The recognition that hyperglycemia is associated with adverse outcomes in hospitalized patients with or without diabetes has engaged the medical community in creating a system of inpatient glycemic management. The question has remained as to what specific glycemic targets can be safely achieved in patients with acute illness. Recently published data have demonstrated inconsistent results on interventions used to manage blood glucose levels in critically ill and non-critically ill patients. To address these inconsistencies, the American Diabetes Association and the American Association of Clinical Endocrinologists joined forces to update their consensus statement on inpatient glycemic management. Published in the June 2009 issues of Endocrine Practice and Diabetes Care, this updated and revised consensus statement advocates significant changes in the glycemic targets for both critically ill and non-critically ill hospitalized patients.
“Studies have demonstrated a higher frequency of hypoglycemia with use of protocols targeting tight glycemic control in hospitalized patients, raising concern as to the appropriateness of continuing these more aggressive treatment strategies,” says Mary T. Korytkowski, MD, who served as the American Diabetes Association chair of the updated consensus statement. “Because protocols targeting very tight glucose control now appear to be associated with a high frequency of hypoglycemia, there was concern that there would be a return to the days of uncontrolled glucose levels in the hospital. For this reason, it was necessary to review the literature and develop a guideline for physicians that would allow them to pursue glycemic control in hospital settings safely and without high risk for hypoglycemia.”
The fundamental goals of the consensus statement were to identify reasonable, achievable, and safe glycemic targets as well as describe protocols, procedures, and system improvements that are essential to their implementation. Due to the complexity of inpatient glycemic management, the expert panel recommended a multidisciplinary approach from hospital admission to discharge. The consensus group calls for major changes in the way healthcare professionals treat inpatients with high blood glucose levels (Table 1).
Study Influences Ideal Glucose Targets
The recently-published NICE-SUGAR study is a large, international, randomized trial, which found an increase in 90-day mortality in subjects randomized to receive intensive insulin therapy targeting blood glucose levels of 80 mg/dL to 110 mg/dL when compared with those who received conventional control (a target of 144 mg/dL to180 mg/dL). “Referencing these outcomes, the consensus panel recommends glucose targets of 140 mg/dL to 180 mg/dL in the majority of patients in the ICU setting,” Dr. Korytkowski says. “The preferred method of achieving glycemic control is IV insulin infusion with frequent glucose monitoring. Outside of critical care units, we recommended that pre-meal blood sugars are kept below 140 mg/dL with random blood glucose values less than 180 mg/dL.”
Frequent glucose monitoring is emphasized as an essential component of any inpatient glycemic management program. There may be patients for whom tighter control is acceptable (eg, 110 mg/dL to 140 mg/dL), particularly those with prior tight glycemic control. However, safety precautions should be taken when tighter glycemic levels are considered. “Improving glycemic control has been shown to improve clinical outcomes in hospitalized patients with and without a prior history of diabetes,” adds Dr. Korytkowski. “For example, substantial reductions in wound infection following coronary artery bypass surgery in patients with diabetes have been demonstrated when using insulin protocols that target blood glucose less than 150 mg/dL for 3 days following surgery. Other studies have also shown that length of hospital stay and the frequency of arrhythmia are decreased.”
Safe Practices & Patient Discharge
Inpatient glycemic management requires a systems approach to ensure safe practices and reduce the risk of errors. “A multidisciplinary steering committee supported by diabetes experts can help establish management goals as well as protocols and order sets,” Dr. Korytkowski says. “Both overtreatment and undertreatment of hyperglycemia are safety concerns, so we emphasize the importance of education among inpatient providers on the aspects of inpatient diabetes care.” Potential cost savings such as reductions in morbidity, length of hospital stay, and the need for readmission can be presented to hospital administrators as a way of obtaining institutional support and buy-in. This is essential to cover costs of staff education, equipment, and personnel to oversee an inpatient diabetes management program.
Hospitalization provides an opportunity to initiate or reinforce self-management education among patients with diabetes (Table 2). “This is particularly important among patients who are newly diagnosed with diabetes or those who have diabetes but haven’t received adequate treatment,” says Dr. Korytkowski. “Establishing a transition team may enable healthcare professionals to track patients after discharge before they are able to follow up with their primary care physicians.”
Mary T. Korytkowski, MD, has indicated to Physician’s Weekly that she has received consultant fees from Eli Lilly, and Novo Nordisk and research grant support from sanofi-aventis
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