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The NICE-SUGAR Study...
How "Nice" Was It?

Diabetes Experts Issue New Recommendations for Inpatient Glycemic Control - Call for Systemic Changes in Hospitals Nationwide

Recommend revised glucose targets of 140-180 mg/dL in the ICU setting, and between 100-180 mg/dL for most patients admitted to general medical-surgical wards.

JACKSONVILLE, Fla. and ALEXANDRIA, Va., May 8 /PRNewswire-USNewswire/ -- New recommendations released today by a consensus group of the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) are calling for major changes in the way health care professionals treat hospitalized patients with high blood glucose (sugar) levels. The authors recommend revised glucose targets of 140-180 mg/dL in the ICU setting, and between 100-180 mg/dL for most patients admitted to general medical-surgical wards.

The recommendations, which were published online today and will appear in the June issues of Endocrine Practice (Link here) and Diabetes Care (Link here), come at a time when attempts to intensively manage glucose targets in the ICU setting have shown inconsistent results in patient outcomes. Several recent randomized controlled clinical trials in critically ill patients in ICUs with diabetes or elevated blood glucose levels have failed to show a significant improvement in mortality with intensive insulin therapy to achieve near normal glucose levels. Moreover, a large newly-published randomized controlled trial showed an increase in mortality risk associated with intensive control of glycemia targeting blood glucose of 80-110 mg/dL. These outcomes have raised concerns regarding specific glycemic targets and the means for achieving them in both critically and non-critically ill patients.

Recognizing the importance of glycemic control across the continuum of care, experts from AACE and ADA were invited to develop an updated consensus statement on inpatient glycemic management.

After a thorough analysis of all the published trials, the authors believe that patients with elevations in blood glucose should continue to be carefully treated, but to less intensive blood glucose targets than were previously suggested. The authors recommend revised glucose targets of 140-180 mg/dL for critically ill patients in ICU settings.

"We are witnessing an evolution in the management of hyperglycemia in inpatient settings," Dr. Etie S. Moghissi, AACE Chair of the Inpatient Glycemic Control Consensus Panel said. "Despite some inconsistencies in the clinical trial results, it would be a serious error to conclude that judicious control of glycemia in hospitalized patients is not warranted."

The complexity of inpatient glycemic management necessitates a system approach that facilitates safe practices that reduce the risk for errors and episodes of severe hypoglycemia. The consensus group recommends a multidisciplinary approach for care from admission to discharge from the hospital.

"The responsibility for management of hyperglycemia shifts from the health care team to the patient following hospital discharge," said Dr. Mary Korytkowski, ADA Chair of the Inpatient Glycemic Control Consensus Panel. "It is therefore important that patients receive the information necessary to safely manage this aspect of their care once they are at home."

Members from the AACE/ADA Inpatient Glycemic Control Task Force will discuss the new AACE/ADA consensus statement highlighting the relationship between glycemic control and clinical outcomes during special symposium scheduled on Friday 7:15 p.m., May 15, 2009 at the AACE 18th Annual Meeting & Clinical Congress in Houston, Texas.

The NICE-SUGAR Study...How "Nice" Was It?

The results are in, but the debate rages on. Click on one of the links below to see what associations, publications and people are saying, and decide for yourself. Information has been divided into 4 groups according to content/intent:

Sliding Scale Insulin—Time to Stop Sliding
Irl B. Hirsch. JAMA 2009;301(2):213-214

Dr. Hirsch discusses why the practice of sliding scale insulin (SSI) continues to flourish in academic medical centers and community hospitals. He writes that "SSI is convenient and straightforward to administer, but it has not been shown to provide benefit and it may induce harm". He also states that SSI is a relic of past generations of ineffective and potentially dangerous glucose management that is not evidence-based and does not attempt to mimic normal physiology. More >

Intensive Glycemic Control and the Prevention of Cardiovascular Events: Implications of the ACCORD, ADVANCE, and VA Diabetes Trials
JS Skyler et al. Diabetes Care 2009;32:1

A position statement of the American Diabetes Association and a scientific statement of the American College of Cardiology Foundation and the American Heart Association. More >

Tight Control of Blood Glucose in the Brain-Injured Patient is Important and Desirable
JL Suarez. J Neurosurg Anesthesiol 2009;21

Dr. Suarez reviews the evidence on intensive intensive therapy and concludes that intensive insulin therapy (IIT) has been found to have several beneficial effects in critically ill neurologic patients stating that IIT improves important morbidity end points such as infection rates, need for prolonged mechanical ventilation, and ICU length of stay. In addition, IIT reduces mortality in certain ICU populations. He also concludes that until further large, prospective, randomized clinical trials are carried out, the AACE consensus recommendations of a target blood glucose level of 110 mg/dL in ICU patients regardless of presence or absence of prior diagnosis of diabetes should be adopted. More >

Tight Glucose Control After Brain Injury is Unproven and Unsafe
J Yoder. J Neurosurg Anesthesiol 2009;21(1)

Dr. Yoder writes that most clinicians agree that significant hyperglycemia must be avoided after brain injury, however, tight glycemic control (<110 mg/dL) has not been proven beneficial in these patients by randomized controlled trials with no evidence of benefit to mortality or neurologic outcomes and a significant increase in severe system hypoglycemia. More >

Insulin Strategies for Managing Inpatient and Outpatient Hyperglycemia and Diabetes
ES Moghissi. Mount Sinai Journal of Medicine 75:558-566, 2008

This article reviews effective strategies for insulin initiation, titration, and intensification in inpatient and outpatient settings and discusses current treatment strategies when patients are being transitioned from the intensive care unit to general wards and discharged. The development of insulin analogs and premixed insulin analogs has created new options for treating inpatients and outpatients. The more physiologic time-action profiles, improved insulin delivery systems, and standardized protocols for subcutaneous insulin administration and intravenous insulin infusion have improved the safety and convenience of insulin therapy. More >

MAS Informatics is pleased to provide GlycemicControl.net, a dynamic website that we trust will serve as a central knowledge source (clearinghouse) of up-to-date information on advances in the aggressive treatment of hyperglycemia and diabetes in hospitalized patients - tight glycemic control. We also provide links to web sites that offer a comprehensive list of information on glycemic control protocols, implementation and management of these protocols, data collection and reporting, products designed to provide continuous glucose monitoring in the hospital with the view to improve patient care, and outcomes in the tight glycemic control environment. We welcome your visit!