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health care professionals should considerdiscontinuing saxagliptin and alogliptin inpeople who develop heart failure (87). Dataon the inpatient use of glucagon-like pep-tide 1 (GLP-1) receptor agonists are stillmostly limited to research studies and | [
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are stillmostly limited to research studies and selectpopulations that are medically stable (83). | [
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For people with type 2 diabetes hospital-\nized with heart failure, it is recommendedthat use of a sodium –glucose cotransporter\n2 (SGLT2) inhibitor be initiated or continued | [
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] |
2 (SGLT2) inhibitor be initiated or continued\nduring hospitalization and upon discharge,if there are no contraindications and after\nrecovery from the acute illness (88,89). | [
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recovery from the acute illness (88,89).\nSGLT2 inhibitors should be avoided in casesof severe illness, in people with ketonemiaor ketonuria, and during prolonged fastingand surgical procedures (90– 93). Proac- | [
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tive adjustment of diuretic dosing is rec-ommended during hospitalization and/ordischarge, especially in collaboration witha cardiology/heart failure consult team(90–93). The FDA has warned that SGLT2\ninhibitors should be stopped 3 days before | [
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inhibitors should be stopped 3 days before\nscheduled surgeries (4 days in the case of\nertugli flozin) (94).\nHYPOGLYCEMIA\nRecommendations\n16.12 A hypoglycemia management\nprotocol should be adopted and imple-\nmented by each hospital or hospital | [
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mented by each hospital or hospital\nsystem. A plan for preventing and treat-\ning hypoglycemia should be established\nfor each individual. Episodes of hypo-\nglycemia in the hospital should be\ndocumented in the electronic health | [
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] |
documented in the electronic health\nrecord and tracked for quality assess-\nment and quality improvement. E\n16.13 Treatment plans should be re-\nviewed and changed as necessary to\nprevent hypoglycemia and recurrent\nhypoglycemia when a blood glucose | [
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hypoglycemia when a blood glucose\nvalue of <70 mg/dL ( <3.9 mmol/L) is\ndocumented. C\nPeople with or without diabetes may ex-\nperience hypoglycemia in the hospital | [
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perience hypoglycemia in the hospital\nsetting. While hypoglycemia is associatedwith increased mortality (95,96), in manycases, it is a marker of an underlying dis-\nease rather than the cause of fatality. | [
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However, hypoglycemia is a severe conse-quence of dysregulated metabolism and/ordiabetes treatment, and it is imperativethat it be minimized during hospitalization.Many episodes of inpatient hypoglycemiaare preventable. A hypoglycemia preven-tion and | [
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preventable. A hypoglycemia preven-tion and management protocol should beadopted and implemented by each hos-pital or hospital system. A standardizedhospital-wide, nurse-initiated hypoglycemia | [
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] |
treatment protocol should be in place to\nimmediately address blood glucose levels<70 mg/dL ( <3.9 mmol/L) (97,98). In addi- | [
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tion, individualized plans for preventingand treating hypoglycemia for each individ-ual should also be developed. An AmericanDiabetes Association consensus statementrecommends that an individual ’st r e a t m e n tplan be reviewed any time a blood glucose | [
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value of <70 mg/dL ( <3.9 mmol/L) occurs,\nas this level often predicts subsequent level\n3 hypoglycemia (99). Episodes of hypoglyce-\nmia in the hospital should be documented\nin the EHR and tracked (1). A key strategy is | [
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in the EHR and tracked (1). A key strategy is\nembedding hypoglycemia treatment into allinsulin and insulin infusion orders.\nInpatient Hypoglycemia: Risk\nFactors, Treatment, and Prevention\nInsulin is one of the most common medi- | [
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Insulin is one of the most common medi-\ncations causing adverse events in hospital-\nized individuals. Errors in insulin dosing,missed doses, and/or administration errors\nincluding incorrect insulin type and incor-\nrect timing of dose occur relatively fre- | [
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rect timing of dose occur relatively fre-\nquently (100 –102) and include prescriber\n(ordering), pharmacy (dispensing), and\nnursing (administration) errors. Common\npreventable sources of iatrogenic hypogly-\ncemia are improper prescribing of other | [
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cemia are improper prescribing of other\nglucose-lowering medications and inap-\npropriate management and follow-up ofthefirst episode of hypoglycemia (103). Kid-\nney failure is an important risk factor for hy-poglycemia in the hospital (104), possibly | [
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as a result of decreased insulin clearance.\nStudies of “bundled” preventive therapies,\nincluding proactive surveillance of glycemic\noutliers and an interdisciplinary data-driven\napproach to glycemic management, showed | [
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approach to glycemic management, showed\nthat hypoglycemic episodes in the hospi-\ntal could be reduced or prevented. Com-pared with baseline, studies found that\nhypoglycemic events decreased by\n56–80% (98,105,106). The Joint Commis- | [
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56–80% (98,105,106). The Joint Commis-\nsion, a global quality improvement andpatient safety in health care organiza-tion, recommends that all hypoglycemic\nepisodes be evaluated for a root cause\nand the episodes be aggregated and re- | [
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and the episodes be aggregated and re-\nviewed to address systemic issues (23).\nIn addition to errors with insulin treatment,\niatrogenic hypoglycemia may be induced by asudden reduction of corticosteroid dose, | [
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reduced oral intake, emesis, inappropriatetiming of short- or rapid-acting insulin\ndoses in relation to meals, reduced infusion\nrate of intravenous dextrose, unexpected\ninterruption of enteral or parenteral feedings, | [
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interruption of enteral or parenteral feedings,\ndelayed or missed blood glucose checks, andaltered ability of the individual to report\nsymptoms (107).\nRecent inpatient studies show promise | [
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] |
Recent inpatient studies show promise\nfor CGM as an early warning system toalert of impending hypoglycemia, offering\nan opportunity to mitigate it before it hap-pens (46 –49). The use of personal CGM | [
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that can automatically deliver correction\ndoses and change basal delivery rates in | [
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real time, should be supported for ongo-ing use during hospitalization for individu-als who are capable of using their devicessafely and independently when properoversight supervision is available. Hospi-tals should be encouraged to develop poli-cies and | [
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should be encouraged to develop poli-cies and protocols to support inpatientuse of individual- and hospital-owned dia-betes technology and have expert staffavailable for safe implementation andevaluation of continued use during the | [
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hospital stay (51). Hospital information | [
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technology teams are beginning to inte-grate CGM data into the EHR. The abilityto download and interpret diabetes de-vice data during hospitalization can informinsulin dosing during hospitalization andcare transitions (41). | [
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] |
For more information on CGM, see\nSection 7, “Diabetes Technology. ”\nPredictors of Hypoglycemia | [
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] |
In people with diabetes, it is well establishedthat an episode of severe hypoglycemia in-creases the risk for a subsequent event,partly because of impaired counterregula-tion (108,109). In a study of hospitalizedindividuals, 84% of people who had an | [
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<40 mg/dL [ <2.2 mmol/L]) had a preced-\ning episode of hypoglycemia (< 70 mg/dL\n[<3.9 mmol/L]) during the same admis-\nsion (110). In another study of hypoglyce-\nmic episodes (de fined as <50 mg/dL\n[<2.8 mmol/L]), 78% of individuals were | [
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[<2.8 mmol/L]), 78% of individuals were\ntaking basal insulin, with the incidence of\nhypoglycemia peaking between midnightand 6:00\nA.M. Despite recognition of hypo- | [
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A.M. Despite recognition of hypo-\nglycemia, 75% of individuals did not havetheir dose of basal insulin changed beforethe next basal insulin administration (111).\nRecently, several groups have devel-\noped algorithms to predict episodes of | [
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oped algorithms to predict episodes of\nhypoglycemia in the inpatient setting\n(112,113). Models such as these are po- | [
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tentially important and, once validatedfor general use, could provide a valu-able tool to reduce rates of hypoglyce-mia in the hospital. In one retrospectivecohort study, a fasting blood glucose of<100 mg/dL was shown to be a predic- | [
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tor of next-day hypoglycemia (34).\nMEDICAL NUTRITION THERAPY IN\nTHE HOSPITAL\nThe goals of medical nutrition therapy\nin the hospital are to provide adequatecalories to meet metabolic demands, opti-\nmize glycemic outcomes, address personal | [
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mize glycemic outcomes, address personal\nfood preferences, and facilitate the crea-tion of a discharge plan. The American Di-abetes Association does not endorse anysingle meal plan or speci fied percentages\nof macronutrients. Current nutrition rec- | [
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of macronutrients. Current nutrition rec-\nommendations advise individualizationb a s e do nt r e a t m e n tg o a l s ,p h y s i o l o g i c a lparameters, and medication use. Con-trolled carbohydrate meal plans, wherethe amount of carbohydrate on each | [
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meal tray is calculated, are preferred by\nmany hospitals, as they facilitate match-ing the prandial insulin dose to theamount of carbohydrate given (114). Or-ders should also indicate that the mealdelivery and nutritional insulin coverage | [
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should be coordinated, as their variability\noften creates the possibility of hypergly-cemic and hypoglycemic events (20).Some hospitals offer “meals on demand, ”\nwhere individuals may order meals from\nthe menu at any time during the day. This | [
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the menu at any time during the day. This\noption improves patient satisfaction but\ncomplicates insulin –meal coordination\nand can lead to insulin stacking if meals\nare too close together. Finally, if the hos-pital food service supports carbohydrate | [
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counting, this option should be made\navailable to people with diabetes count-ing carbohydrates at home and peoplewearing insulin pumps (115,116).\nSELF-MANAGEMENT IN THE\nHOSPITAL\nDiabetes self-management in the hospital | [
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HOSPITAL\nDiabetes self-management in the hospital\nmay be appropriate for speci fic individuals\nwho wish to continue to perform self-care\nwhile acutely ill (117 –119). Candidates in- | [
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while acutely ill (117 –119). Candidates in-\nclude children with parental supervision,adolescents, and adults who successfullyperform diabetes self-management athome and whose cognitive and physical\nskills needed to successfully self-administer | [
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skills needed to successfully self-administer\ninsulin and perform glucose monitoring arenot compromised (7,41). In addition, theyshould have adequate oral intake, be profi -\ncient in carbohydrate estimation, take mul- | [
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cient in carbohydrate estimation, take mul-\ntiple daily insulin injections or wear insulin\npumps, have stable insulin requirements, | [
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pumps, have stable insulin requirements,\nand understand sick-day management. Ifself-management is supported, a policyshould include a requirement that peoplewith diabetes and the care team agree\nthat self-management is appropriate on a | [
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daily basis during hospitalization. Hospitalpersonal medication policies may includeguidance for people with diabetes whowish to take their own or hospital-dispensedinsulin and noninsulin injectable medica-tions during their hospital stay. A | [
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medica-tions during their hospital stay. A hospitalpolicy for personal medication may considera pharmacy exception on a case-by-case ba- | [
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sis along with the care team. Pharmacy\nmust verify any home medication and re-quire a prescriber order for the individualto self-administer home or hospital-\ndispensed medication under the su- | [
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] |
dispensed medication under the su-\npervision of the registered nurse. If aninsulin pump or CGM device is worn,hospital policy and procedures delin-eating guidelines for wearing an insulin\npump and/or CGM device should be de- | [
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] |
pump and/or CGM device should be de-\nveloped according to consensus guide-lines, including the changing of insulininfusion sites and CGM glucose sensors(41,120,121). As outlined in Recommenda-\ntions 7.33 and 7.34, people with diabetes | [
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tions 7.33 and 7.34, people with diabetes\nwearing diabetes devices should be sup-ported to continue them in an inpatientsetting if they are assessed and deemed\ncompetent to perform self-care and proper\nsupervision is available.\nSTANDARDS FOR SPECIAL | [
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] |
supervision is available.\nSTANDARDS FOR SPECIAL\nSITUATIONS\nEnteral/Parenteral Feedings\nFor individuals receiving enteral or parenteral\nfeedings who require insulin, the insulin or-ders should include coverage of basal, pran- | [
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] |
dial, and correctional needs (115,122,123).\nIt is essential that people with type 1 diabe-tes continue to receive basal insulin even iffeedings are discontinued.\nMost adults receiving basal insulin\nshould continue with their basal dose, | [
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should continue with their basal dose,\nwhile the insulin dose for the total daily\nnutritional component may be calculatedas 1 unit of insulin for every 10 –15 g of\ncarbohydrate in the enteral and paren-\nteral formulas. Commercially available | [
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teral formulas. Commercially available\ncans of enteral nutrition contain variableamounts of carbohydrates and may beinfused at different rates.\nAll of this must be considered when | [
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] |
All of this must be considered when\ncalculating insulin doses to cover the nu-tritional component of enteral nutrition(116). Giving NPH insulin two or threetimes daily (every 8 or 12 h) to cover indi-vidual requirements is a reasonable op- | [
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tion. Adjustments in insulin doses should\nbe made frequently. Correctional insulinshould also be administered subcutane-ously every 6 h with regular human insu-\nlin. If enteral nutrition is interrupted, a | [
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lin. If enteral nutrition is interrupted, a\ndextrose infusion should be started im-mediately to prevent hypoglycemia andS300 Diabetes Care in the Hospital Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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to allow time to determine more appro-\npriate insulin doses.\nFor adults receiving enteral bolus feed-\nings, approximately 1 unit of regular humaninsulin or rapid-acting insulin per every10–15 g of carbohydrate should be given | [
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] |
subcutaneously before each feeding. To mit-igate any hyperglycemia, correctional insu-lin should be added as needed before eachfeeding.\nIn individuals receiving nocturnal tube | [
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] |
In individuals receiving nocturnal tube\nfeeding, NPH insulin administered alongwith the initiation of the feeding is a rea-sonable approach to cover this nutritionalload.\nFor individuals receiving continuous pe- | [
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For individuals receiving continuous pe-\nripheral or central parenteral nutrition,human regular insulin may be added tothe solution, particularly if >20 units of\ncorrectional insulin have been required inthe past 24 h. A starting dose of 1 unit of | [
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] |
regular human insulin for every 10 g of | [
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dextrose has been recommended (105)and should be adjusted daily in the solu-tion. Adding insulin to the parenteral nu-trition bag is the safest way to preventhypoglycemia if the parenteral nutrition isstopped or interrupted. Correctional insu-lin should | [
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or interrupted. Correctional insu-lin should be administered subcutane-ously to address any hyperglycemia. | [
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] |
nutrition results in a continuous postpran-dial state, efforts to bring blood glucoselevels to below 140 mg/dL (7.8 mmol/L)substantially increase the risk of hypoglyce-mia in these individuals. For full enteral/parenteral feeding guidance, please referto | [
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] |
feeding guidance, please referto randomized controlled trials detailingthis topic (122,124). | [
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Glucocorticoid Therapy\nThe prevalence of consistent use of gluco-corticoid therapy in hospitalized individualscan approach 10 –15%, and these medica-\ntions can induce hyperglycemia in 56 –86%\nof these individuals with and without | [
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of these individuals with and without\npreexisting diabetes (125 –127). If left un-\ntreated, this hyperglycemia increases mor- | [
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tality and morbidity risk, e.g., infectionsand cardiovascular events. Glucocorticoidtype and duration of action must be con-sidered in determining appropriate insulintreatments. Daily-ingested intermediate-acting glucocorticoids such as prednisonereach | [
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glucocorticoids such as prednisonereach peak plasma levels in 4 –6 h (128) | [
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] |
but have pharmacologic actions that canlast throughout the day. Individuals placedon morning steroid therapy have dispro-portionate hyperglycemia during the daybut frequently reach blood glucose goals\novernight regardless of treatment (125). In | [
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overnight regardless of treatment (125). In\nindividuals on once- or twice-daily steroids,administering NPH insulin is a standardapproach. NPH is usually administered inaddition to daily basal-bolus insulin or inaddition to oral glucose-lowering medica- | [
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tions, depending on the type of diabetes\nand recent diabetes medication prior tostarting steroids. Because NPH actionpeaks about 4 –6 h after administration, it\nis recommended that it be administered\nconcomitantly with intermediate-acting | [
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concomitantly with intermediate-acting\nsteroids (129). For long-acting glucocorti-coids such as dexamethasone and multi-dose or continuous glucocorticoid use,long-acting basal insulin may be requiredto manage fasting blood glucose levels | [
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(53,130). For higher doses of glucocorti-\ncoids, increasing doses of prandial (if eat-ing) and correction insulin, sometimes asmuch as 40 –60% or more, are often\nneeded in addition to basal insulin(131,132). A retrospective study found | [
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that increasing the ratio of insulin to\nsteroids was positively associated withimproved time in range (70 –180 mg/dL);\nhowever, there was an increase in hypo-glycemia (133). If insulin orders are initi-ated, daily adjustments based on levels | [
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of glycemia and anticipated changes in\ntype, dosages, and duration of glucocor-ticoids, along with POC blood glucosemonitoring, are critical to reducing hypo-glycemia and hyperglycemia.\nPerioperative Care | [
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] |
Perioperative Care\nI ti se s t i m a t e dt h a tu pt o2 0 %o fi n d i v i d u -als undergoing general surgery have dia-\nbetes, and 23 –60% have prediabetes or\nundiagnosed diabetes. Surgical stress and | [
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] |
undiagnosed diabetes. Surgical stress and\ncounterregulatory hormone release in-crease the risk of hyperglycemia as wellas mortality, infection, and length of stay(134– 136). There are little data available | [
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to guide care of people with diabetesthrough the perioperative period. To reducesurgical risk in people with diabetes, someinstitutions (135,137,138) have A1C cutoffsfor elective surgeries, and some have devel-oped optimization programs to lower A1C | [
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] |
prior to surgery (134,135,137,138).\nThe following approach (134,135,137)\nmay be considered:\n1. A preoperative risk assessment should\nbe performed for people with diabe-\ntes who are at high risk for ischemicheart disease and those with auto- | [
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] |
nomic neuropathy or renal failure.\n2 . T h eA 1 Cg o a lf o re l e c t i v es u r g e r i e s\nshould be <8% (<63.9 mmol/L) when-\never possible.\n3. The blood glucose goal in the periopera-\ntive period should be 100 –180 mg/dL | [
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] |
tive period should be 100 –180 mg/dL\n(5.6–10.0 mmol/L) (135) within 4 h\nof the surgery. CGM should not be\nused alone for glucose monitoring dur-\ning surgery (138).\n4. Metformin should be held on the\nday of surgery.\n5. SGLT2 inhibitors should be discon- | [
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] |
5. SGLT2 inhibitors should be discon-\ntinued 3 –4 days before surgery.\n6. Hold other oral glucose-lowering agents\nthe morning of surgery or procedureand give one-half of NPH dose or75–80% doses of long-acting analog in- | [
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sulin or adjust insulin pump basal ratesbased on the type of diabetes and clini-cal judgment.\n7. Monitor blood glucose at least every\n2–4 h while the individual takes noth-\ning by mouth and dose with short- orrapid-acting insulin as needed. | [
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] |
8. There are little data on the safe use\nand/or in fluence of GLP-1 receptor\nagonists on glycemia and delayedgastric emptying in the perioperativeperiod.\n9. Stricter perioperative glycemic goals | [
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9. Stricter perioperative glycemic goals\nare not advised, as perioperative glyce-mic goals stricter than 80 –180 mg/dL\n(4.4–10.0 mmol/L) may not improve\noutcomes and are associated withmore hypoglycemia (137).\n10. Compared with usual dosing, a reduc- | [
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10. Compared with usual dosing, a reduc-\ntion by 25% of basal insulin given theevening before surgery is more likely\nto achieve perioperative blood glucose\ngoals with a lower risk for hypoglyce-mia (139).\n11. In individuals undergoing noncardiac | [
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11. In individuals undergoing noncardiac\ngeneral surgery, basal insulin pluspremeal short- or rapid-acting insulin(basal-bolus) coverage has been\nassociated with improved glycemic out- | [
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associated with improved glycemic out-\ncomes and lower rates of perioperativecomplications compared with the re-\nactive, correction-only short- or rapid-\nacting insulin coverage alone with nobasal insulin dosing (63,134,135).\nDiabetic Ketoacidosis and | [
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