Diabetes Care in Hospital Settings

▪️    A1C test should be performed for any patient with random blood glucose sample > 140 mg/dl during hospitalization or for any patient with a known history of diabetes. (strong recommendation)

▪️  Health care facilities should implement validated protocols for diabetes inpatient management (written or computerized) and delivered to all departments including: emergency units, ICU units, general wards, obstetrician/delivery units and dialysis suits. (strong recommendation)

▪️  When caring of hospitalized patients with existing diabetes or stress induced hyperglycemia, consult with a diabetes specialized team whenever possible. (conditional recommendation)

▪️  Insulin should be initiated and intensified for the treatment of persistent hyperglycemia (blood glucose level ≥ 180 mg/dl on two occasions within 24 hours). (strong recommendation)

▪️  Once insulin therapy started, a glycemic goal of 140 – 180 mg/dl is recommended for most critically ill and noncritically ill hospitalized patients. (strong recommendation)

▪️  More stringent goals such as 110-140 mg/dl may be acceptable in some patients if these goals could be reached without significant hypoglycemia. (conditional recommendation)

▪️   For hospitalized individuals with diabetes who are consuming meals, it's recommended to conduct point-of-care (POC) blood glucose monitoring before meals. For those who are not eating, glucose monitoring every 4-6 hours is advised. However, when using intravenous insulin therapy, more frequent POC blood glucose monitoring, ranging from every 30 minutes to every 2 hours, is necessary to ensure safe implementation. (Good clinical practice )

▪️  Basal insulin or a basal plus bolus correction insulin is the preferred treatment for noncritically ill hospitalized patients with poor oral intake or who are fasting. (strong recommendation)

▪️  An insulin regimen consisting of basal, prandial and correction components is the preferred treatment for noncritically ill hospitalized patients with adequate nutritional intake. (strong recommendation)

▪️  The sole use of sliding scale insulin regimen in the inpatient settings is strongly discouraged. (strong recommendation) 

▪️  For patients with type 2 diabetes who are admitted with heart failure (after recovery from the acute illness), it is recommended to initiate or continue SGLT 2 inhibitors during hospitalization and upon discharge, if there are no contraindications to this group.  (strong recommendation)

▪️  In adult patients who are hospitalized for noncritical illness and experience hyperglycemia while receiving glucocorticoids (GCs) glycemic management should be pursued with either neutral protamine Hagedorn (NPH)-based insulin or basal bolus insulin (BBI) regimens (conditional recommendation)

▪️   In select adult patients with mild hyperglycemia and type 2 diabetes (T2D) hospitalized for a noncritical illness, we suggest using either dipeptidyl peptidase-4 inhibitor (DPP4i) with correction insulin or scheduled insulin therapy. (conditional recommendation)

▪️  For adult patients with diabetes undergoing elective surgical procedures, we suggest targeting preoperative hemoglobin A1c (HbA1c) levels < 8% (63.9 mmol/mol) and blood glucose (BG) concentrations 100 to 180 mg/dL (5.6 to10 mmol/L). (conditional recommendation)

▪️   For adult patients with diabetes undergoing elective surgical procedures, when targeting hemoglobin A1c (HbA1c) to < 8% (63.9 mmol/mol) is not feasible, we suggest targeting preoperative blood glucose (BG) concentrations 100 to 180 mg/dL (5.6 to 10 mmol/L). (conditional recommendation)

▪️   In adult patients hospitalized for noncritical illness who are receiving enteral nutrition with diabetes-specific and nonspecific formulations, we suggest using neutral protamine Hagedorn (NPH)-based or basal bolus regimens. (conditional recommendation)

▪️   Metformin administration should be withheld on the day of surgery. Other oral glucose-lowering agents should be withheld on the morning of the surgery or procedure, and instead, administer half of the NPH dose or 75-80% doses of long-acting analog insulin. (Good clinical practice )

▪️   SGLT2 inhibitors should be discontinued 3–4 days before surgery. (Good clinical practice)

▪️   Reducing basal insulin by 25% the evening before surgery, compared to usual dosing, is more likely to help achieve perioperative blood glucose goals with a reduced risk of hypoglycemia. (Good clinical practice )

▪️   In individuals undergoing noncardiac general surgery, utilizing basal insulin in combination with premeal short or rapid-acting insulin (basal-bolus) coverage has been linked to enhanced glycemic outcomes and reduced rates of perioperative complications compared to corrective rapid/short acting insulin dosing. (Good clinical practice )

▪️  Treatment plans should be reviewed and changed as necessary to prevent hypoglycemia and recurrent hypoglycemia when a blood glucose value of <70 mg/dL (<3.9 mmol/L) is documented.  (Conditional recommendation)

▪️   A structured discharge plan tailored to the individual may reduce the length of hospital stay and readmission rates and increase satisfaction with the hospital experience. (strong recommendation)