New guidelines suggest blood glucose testing for all inpatients

Laurie Barclay and Shelley Wood

January 10, 2012

Atlanta, GA - New clinical-practice guidelines (CPG) by the Endocrine Society recommend blood glucose testing for all patients on admission to the hospital and describe optimal management of hyperglycemia in patients who do not require intensive care [1].

The guidelines are published in the January 2012 issue of the Journal of Clinical Endocrinology and Metabolism.

"Hyperglycemia is associated with prolonged hospital stay, increased incidence of infections, and death in non-critically ill hospitalized patients," CPG task force chair Dr Guillermo Umpierrez (Emory University, Atlanta, GA) said in a news release [2]. "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, the document notes. Better glycemic control has been associated with fewer hospital complications in general-medicine and surgery patients in observational studies and randomized controlled trials.

According to Dr Mikhail Kosiborod (St Luke's Health System, Kansas City, MO), a cardiologist and coauthor on the new guidelines, glucose tests are frequently a part of the blood work done at the time of admission for patients hospitalized for cardiovascular events. "But if a patient is found to have elevated glucose, we don't know how many patients actually undergo subsequent testing" to determine whether hyperglycemia was acute or persists beyond the initial event.

One of the goals of these guidelines is to recommend not just initial screening of glucose in hospitalized patients, but if glucose is found to be elevated, to continue to monitor that for a specific period of time, he added.

"We know that hyperglycemia is very common in patients hospitalized with cardiovascular disease and is a harbinger of poor prognosis—particularly during ACS and especially among patients who do not have known diabetes. Initial assessment of glucose levels—which is inexpensive and readily available—in all patients hospitalized with CVD provides clinicians with prognostically useful information, can help identify patients who should be screened for diabetes, and, in some patients, can direct decisions in regard to the intensity of subsequent glucose monitoring and, if necessary, glucose-lowering treatment."

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.

Specific recommendations include:

  • All patients, independent of a prior diagnosis of diabetes, should undergo laboratory blood glucose testing on admission. Inpatients with known diabetes or hyperglycemia (glucose >140 mg/dL) should undergo glycated hemoglobin testing if not done in the preceding two to three months.

  • For most hospitalized patients with noncritical illness, the premeal glucose target is <140 g/dL and the random blood glucose target is <180 mg/dL. Antidiabetic treatment should be reevaluated when glucose levels drop below 100 mg/dL (5.6 mmol/L) and should be modified if glucose levels are below 70 mg/dL (3.9 mmol/L).

  • 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 (<200 mg/dL, or <11.1 mmol/L) 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 levels (>140 mg/dL, or >7.8 mmol/L) on admission and all patients receiving enteral or parenteral nutrition should be monitored using 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 (Sandostatin, Novartis).

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

The guidelines were developed with input from the American Diabetes Association, American Heart Association, American Association of Diabetes Educators, European Society of Endocrinology, and Society of Hospital Medicine.

The guidelines were entirely supported by funds from the Endocrine Society .

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