ACP Releases New Guidelines for In-Hospital Hyperglycemia

May 28, 2013

The American College of Physicians (ACP) has revised the target blood glucose level for hospitalized patients, stating that doctors should aim for 140 to 200 mg/dL rather than trying to get to normoglycemia — a value of around 80 to 110 mg/dL. The greatest care should be taken among those in intensive care, who should not be given intensive insulin therapy (ITT), says the guidance.

The change is based on a new evidence-based paper published online May 23 in the American Journal of Medical Quality.

"Hyperglycemia is a very common finding in hospital, in medical or surgical patients, and it doesn't matter whether they have diabetes or not," lead author Amir Qaseem MD, PhD, MHA, director of clinical policy at ACP, told Medscape Medical News. "Hyperglycemia is associated with increased morbidity and mortality; it can lead to a poor immune response, delayed healing, and an increase in cardiovascular events," he added.

However, if a patient ends up with severe hypoglycemia, that too can be dangerous; "it can increase mortality and increases the length of hospital stay, so it comes down to a fine balance; it's hard to achieve tight glycemic control."

Current practice has been for most doctors to try to achieve normal blood glucose levels of 80 to 110 mg/dL in patients in intensive care units (ICUs) in the hospital, he said, and to do this they normally employ ITT. But evidence regarding whether this is beneficial has been conflicting, Dr. Qaseem explained. Outside of the ICU, targets have been more variable, ranging from normoglycemia to less than 200 mg/dL.

Now the ACP has reviewed the literature and determined that there is no evidence supporting any short-term (28-day) mortality benefit in aiming for 80 to 110 mg/dL as opposed to 140 to 200 mg/dL. Also, it finds that targeting less than 140 mg/dL is more likely to lead to harm, as is use of ITT, said Dr. Qaseem.

"When managing [in-hospital] hyperglycemia, avoid aggressive management," including ITT, he noted, adding that whatever method is used, patients must be "closely monitored."

The new guidance, for which ACP has developed an "app," is aimed all doctors, he stressed, including those caring for hospitalized patients, internists, and family practitioners.

"Clinicians caring for hospitalized patients must keep the harms of hypoglycemia in mind when managing hyperglycemia and should avoid aggressive glucose management. ITT should not be used to strictly control blood glucose or to normalize blood glucose in surgical and medical ICU patients, with or without diabetes," he concluded.

The authors have reported no relevant financial relationships.

Am J Med Qual.Published online May 23, 2013. Abstract

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