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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.
More
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:
-
Study Design
-
The Normoglycemia in Intensive Care Evaluation
(NICE) and Survival Using
Glucose Algorithm Regulation (SUGAR) Study
-
NICE-SUGAR
Algorithm
-
The NICE-SUGAR (Normoglycaemia in Intensive Care
Evaluation and Survival Using Glucose Algorithm
Regulation) Study: statistical analysis plan
-
A phase II randomised controlled trial of
intensive insulin therapy in general intensive
care patients
-
Study Reports
-
Intensive versus Conventional Glucose Control in
Critically Ill Patients. NEJM
-
The NICE-SUGAR Study on Intensive versus
Conventional Glucose control-The Importance of
Patient Safety in Achieving the Desired
Outcomes. AACE
-
Regulation (NICE-SUGAR)
study: analysis of the first 100 hypoglycaemic
events
-
Additional research
-
Intensive insulin therapy and mortality among
critically ill patients: a meta-analysis
including NICE-SUGAR study data. CMAJ
-
Intensive insulin therapy in the intensive care
unit. CMAJ
-
Thought leader responses
-
Joint Statement from the American Diabetes
Association and American Association of Clinical
Endocrinologists on the NICE-SUGAR Study on
Intensive versus Conventional Glucose Control In
Critically Ill Patients
-
The Endocrine Society
Statement to Providers on the Report Published
in the New England
Journal of Medicine
on NICE-SUGAR
-
Glucose Control in the ICU — How Tight Is Too
Tight? NEJM
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 >
Back to
top
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 >
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