Reexamining the evidence for inpatient glucose control: new recommendations for glycemic targets.

PURPOSE

To review the risks of hyperglycemia in hospitalized patients, data supporting the benefits of treating hyperglycemia, and recommendations from the 2009 American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on the management of inpatient hyperglycemia.

SUMMARY

Inpatient hyperglycemia is common, costly, and associated with poor clinical outcomes in many disease states. Despite inconsistencies in clinical trial results, good glucose management in the hospital remains important. Target blood glucose concentrations (BGs) were recently modified to somewhat higher values with the expectation that the benefit of treatment will persist with a lower risk of hypoglycemia, which is itself another marker of poor outcome in critically and non-critically ill patients. In the intensive care unit (ICU), the threshold to start treatment is a BG of <or=180 mg/dL. I.V. insulin is the treatment of choice in critically ill patients because of its rapid onset and offset of action. Once i.v. insulin is started, the BG should be maintained between 140 and 180 mg/ dL; a lower BG target (110-140 mg/dL) may be appropriate in selected patients. Targets of <110 mg/dL or >180 mg/dL are no longer recommended. In non-critically ill patients, premeal BG targets are <140 mg/dL; random BGs of <180 mg/dL are recommended. Scheduled subcutaneous insulin is the treatment of choice for hyperglycemia in non-critically ill patients; use of sliding-scale insulin is strongly discouraged. To avoid hypoglycemia, insulin regimens should be reassessed if BG falls to <100 mg/dL.

CONCLUSION

Poor glycemic control in the hospital setting is a quality-of-care, safety, and cost issue. Safe and effective strategies to implement optimal glycemic control require multidisciplinary involvement. Insulin given i.v. in the ICU or subcutaneously on an as-scheduled regimen in other parts of the hospital is the treatment of choice.