Guidelines Suggest Blood Glucose Testing for All Inpatients

Laurie Barclay, MD

January 06, 2012

January 6, 2012 — A new clinical practice guideline (CPG) from The Endocrine Society, published in the January 2012 issue of the Journal of Clinical Endocrinology & Metabolism, recommends blood glucose testing for all patients on admission to a hospital and describes optimal management of hyperglycemia in patients not requiring intensive care.

"Hyperglycemia is associated with prolonged hospital stay, increased incidence of infections and death in non-critically ill hospitalized patients," CPG task force chair Guillermo Umpierrez, MD, from Emory University in Atlanta, Georgia, said in a news release. "This new guideline contains consensus recommendations from experts in the field for the management of hyperglycemia in hospitalized patients in non-critical care settings."

Hyperglycemia affects 32% to 38% of patients in community hospitals and is not restricted to individuals with a history of diabetes, according to previous observational studies. Better glycemic control has been associated with fewer hospital complications in general medicine and surgery patients in observational studies and randomized controlled trials.

In addition to suggesting that all patients have a blood glucose test, the new guidelines also set glycemic targets and describe protocols and system improvements designed to help reach these goals.

The task force, consisting of a chair, 6 additional experts, and a methodologist, developed these evidence-based guidelines, using the Grading of Recommendations, Assessment, Development, and Evaluation system, to rate the strength of recommendations and the quality of underlying evidence.

Specific recommendations in the guideline include the following:

  • All patients, independent of a prior diagnosis of diabetes, 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 premeal glucose target is less than 140 mg/dL and the target for a random blood glucose level is less than 180 mg/dL. Antidiabetic treatment should be reevaluated when glucose levels drop below 5.6 mmol/L (100 mg/dL) and should be modified if glucose levels are 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 receive a scheduled regimen of subcutaneous insulin while they are hospitalized.

  • To prevent perioperative hyperglycemia, all 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 as-needed bolus insulin.

  • 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.

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

After the task force reached consensus on the recommendations and wrote preliminary drafts, the CPG was reviewed and commented on by Endocrine Society members, the American Diabetes Association, the American Heart Association, the American Association of Diabetes Educators, the European Society of Endocrinology, and the Society of Hospital Medicine.

The Hormone Foundation, which is the patient education affiliate of the Endocrine Society, has published an online companion patient guide to this CPG, describing the causes and effects of hyperglycemia and various treatment options.

All CPGs are supported entirely by Endocrine Society funds.

J Clin Endocrinol Metabol. 2012;97:16-38. Abstract

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