Guideline sources The following summarized guidelines for the evaluation and management of in-hospital hyperglycemia are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2023), the Endocrine Society (ES 2022), the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the European Society of Cardiology (ESC 2021; 2018), and the American Heart Association (AHA/ASA 2019). 1 2 3 4 5 6 Guidelines 1. Diagnostic investigations HbA1C testing: obtain Hgb A1C testing in all patients with diabetes or hyperglycemia (blood glucose > 140 mg/dL; 7.8 mmol/L) admitted to the hospital, if not performed in the prior 3 months. B 2. Medical management General principles: as per ADA 2023 guidelines, consult with a specialized diabetes or glucose management team, when possible, when caring for hospitalized patients with diabetes. B Treatment targets: https://web.pathway.md/diseases/recwGSpbd6Q7lKkPa 1/4 6/24/23, 2:28 PM In-hospital hyperglycemia Pathway As per ADA 2023 guidelines: Set a target glucose range of 140-180 mg/dL (7.8-10.0 mmol/L) for the majority of critically ill and non-critically ill patients with T2DM once insulin therapy is started. A Consider setting more stringent goals, such as 110-140 mg/dL (6.1-7.8 mmol/L), in selected patients with T2DM if those can be achieved without significant hypoglycemia. C As per ES 2022 guidelines: Consider targeting preoperative Hgb A1C levels of < 8% (63.9 mmol/mol) and blood glucose levels of 100-180 mg/dL (5.6-10 mmol/L) in adult patients with diabetes undergoing elective surgical procedures. C Consider targeting preoperative blood glucose levels of 100-180 mg/dL (5.6-10 mmol/L) in adult patients with diabetes undergoing elective surgical procedures if a Hgb A1C < 8% (63.9 mmol/mol) target is not feasible. C Insulin therapy: As per ADA 2023 guidelines, use validated written or computerized protocols for insulin administration allowing for predefined adjustments in the insulin dosage based on glycemic fluctuations. B Show 4 more As per ES 2022 guidelines, consider administering scheduled insulin therapy for glycemic control in most adult patients with hyperglycemia (with or without known T2DM) hospitalized for a non-critical illness. C Show 9 more Landmark trials: RABBIT 2 In non-critically ill, hospitalized patients with T2DM who are insulin-naive, use of a basal- bolus insulin regimen was superior to use of a standard sliding-scale insulin protocol with respect to the percentage of patients achieving mean glucose target of < 140 mg/dL. Umpierrez GE et al. Diabetes Care. 2007 Sep. 3. Inpatient care Glucose monitoring: consider obtaining real-time continuous glucose monitoring with confirmatory bedside point-of-care blood glucose monitoring for adjustments in insulin dosing (in hospital settings where resources and training are available) in adult patients with insulin-treated diabetes at high risk of hypoglycemia hospitalized for a non-critical illness. C Prevention of hypoglycemia: Review treatment regimens and change as necessary to prevent further hypoglycemia when a blood glucose value of < 70 mg/dL (3.9 mmol/L) is documented. B https://web.pathway.md/diseases/recwGSpbd6Q7lKkPa 2/4 6/24/23, 2:28 PM In-hospital hyperglycemia Pathway Adopt a hypoglycemia management protocol and implement it in each hospital or hospital system. Establish a plan for the prevention and treatment of hypoglycemia for each patient. Document episodes of hypoglycemia in the hospital in the medical record and track for quality improvement/quality assessment. B Oral carbohydrate fluids: avoid administering preoperative carbohydrate-containing oral fluids in adult patients with T1DM, T2DM, or other forms of diabetes undergoing surgical procedures. D 4. Specific circumstances Patients with myocardial infarction: As per ACC 2022 guidelines, administer intraoperative continuous insulin infusion to maintain serum glucose level < 180 mg/dL to reduce sternal wound infection in patients undergoing CABG. B Show 2 more As per ESC 2021 guidelines, screen all patients with myocardial infarction for diabetes and monitor blood glucose levels frequently in patients with known diabetes or admission hyperglycemia. B Show 4 more As per ESC 2018 guidelines, measure glycemic status at initial evaluation in all patients and obtain frequent monitoring in patients with known diabetes or hyperglycemia (blood glucose 11.1 mmol/L; 200 mg/dL). B Show 3 more Patients with stroke: consider treating hyperglycemia to achieve blood glucose levels in a range of 140-180 mg/dL and obtaining closely monitoring to prevent hypoglycemia in patients with acute ischemic stroke as persistent in-hospital hyperglycemia during the first 24 hours after acute ischemic stroke is associated with worse outcomes. C 5. Patient education Patient education: consider providing inpatient diabetes education as part of a comprehensive diabetes discharge-planning process in adult patients with diabetes hospitalized for a non-critical illness. C References 1. Borja Ibanez, Stefan James, Stefan Agewall et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology ESC . Eur Heart J. 2018 Jan 7;39 2 119 177. Open https://web.pathway.md/diseases/recwGSpbd6Q7lKkPa 3/4 6/24/23, 2:28 PM In-hospital hyperglycemia Pathway 2. Steven E. Kahn, Cheryl A.M. Anderson, John B. Buse et al. Standards of Care in Diabetes 2023. Diabetes Care. 2023 Jan;46 Supplement_1 S1 S291. Open 3. William J Powers, Alejandro A Rabinstein, Teri Ackerson et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50 12):e344-e418. Open 4. Mary T Korytkowski, Ranganath Muniyappa, Kellie Antinori-Lent et al. Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2022 Jun 12;dgac278. Open 5. Jean-Philippe Collet, Holger Thiele, Emanuele Barbato et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021 Apr 7;42 14 1289 1367. Open 6. Jennifer S Lawton, Jacqueline E Tamis-Holland, Sripal Bangalore et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 Jan 18;145 3):e18-e114. Open https://web.pathway.md/diseases/recwGSpbd6Q7lKkPa 4/4