Cleveland Clinic Journal of MedicineInpatient Glycemic Management in Noncritically Ill Patients: Updated Guidelines

Endocrine Society’s Updated Guidelines Embrace Technology and Personalized Approaches in Inpatient Glycemic Management

The Endocrine Society’s 2022 guidelines for inpatient glycemic management in noncritically ill patients introduce significant updates to the 2012 recommendations. These changes reflect advancements in diabetes technology and treatment options, aiming to improve glycemic control while reducing hypoglycemia risk. The guidelines offer a more nuanced approach to insulin therapy and expand the role of continuous glucose monitoring and insulin pumps in hospital settings.

Key Points:

• Target blood glucose range for noncritically ill inpatients remains 100-180 mg/dL
• Basal-bolus insulin therapy continues as the preferred treatment for most patients
• DPP-4 inhibitors, with or without correctional insulin, now recommended for select patients with well-controlled type 2 diabetes and mild hyperglycemia
• Correctional insulin alone suitable for newly recognized hyperglycemia or well-managed diabetes with admission blood glucose <180 mg/dL
• Scheduled insulin therapy advised for persistent hyperglycemia (≥2 readings ≥180 mg/dL in 24 hours)
• Glucocorticoid-associated hyperglycemia managed with NPH-based or basal-bolus insulin regimens
• Carbohydrate counting considered as an alternative to fixed prandial insulin dosing in type 1 and insulin-treated type 2 diabetes
• Continued use of insulin pumps preferred for patients using them pre-hospitalization
• Hybrid closed-loop insulin delivery systems allowed for continued use in hospital
• Continuous glucose monitoring recommended for patients at risk of hypoglycemia, alongside point-of-care testing
• Pre-operative targets: HbA1c <8% and blood glucose 100-180 mg/dL for elective surgery
• Carbohydrate-containing oral fluids avoided pre-operatively in diabetic patients
• Inpatient diabetes education included in comprehensive discharge planning
• Guidelines do not apply to pediatric or critical care settings
• Contraindications for DPP-4 inhibitors include type 1 diabetes, pancreatitis history, pregnancy, and lactation

According to data from German and Austrian DPV and US T1D Exchange registries, CGM use increased exponentially from 2011 to 2017 in all pediatric age‐groups (DPV: 4% in 2015 to 44% in 2017; T1DX: 4% in 2013 to 14% in 2015 and to 31% in 2017), with the highest use among preschool‐aged and early school‐aged children. (Diabetes Care)

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