May 24 2013
High blood glucose is associated with poor outcomes in hospitalized patients, and use of intensive insulin therapy (IIT) to control hyperglycemia is a common practice in hospitals. But the recent evidence does not show a consistent benefit and even shows harms associated with the use of IIT, according to the American College of Physicians' (ACP) Clinical Guidelines Committee in a new evidence-based paper published today online in the American Journal of Medical Quality.
"Clinicians caring for hospitalized patients must keep the harms of hypoglycemia in mind when managing hyperglycemia and should avoid aggressive glucose management," said Amir Qaseem, MD, PhD, MHA, FACP, Director, Clinical Policy, ACP. "Intensive insulin therapy should not be used to strictly control blood glucose or to normalize blood glucose in SICU and MICU patients with or without diabetes."
ACP recommends that clinicians should target a blood glucose level of 140 to 200 mg/dL if IIT is used in surgical or medical intensive care unit patients (SICU/MICU) and clinicians should avoid targets less than 140 mg/dL because harms are likely to increase with lower blood glucose targets.
Evidence for Benefits, Harms, and Costs of IIT
ACP's review of the evidence found that IIT with a goal of achieving normal or near-normal blood glucose in patients with or without diabetes does not provide substantial benefits and may lead to harm. The results from various studies indicate that using IIT to achieve strict glucose control compared to standard therapy with less strict control did not reduce mortality or length of hospital stay but did substantially increase the risk for severe hypoglycemia, especially in critically ill patients.
"The current evidence does not support that the benefits of intensive insulin therapy outweigh its harms," said Dr. Qaseem. "In addition, intensive insulin therapy consumes more resources and is a more expensive than managing hyperglycemia with standard therapy."
IIT costs include implementation in a hospital and downstream expenses incurred to manage the consequent harms. No recent cost-effectiveness studies have incorporated results from the recent trials to evaluate the impact of IIT in light of the new evidence.
ACP's High Value Care Initiative
"Inpatient Glycemic Control" is part of ACP's High Value Care initiative, launched in 2010 to help physicians provide the best possible care to their patients while simultaneously reducing unnecessary health care costs. ACP defines high value care as the delivery of services providing benefits that make their harms and costs worthwhile.
Value is not merely cost. Some expensive tests and treatments have high value because they provide high benefit and low harm. Conversely, some inexpensive tests or treatments have low value because they do not provide enough benefit to justify even their low costs and might even be harmful.
ACP's evidence-based recommendations aim to educate physicians and patients about how to pursue care together that improves health, avoids harms, and eliminates wasteful practices.