What are the diagnostic criteria and initial management for diabetes in a hospital setting according to the American Diabetes Association (ADA) guidelines?

From the Guidelines

The American Diabetes Association (ADA) guidelines for diagnosing diabetes in a hospital setting include: fasting plasma glucose ≥126 mg/dL (7.0 mmol/L), 2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test, random plasma glucose ≥200 mg/dL with symptoms of hyperglycemia, or hemoglobin A1C ≥6.5%. For initial management, insulin is the preferred treatment for hospitalized patients with hyperglycemia. A basal-bolus insulin regimen is recommended, typically starting with a total daily dose of 0.3-0.5 units/kg for most patients, divided into basal insulin (50% of total dose, using insulin glargine, detemir, or degludec) and prandial insulin (50% of total dose, divided before meals, using rapid-acting insulins like lispro, aspart, or glulisine) 1. Blood glucose targets are generally 140-180 mg/dL for most hospitalized patients, though tighter control (110-140 mg/dL) may be appropriate for select stable patients without hypoglycemia risk. Regular monitoring of blood glucose (before meals and at bedtime, with additional checks for those NPO or on continuous enteral/parenteral nutrition) is essential. Hypoglycemia protocols should be established, treating blood glucose <70 mg/dL with 15-20g of glucose and rechecking in 15 minutes. This approach balances glycemic control while minimizing hypoglycemia risk, as insulin requirements often fluctuate during hospitalization due to illness, medication effects, and nutritional changes. Some key points to consider in the management of diabetes in the hospital setting include:

• Transitioning from intravenous to subcutaneous insulin using a protocol to minimize morbidity and costs of care 1
• Implementing a hypoglycemia prevention and management protocol to address blood glucose levels of <70 mg/dL (3.9 mmol/L) 1
• Reviewing a patient’s treatment regimen any time a blood glucose value of <70 mg/dL (3.9 mmol/L) occurs to predict subsequent level 3 hypoglycemia 1. The most recent guidelines from the ADA, published in 2023, provide the foundation for these recommendations, emphasizing the importance of individualized care and careful monitoring to achieve optimal outcomes for patients with diabetes in the hospital setting 1.

From the Research

Diagnostic Criteria for Diabetes in a Hospital Setting

According to the American Diabetes Association (ADA) guidelines, the diagnostic criteria for diabetes in a hospital setting include:

• Fasting plasma glucose (FPG) level ≥ 126 mg/dL 2
• Hemoglobin A1c (HbA1c) level ≥ 6.5% 2
• 2-hour plasma glucose level ≥ 200 mg/dL during an oral glucose tolerance test (OGTT)

Initial Management of Diabetes in a Hospital Setting

The initial management of diabetes in a hospital setting involves:

• Assessing the patient's glucose control and overall health status
• Developing an individualized treatment plan, which may include lifestyle modifications, such as diet and exercise, and pharmacological therapy, such as metformin or insulin 3, 4
• Monitoring the patient's glucose levels and adjusting the treatment plan as needed to achieve optimal glucose control

Importance of Fasting and Postprandial Plasma Glucose

Both fasting and postprandial plasma glucose levels are important in the management of diabetes, as they contribute to the overall glucose control and can impact the risk of complications 5, 4

• A 1-mmol/L reduction in FPG and PPG can be associated with an increase in time in range (TIR) of 6.5% and 5.3%, respectively 4

Distribution of Glucose Levels in the Population

The distribution of glucose levels, including FPG, 2-hour plasma glucose, and HbA1c, can vary by demographics, such as age, race-ethnicity, and sex 6

• The distributions of these glucose levels are generally unimodal and right-skewed, and can be shifted higher and more right-skewed for older age groups and certain racial-ethnic groups 6