Insulin Therapy for Hospitalized Patients Should Not Be Abandoned

February 16, 2011

The American Association of Clinical Endocrinologists and the American Diabetes Association joint statement in response to American College of Physicians (ACP) clinical guidelines for inpatient glucose control

The publication of the systematic review of intensive insulin therapy in hospitalized patients and the American College of Physicians (ACP) clinical guidelines for inpatient glucose control in the February 15^th [2011] issue of Annals of Internal Medicine has again raised the issue of optimal management of hyperglycemia in the hospital.

The American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) have published updated guidelines for treating high blood glucose while avoiding low blood glucose in hospitalized patients. The main objectives of the 2009 AACE/ADA recommendations were to identify reasonable, achievable, and safe glycemic targets and to describe the protocols, procedures, and system improvements needed to facilitate their implementation. For most patients a blood glucose target of 140-180 mg/dL is recommended and appropriate use of insulin is the preferred approach for achieving safe, optimal glucose control.

 “Hyperglycemia in hospitalized patients is common and associated with increased risk of infection, mortality, and increased cost,” said AACE President Daniel Einhorn, MD, FACP, FACE. “Although near normalization of glucose in these patients appears to be of no greater benefit than moderate glycemic targets, ignoring hyperglycemia in this population is no longer acceptable.”

There is substantial observational evidence linking hyperglycemia in hospitalized patients (with or without diabetes) to poor outcomes. Although initial small studies suggested that intensive glycemic control (insulin infusion with goal blood glucose targets of 80-110 mg/dl) improved outcomes in surgical ICU and medical ICU patients, subsequent trials have failed to show a benefit or have even shown increased mortality of intensive targets compared to more moderate targets (140-180 mg/dl).  Moreover, these recent studies have highlighted the risk of severe hypoglycemia resulting from attempts to completely normalize blood glucose.

 “Both over treatment and under treatment of hyperglycemia in hospitalized patient are patient safety issues,” said Robert R. Henry, MD, President, Medicine and Science for the American Diabetes Association. “Coordinated, interdisciplinary teams have been shown to achieve both safe and effective control of hyperglycemia in hospitalized patients.”

The recent ACP guidelines are for the most part consistent with the AACE/ADA recommendations. AACE/ADA maintains that the upper limit of 180 mg/dl is safe and justified by data on benefits of glycemic control and the harms of uncontrolled hyperglycemia. Practitioners should take heart in the commonality of recommendations among all the organizations to address hospital hyperglycemia in the safest manner.

 

The American Association of Clinical Endocrinologists is the world’s largest professional medical organization of clinical endocrinologists with more than 6,500 members in the United States and 91 other countries. AACE members are physicians who specialize in endocrinology, diabetes, and metabolism. For more information about AACE, visit our Web site at www.aace.com, become a fan on Facebook at www.facebook.com/theaace or follow us on Twitter at www.twitter.com/theaace. 

The American Diabetes Association is leading the fight to stop diabetes and its deadly consequences and fighting for those affected by diabetes. The Association funds research to prevent, cure and manage diabetes; delivers services to hundreds of communities; provides objective and credible information; and gives voice to those denied their rights because of diabetes. Founded in 1940, our mission is to prevent and cure diabetes and to improve the lives of all people affected by diabetes. For more information please call the American Diabetes Association at 1-800-DIABETES (1-800-342-2383) or visit www.diabetes.org. Information from both these sources is available in English and Spanish.

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