Practical implications of the revised guidelines for inpatient glycemic control

Abstract

Substantial observational data has linked hyperglycemia in hospitalized patients with poor patient outcomes. While early studies suggested improved clinical outcomes with interventions targeting near euglycemia, more recent studies have yielded inconsistent results, with the suggestion of harm with more severe hypoglycemia. The American Association of Clinical Endocrinologists and American Diabetes Association published a revised consensus statement on inpatient glycemic management that takes into account this recent evidence. This statement identifies reasonable, achievable, and safe glycemic targets and describes protocols, procedures, and system improvements necessary to achieve these effectively. These modified glycemic targets promote a rational approach to inpatient glycemic management that minimizes risks associated with uncontrolled hyperglycemia and hypoglycemia. Intravenous insulin infusions are recommended for critically ill patients who experience blood glucose (BG) levels above 140 mg/dl with a target of 140 to 180 mg/dl. Lower BG targets (i.e., 110-140 mg/dl) may be appropriate for patients following cardiac or vascular surgical procedures. In noncritically ill patients, scheduled subcutaneous basal:bolus insulin is the preferred therapy for achieving fasting and preprandial BG below 140 mg/dl and random BG values below 180 mg/dl, with consideration of more or less stringent targets based on a patient's clinical status. Prolonged use of correctional insulin as monotherapy is discouraged. Oral and injectable noninsulin glucose-lowering agents have a limited role for hospital use but may be appropriate for selected noncritically ill patients. Educating personnel about appropriate inpatient glycemic management practices, obtaining reliable and reproducible measures of BG, and careful implementation of standardized protocols can help to ensure patient safety.