New Guidelines Address Treatment of Hospitalized Patients With High Blood Glucose Levels

Laurie Barclay, MD

May 08, 2009

May 8, 2009 — A consensus statement of the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) issues clinical recommendations on the proper treatment of hospitalized patients with high blood glucose levels.

The new guidelines, which target healthcare professionals, supporting staff, hospital administrators, and others involved in improved management of hyperglycemia in inpatient settings, are published in the May/June issue of Endocrine Practice and in the May issue of Diabetes Care.

"Although the costs of illness-related stress hyperglycemia are not known, they are likely to be considerable in light of the poor prognosis of such patients," write Etie S. Moghissi, MD, FACP, FACE, from the University of California in Los Angeles, and colleagues. "There is substantial observational evidence linking hyperglycemia in hospitalized patients (with or without diabetes) to poor outcomes. Cohort studies as well as a few early randomized controlled trials (RCTs) suggested that intensive treatment of hyperglycemia improved hospital outcomes."

In 2004, the American College of Endocrinology (ACE) and the AACE, in collaboration with the ADA and other medical organizations, developed recommendations for treatment of inpatient hyperglycemia. These guidelines generally endorsed tight glycemic control in critical care units. In 2005, the ADA annual Standards of Medical Care included recommendations for treatment of inpatient hyperglycemia. In 2006, the ACE and ADA collaborated on a joint "Call to Action" for inpatient glycemic control, highlighting several barriers to systematic implementation in hospitals.

Questions to Be Considered

The main objectives of the AACE and ADA in preparing this updated consensus statement were to identify reasonable, achievable, and safe glycemic targets and to describe the protocols, procedures, and system improvements needed to facilitate their implementation. After extensive review of the most current literature, members of the consensus panel considered the following questions:

1. Does improving glycemic control for inpatients with hyperglycemia improve clinical outcomes?

2. What glycemic targets should be recommended for different patient populations?

3. In specific clinical situations, which available treatment options can safely and effectively achieve optimal glycemic targets?

4. What safety issues are associated with inpatient management of hyperglycemia?

5. What systems need to be in place to implement these recommendations?

6. Is it cost-effective to treat hyperglycemia in hospitalized patients?

7. What are the best strategies to shift management of hyperglycemia to outpatient care?

8. What additional research is needed?

Recommendations for Critically Ill Patients

Specific clinical recommendations for critically ill patients are as follows:

• For treatment of persistent hyperglycemia, beginning at a threshold of no greater than 180 mg/dL (10.0 mmol/L), insulin therapy should be started.

• For most critically ill patients, a glucose range of 140 to 180 mg/dL (7.8 - 10.0 mmol/L) is recommended once insulin therapy has been started.

• To achieve and maintain glycemic control in critically ill patients, the preferred method is intravenous insulin infusions.

• Validated insulin infusion protocols that are shown to be safe and effective and to have low rates of hypoglycemia are recommended.

• To reduce hypoglycemia and to achieve optimal glucose control, frequent glucose monitoring is essential in patients receiving intravenous insulin.

Recommendations for Patients Who Are Not Critically Ill

Specific clinical recommendations for noncritically ill patients are as follows:

• For most noncritically ill patients receiving insulin therapy, the premeal blood glucose target should generally be less than 140 mg/dL (< 7.8 mmol/L), and random blood glucose levels should be less than 180 mg/dL (< 10.0 mmol/L), provided these targets can be safely achieved.

• In stable patients in whom tight glycemic control was previously achieved, more rigorous targets may be appropriate.

• In terminally ill patients or in those with severe comorbidities, less stringent targets may be appropriate.

• For achieving and maintaining glucose control, the preferred method is scheduled subcutaneous administration of insulin, with basal, nutritional, and correction components.

• Prolonged treatment with sliding-scale insulin as the only therapeutic agent is discouraged.

• For most hospitalized patients who require treatment for hyperglycemia, noninsulin antihyperglycemic agents are not appropriate.

• Day-to-day decisions concerning treatment of hyperglycemia must be based on clinical judgment and ongoing evaluation of clinical status.

Safety Recommendations

Specific recommendations geared toward improving safety in management of inpatient hyperglycemia are as follows:

• Major safety issues include overtreatment and undertreatment of hyperglycemia.

• Hospital staff must be educated to engage the support of those involved in the care of inpatients with hyperglycemia.

• In patients with anemia, polycythemia, hypoperfusion, or use of some medications, caution is needed when interpreting results of point-of-care glucose meters.

• To promote a rational systems approach to inpatient glycemic management, buy-in and financial support from hospital administration are required.

The guidelines also propose a selected number of research questions and topics to guide the management of inpatient hyperglycemia in different hospital settings.

"Appropriate inpatient management of hyperglycemia is cost-effective," the guidelines authors conclude. "Preparation for transition to the outpatient setting should begin at the time of hospital admission. Discharge planning, patient education, and clear communication with outpatient providers are critical for ensuring a safe and successful transition to outpatient glycemic management."

Some of the guidelines authors have disclosed various financial relationships with sanofi-aventis U.S. LLC; Amylin Pharmaceuticals, Inc;Takeda Pharmaceuticals North America, Inc; AstraZeneca; GlaxoSmithKline; Johnson & Johnson Services, Inc; Eli Lilly & Co; Medtronic, Inc; Novo Nordisk A/S; Halozyme Therapeutics; MannKind Corporation; Abbott Laboratories; F. Hoffman La Roche Ltd. (Roche); and/or Merck & Co.

Endocr Pract. 2009;15:1-15.

Diabetes Care. Published online May 8, 2009.

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