Research indicates that hyperglycemia is a common finding among both medical and surgical patients, regardless of whether or not they have diabetes. When compared with patients who have normal glycemic levels, those with uncontrolled hyperglycemia have higher mortality and morbidity. These patients tend to have:
• Delays in healing.
• Poor immune responses.
• Higher risks for cardiovascular events, inflammatory issues, and thrombosis.
The extra care associated with these issues can increase healthcare costs unnecessarily.
Need for Changes
Many hospitals in the United States have protocols intended to implement intensive insulin therapy routinely in critically sick patients. However, based on new evidence, Amir Qaseem, MD, PhD, MHA, FACP, warns that physicians should not use intensive insulin therapy to strictly control blood glucose in hospitalized patients with or without diabetes. According to Dr. Qaseem, a potentially major harm in using intensive insulin therapy is that it can increase the risk of hypoglycemia. “This can lead to the same poor outcomes and adverse effects that we try to avoid with efforts to prevent or treat hyperglycemia,” he says. “Physicians should avoid aggressive glucose management and instead target levels of 140 mg/dL to 200 mg/dL when using insulin therapy.”
To help clinicians find a balance between hyperglycemia and hypoglycemia, Dr. Qaseem and colleagues at the American College of Physicians (ACP) reviewed recently published studies and developed recommendations on inpatient glycemic control. The document was published in the American Journal of Medical Quality. The first recommendation made by the ACP committee was that clinicians should avoid intensive insulin therapy to strictly control blood glucose or to normalize blood glucose in surgical and medical ICU patients, regardless of diabetes status.
“Physicians should avoid aggressive glucose management and instead target levels of 140 mg/dL to 200 mg/dL when using insulin therapy.”
“The current evidence is not quite sufficient to provide a precise range for optimal blood glucose levels in these patients,” explains Dr. Qaseem. “Insulin therapy that targets blood glucose levels between 140 mg/dL and 200 mg/dL appears to be associated with similar mortality outcomes as intensive insulin therapy targeting levels of 80 mg/dL to 110 mg/dL, but there’s a lower risk of hypoglycemia.”
Monitor Patients Closely
Dr. Qaseem notes that patients must be closely monitored, regardless of the method used to manage hyperglycemia. “The bottom line,” he says, “is that physicians who care for hospitalized patients need to consider the harms of hypoglycemia when attempting to treat or prevent hyperglycemia and avoid intensive insulin therapy.”
Readings & Resources (click to view)
Qaseem A, Chou R, Humphrey L, et al. Inpatient glycemic control: best practice advice from the clinical guidelines committee of the American College of Physicians. Am J Med Qual. 2013 Jun 7 [ePub ahead of print]. Available at http://ajm.sagepub.com/content/early/2013/06/06/1062860613489339.full.pdf+html.
A balancing act: achieving glycemic control in hospitalized patients. Nursing. 2014;44:37-38.
Tseng C, Soroka O, Maney M. Assessing potential glycemic overtreatment in persons at hypoglycemic risk. JAMA Intern Med. 2013 Dec 9 [ePub ahead of print]. Available at http://dx.doi.org/10.1001/jamainternmed.2013.12963.
Liou J, Soon M, Chen C. Shared care combined with telecare improves glycemic control of diabetic patients in a rural underserved community. Telemed J E Health. 2013 Dec 9 [ePub ahead of print]. Available at http://online.liebertpub.com/doi/abs/10.1089/tmj.2013.0037.