By Jordan Messler, MD, SFHM, FACP, Chief Medical Officer, Glytec
The American Diabetes Association (ADA) released the latest “Standards of Care in Diabetes” in December 2024, sharing their annual clinical practice recommendations, general treatment guidelines, and tools to elevate care. Their highlights for inpatient glycemic management include:
- Safe use of IV insulin for critically ill patients
- Basal bolus for non-ICU patients eating, with daily safe adjustments
- Customized treatment options (aiming for target 140-180, or tighter in certain populations)
This blog highlights some of these ADA recommendations and why specialized diabetes management solutions for inpatient care are more important than ever before.
The highlights: ADA recommendations for inpatient glycemic management
16.1 Perform an A1C test on all people with diabetes or hyperglycemia (random blood glucose >140 mg/dL [>7.8 mmol/L]) admitted to the hospital if no A1C test result is available from the prior 3 months. B
An A1c is integral to understanding a patient’s current glycemic status, helping identify patients with prediabetes or undiagnosed diabetes, as well as guiding inpatient treatment and discharge planning.
For instance, an elevated A1c in a patient with diabetes may indicate the home regimen needs to be increased, whereas a normal A1c in a patient with elevated glucose is more consistent with stress hyperglycemia.
16.2 Institutions should implement protocols using validated written or computerized provider order entry sets for management of dysglycemia in the hospital that allow for a personalized approach. B
Evidence-based and standardized order sets are critical for following best practice. In particular, the use of computerized order sets or computerized software can help reduce preventable hypoglycemia and treat hyperglycemia. Personalized care is important as well, meaning directed target ranges and patient-specific insulin dosing.
16.4a Insulin should be initiated or intensified for treatment of persistent hyperglycemia starting at a threshold of 180 mg/dL (10.0 mmol/L) (confirmed on two occasions within 24 h) for the majority of critically ill individuals (those in the intensive care unit [ICU]).
16.8a Continuous intravenous insulin infusion is recommended for achieving glycemic goals and avoiding hypoglycemia in critically ill individuals. A
The use of IV insulin remains the standard for treating critically ill patients with hyperglycemia. Studies show underuse, with one study showing only 13% of patients in the ICU with sepsis who met criteria for IV insulin were started.
16.4b Insulin and/or other glucose lowering therapies should be initiated or intensified for treatment of persistent hyperglycemia starting at a threshold of 180 mg/dL (10.0 mmol/L) (confirmed on two occasions within 24 h) for the majority of noncritically ill individuals (those not in the ICU). B
16.9 An insulin plan with basal, prandial, and correction components is the preferred treatment for most noncritically ill hospitalized individuals with adequate nutritional intake. A
In the non-ICU setting, subcutaneous insulin remains the cornerstone of management, particularly for patients with persistent hyperglycemia. The mainstay of treatment for those with adequate nutrition remains basal insulin with scheduled mealtime (bolus) insulin. Glucommander SubQ is basal/bolus therapy, with key safety guardrails and tools to prevent hypoglycemia and treat hyperglycemia.
The automatic insulin adjustments driving toward personalized target ranges are a key aspect of Glucommander. Dose adjustments often are not done in response to BGs out of target. For instance, one study showed that following a hypoglycemia event, physicians adjusted basal insulin only 25% of the time.
16.5a Once therapy is initiated, a glycemic goal of 140–180 mg/dL (7.8–10.0 mmol/L) is recommended for most critically ill individuals (those in the ICU) with hyperglycemia. A More stringent individualized glycemic goals may be appropriate for selected critically ill individuals if they can be achieved without significant hypoglycemia. B
This target remains unchanged in the latest guidelines. The Society of Critical Care Medicine has similar target recommendations. This is largely based on what we know from the NICE-SUGAR trial showing intensive glycemic management had a slightly higher mortality and significantly higher hypoglycemia rate.
The lower targets may benefit certain groups, such as patients without diabetes or CABG patients—if these lower targets can be safely achieved, such as with the use of glycemic software like Glucommander.
16.5b For noncritically ill individuals (those not in the ICU), a glycemic goal of 100–180 mg/dL (5.6- 10.0 mmol/L) is recommended if it can be achieved without significant hypoglycemia. B
These goals are largely extrapolated from the ICU literature, and suggest a fasting target of <140 mg/dl and random target BG of <180 mg/dl.
16.10 For most individuals, sole use of a correction or supplemental insulin without basal insulin (formerly referred to as a sliding scale) in the inpatient setting is discouraged. A
For too long, hospital protocols have allowed patients with hyperglycemia to manage with an outdated, reactive treatment to hyperglycemia.
These are just a few highlights from this year’s recommendations from the ADA. For the full ADA Standards of Care in Diabetes, click here.
Take the guessing out of diabetes management
Managing diabetes in the hospital doesn’t have to be a guessing game. A specialized diabetes management solution for inpatient care can save money and reduce the risk of 30-day readmission following hospitalization.1,2,3
How can it do that?
Our collaborative diabetes management and insulin dosing solution is built to leverage next-generation insights to provide decision support to healthcare leaders and clinicians.
This industry-leading technology is trusted by more than 350 hospitals to help reduce readmissions and length of stay, improve patient safety and outcomes, and decrease workflow time and errors.
Hospitals using our solutions have seen up to 99% reduction in severe hypoglycemia and 70% reduction in non-ICU hypoglycemia.
REFERENCES
- Akiboye F, Sihre HK, AlMulhemM, Rayman G, Nirantharakumar K, Adderley NJ. Impact of diabetes specialist nurses on inpatient care: a systematic review. DiabetMed 2021;38:e14573
- Bansal V,Mottalib A, Pawar TK, et al. Inpatient diabetes management by specialized diabetes team versus primary service team in non-critical care units: impact on 30-day readmission rate and hospital cost. BMJ Open Diabetes Res Care 2018;6:e000460
- Ostling S,Wyckoff J, Ciarkowski SL, et al. The relationship between diabetes mellitus and 30-day readmission rates. Clin Diabetes Endocrinol 2017;3:3
