes who undergo surgery should be treated with intravenous continuous insulin infusion or subcutaneous basal insulin with bolus insulin as-needed to prevent perioperative hyperglycemia.

All patients with high glucose values (>7.8 mmol/L [140 mg/dL]) on admission, and all patients receiving enteral or parenteral nutrition, should be monitored with bedside capillary point-of-care glucose testing, independent of diabetes history. The same applies to patients receiving therapies associated with hyperglycemia, such as corticosteroids or octreotide.

All patients with type 1 and type 2 diabetes should be transitioned to scheduled subcutaneous insulin therapy at least 1 to 2 hours before intravenous continuous insulin infusion is discontinued.