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Brief Summary

GUIDELINE TITLE

American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Diabetes management in the hospital setting.

BIBLIOGRAPHIC SOURCE(S)

  • AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. AACE diabetes mellitus guidelines. Diabetes management in the hospital setting. Endocr Pract 2007 May-Jun;13(Suppl 1):59-63. [67 references]

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previously published version: American Association of Clinical Endocrinologists, American College of Endocrinology. Medical guidelines for the management of diabetes mellitus: the AACE system of intensive diabetes self-management--2002 update. Endocr Pract 2002 Jan-Feb;8(Suppl 1):40-82.

BRIEF SUMMARY CONTENT

 
RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

The levels of evidence (1–4) and the recommendation grades (A–D) are defined at the end of the "Major Recommendations" field.

Diabetes Management in the Hospital Setting

Hospital Preadmission Planning

  • For elective hospital admissions, develop a glycemic management plan with the patient before admission and share the plan with colleagues who will be involved in the patient's care (grade C)

Data Collection and Record Keeping

  • Measure the blood glucose concentration at hospital admission (grade A)
  • Record "diabetes mellitus" on the medical chart, if the diagnosis of diabetes mellitus is known (grade C)
  • Measure the HbA1c level at hospital admission if hyperglycemia is present, if a history of diabetes mellitus exists, or if a HbA1c value (within the past 3 months) is not available for review (grade B)
  • Order point-of-care glucose monitoring in a pattern appropriate to the patient's diagnoses and carbohydrate exposure if hyperglycemia is present at hospital admission or if conditions present high risk for developing hyperglycemia (grade A)

Meal Plan

  • For hyperglycemic patients who are eating, either: (a) order a consistent carbohydrate diet or (b) for knowledgeable nurses or insulin-requiring patients, permit the use of advanced carbohydrate counting and nurse-determination or patient self-determination of prandial insulin doses (grade C)

Target Blood Glucose Levels

  • Preprandial, less than 110 mg/dL (grade C)
  • Peak postprandial, less than 180 mg/dL (grade B)
  • Critically ill patients, between 80 to 110 mg/dL (grade A)

Insulin Management Plan

  • If appropriate for the patient, use intravenous insulin infusion (grade A)
  • If hyperglycemia is reproducibly present and intravenous insulin infusion is not necessary, order scheduled subcutaneous insulin (grade B)
  • For subcutaneous management, order amounts of insulin sufficient to cover basal and nutritional needs (grade B)
  • Plan the patterns of glucose monitoring and delivery of insulin to match carbohydrate exposure (grade B)
  • Revise the amounts of scheduled insulin daily or more frequently based on patient response (grade B)
  • For patients receiving scheduled insulin, order an as needed correction dose of subcutaneous insulin with dosing that is: (a) proportionate to blood glucose elevation and insulin sensitivity of the patient and (b) appropriate to time of day; specify the times or mealtimes to which the order applies (grade B)

Hypoglycemia Prevention

  • Modify insulin therapy preventively if a downward trend in blood glucose concentrations is observed or there are other conditions that predispose to hypoglycemia (grade A)
  • For abrupt interruption of carbohydrate exposure within the time frame of action of previously administered nutritional insulin, treat the patient preemptively with intravenous concentrated dextrose before hypoglycemia occurs (grade B)

Comanagement

  • Work collaboratively with diabetes care professionals from the disciplines of nursing, nutrition, pharmacy, quality assurance, hospital administration, and others (grade B)

Hospital Discharge Planning

  • Offer inpatient education to patients regarding medication administration (including subcutaneous insulin injections if appropriate), glucose monitoring, nutrition, physical activity, and other lifestyle factors (grade B)
  • At hospital discharge, offer appropriate intensification of the patient's preadmission management plan (grade B)
  • At hospital discharge, provide an explanation of circumstances that should prompt the patient to call the clinician for guidance (grade B)
  • Plan follow-up visits to be conducted after hospital discharge to discuss glycemic control and to continue patient education (grade B)

Definitions:

Levels of Substantiation in Evidence-Based Medicinea

Level-of-Evidence Categoryb Study Design or Information Type Comments
1 Randomized controlled trials

Multicenter trials

Large meta-analyses with quality ratings
Well-conducted, well-controlled trials at 1 or more medical centers

Data derived from a substantial number of trials with adequate power; substantial number of subjects and outcome data

Consistent pattern of findings in the population for which the recommendation is made – generalizable results

Compelling nonexperimental, clinically obvious evidence (e.g., use of insulin in diabetic ketoacidosis); "all or none" evidence
2 Randomized controlled trials

Prospective cohort studies

Meta-analyses of cohort studies

Case-control studies
Limited number of trials, small number of subjects

Well-conducted studies

Inconsistent findings or results not representative for the target population
3 Methodologically flawed randomized controlled trials

Nonrandomized controlled trials

Observational studies

Case series or case reports
Trials with 1 or more major or 3 or more minor methodologic flaws

Uncontrolled or poorly controlled trials

Retrospective or observational data

Conflicting data with weight of evidence unable to support a final recommendation
4 Expert consensus

Expert opinion based on experience

Theory-driven conclusions

Unproven claims

Experience-based information
Inadequate data for inclusion in level-of-evidence categories 1, 2, or 3; data necessitates an expert panel's synthesis of the literature and a consensus

aAdapted from the American Association of Clinical Endocrinologists Protocol for the Standardized Production of Clinical Practice Guidelines.

bLevel-of-evidence categories 1 through 3 indicate scientific substantiation or proof; level-of-evidence category 4 indicates unproven claims.

Recommendation Grades in Evidence-Based Medicinea

Grade Description
A Homogeneous evidence from multiple well-designed randomized controlled trials with sufficient statistical power

Homogeneous evidence from multiple well-designed cohort controlled trials with sufficient statistical power

>1 conclusive level of evidence category 1 publications demonstrating benefit >> outweighs risk
B Evidence from at least one large well-designed clinical trial, cohort or case-controlled analytic study, or meta-analysis

No conclusive level of evidence category 1 publication; >1 conclusive level of evidence category 2 publications demonstrating benefit >> risk
C Evidence based on clinical experience, descriptive studies, or expert consensus opinion

No conclusive level 1 or 2 publication; >1 conclusive level of evidence category 3 publications demonstrating benefit >> risk

No conclusive risk at all and no conclusive benefit demonstrated by evidence
D Not rated

No conclusive level of evidence category 1, 2, or 3 publication demonstrating benefit >> risk

Conclusive level of evidence category 1, 2, or 3 publication demonstrating risk >> benefit

aAdapted from the American Association of Clinical Endocrinologists Protocol for the Standardized Production of Clinical Practice Guidelines.

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. AACE diabetes mellitus guidelines. Diabetes management in the hospital setting. Endocr Pract 2007 May-Jun;13(Suppl 1):59-63. [67 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2000 Jan (revised 2007)

GUIDELINE DEVELOPER(S)

American Association of Clinical Endocrinologists - Medical Specialty Society
American College of Endocrinology - Medical Specialty Society

SOURCE(S) OF FUNDING

American Association of Clinical Endocrinologists (AACE)

GUIDELINE COMMITTEE

American Association of Clinical Endocrinologists (AACE) Diabetes Mellitus Clinical Practice Guidelines Task Force

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Task Force Members: Helena W. Rodbard, MD, FACP, MACE (Chairperson) Medical Director, Endocrine and Metabolic Consultants Past President, American Association of Clinical Endocrinologists Past President, American College of Endocrinology, Rockville, Maryland; Lawrence Blonde, MD, FACP, FACE, Director, Ochsner Diabetes Clinical Research Unit; Section on Endocrinology, Diabetes, and Metabolic Diseases Associate Residency Program Director, Department of Internal Medicine, New Orleans, Louisiana; Susan S. Braithwaite, MD, FACP, FACE, Clinical Professor of Medicine, University of North Carolina, Division of Endocrinology, Chapel Hill, NC; Elise M. Brett, MD, FACE, Assistant Clinical Professor of Medicine; Division of Endocrinology, Diabetes, and Bone Disease; Mount Sinai School of Medicine, New York, New York; Rhoda H. Cobin, MD, MACE, Clinical Professor of Medicine; Division of Endocrinology, Diabetes, and Bone Disease; Mount Sinai School of Medicine, Immediate Past President, American College of Endocrinology, Past President, American Association of Clinical Endocrinologists, New York, New York; Yehuda Handelsman, MD, FACP, FACE, Medical Director, Metabolic Institute of America, Senior Scientific Consultant, Metabolic Endocrine Education Foundation, Tarzana, California; Richard Hellman, MD, FACP, FACE, Clinical Professor of Medicine, University of Missouri-Kansas City School of Medicine, President, American Association of Clinical Endocrinologists, North Kansas City, Missouri; Paul S. Jellinger, MD, MACE, Professor of Medicine and Voluntary Faculty, University of Miami School of Medicine, Past President, American College of Endocrinology Past President, American Association of Clinical Endocrinologists, Hollywood, Florida; Lois G. Jovanovic, MD, FACE, CEO & Chief Scientific Officer, Sansum Diabetes Research Institute, Adjunct Professor Biomolecular Science and Engineering, University of California-Santa Barbara, Clinical Professor of Medicine, University of Southern California, Keck School of Medicine, Santa Barbara, CA; Philip Levy, MD, FACE, Clinical Professor of Medicine, University of Arizona College of Medicine, Past President, American College of Endocrinology, Phoenix, Arizona; Jeffrey I. Mechanick, MD, FACP, FACE, FACN, Associate Clinical Professor of Medicine and Director of Metabolic Support; Division of Endocrinology, Diabetes, and Bone Disease; Mount Sinai School of Medicine, New York, New York; Farhad Zangeneh, MD, FACP, FACE, Assistant Clinical Professor of Medicine, George Washington University School of Medicine, Washington, DC, Endocrine, Diabetes and Osteoporosis Clinic (EDOC), Sterling, Virginia

Medical Writer: Christopher G. Parkin, MS

Reviewers: Lewis E. Braverman, MD; Samuel Dagogo-Jack, MD, FACE; Vivian A. Fonseca, MD, FACE; Martin M. Grajower, MD, FACP, FACE; Virginia A. LiVolsi, MD; Fernando Ovalle, MD, FACE; Herbert I. Rettinger, MD, FACE; Talla P. Shankar, MD, FACE; Joseph J. Torre, MD, FACP, FACE; Dace L. Trence, MD, FACE

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Dr. Lawrence Blonde reports that he has received grant/research support from Amylin Pharmaceuticals, Inc.; AstraZeneca LP; Bristol-Myers Squibb Company; Eli Lilly and Company; MannKind Corporation; Merck & Co., Inc.; Novo Nordisk Inc.; Novartis Corporation; Pfizer Inc.; and sanofi-aventis U.S. He has received speaker and consultant honoraria from Abbott Laboratories; Amylin Pharmaceuticals, Inc.; Eli Lilly and Company; GlaxoSmithKline; LifeScan, Inc.; Merck & Co., Inc.; Novartis, Novo Nordisk Inc.; Pfizer Inc.; and sanofi-aventis U.S. He has received consultant honoraria from Kos Pharmaceuticals, Inc. and U.S. Surgical. Dr. Blonde has also disclosed that his spouse is a stock shareholder of Amylin Pharmaceuticals, Inc. and Pfizer Inc., in an account that is not part of their community property.

Dr. Susan S. Braithwaite reports that she does not have any financial relationships with any commercial interests.

Dr. Elise M. Brett reports that her spouse is an employee of Novo Nordisk Inc.

Dr. Rhoda H. Cobin reports that she has received speaker honoraria from GlaxoSmithKline; Pfizer Inc.; sanofi-aventis U.S.; and Novartis and consultant honoraria from Abbott Laboratories.

Dr. Yehuda Handelsman reports that he has received speaker honoraria from Abbott Laboratories; Amylin Pharmaceuticals, Inc.; AstraZeneca LP; Bristol-Myers Squibb Company; GlaxoSmithKline; Merck & Co., Inc.; Novartis; and sanofi-aventis U.S. and consultant honoraria from Abbott Laboratories; Daiichi Sankyo, Inc.; Novartis; and sanofi-aventis U.S.

Dr. Richard Hellman reports that he has received speaker honoraria from Daiichi Sankyo, Inc. and Pfizer Inc. and research grants for his role as an independent contractor from Abbott Laboratories; Pfizer Inc.; and Medtronic, Inc.

Dr. Paul S. Jellinger reports that he has received speaker honoraria from Eli Lilly and Company; Merck & Co., Inc.; Novartis; Novo Nordisk Inc.; and Takeda Pharmaceuticals North America, Inc.

Dr. Lois G. Jovanovic reports that she has received research grants for her role as investigator from Eli Lilly and Company; DexCom Inc.; LifeScan, Inc.; Novo Nordisk Inc.; Pfizer Inc.; Roche Pharmaceuticals; sanofi-aventis U.S.; and Sensys Medical, Inc.

Dr. Philip Levy reports that he has received speaker honoraria from Abbott Laboratories; Amylin Pharmaceuticals, Inc.; GlaxoSmithKline; Eli Lilly and Company; Merck & Co., Inc.; Novo Nordisk Inc.; Novartis; Pfizer Inc.; and sanofi-aventis U.S. and research grants from Amylin Pharmaceuticals, Inc.; MannKind Corporation; Novo Nordisk Inc.; Pfizer Inc.; and sanofi-aventis U.S.

Dr. Jeffrey I. Mechanick reports that he does not have any financial relationships with any commercial interests.

Dr. Helena W. Rodbard reports that she has received consultant honoraria from Ortho-McNeil, Inc.; Pfizer Inc.; sanofi-aventis U.S.; and Takeda Pharmaceuticals North America, Inc.; speaker honoraria from Abbott; GlaxoSmithKline; Merck & Co., Inc.; Novo Nordisk; Pfizer Inc.; and sanofi-aventis U.S. and research support from Biodel, Inc. and sanofi-aventis U. S.

Dr. Farhad Zangeneh reports that he has received speaker honoraria from Eli Lilly and Company; GlaxoSmithKline; Novartis; Novo Nordisk Inc.; Pfizer Inc.; Roche Pharmaceuticals; sanofi-aventis U.S.; and Takeda Pharmaceuticals North America, Inc.

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previously published version: American Association of Clinical Endocrinologists, American College of Endocrinology. Medical guidelines for the management of diabetes mellitus: the AACE system of intensive diabetes self-management--2002 update. Endocr Pract 2002 Jan-Feb;8(Suppl 1):40-82.

GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the American Association of Clinical Endocrinologists (AACE) Web site.

Print copies: Available from the American Association of Clinical Endocrinologists (AACE), 1000 Riverside Avenue, Suite 205, Jacksonville, FL 32204.

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI on March 1, 2000. The summary was verified by the guideline developer as of March 8, 2000. This summary was updated on April 16, 2002. The information was verified by the guideline developer on November 11, 2002. This summary was updated by ECRI Institute on September 27, 2007. The updated information was verified by the guideline developer on November 12, 2007.

COPYRIGHT STATEMENT

All rights reserved. No part of these materials may be reproduced or retransmitted in any manner without the prior written permission of American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE).

DISCLAIMER

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