AACE/ADA consensus group recommends less intensive glucose targets in the ICU

Intensive control has yielded inconsistent study results

American Association of Clinical Endocrinologists 18th Annual Meeting

A consensus group of the American Association of Clinical Endocrinologists and American Diabetes Association recommended revised glucose targets of 140 mg/dL to 180 mg/dL for critically ill patients in the ICU setting and between 100 mg/dL and 180 mg/dL for patients admitted to general medical-surgical wards.

“We have known for a very long time that high glucose in the hospital setting is associated with poor outcomes,” said Etie S. Moghissi, MD, chair of the Inpatient Glycemic Control Consensus Panel. Panel members discussed the new recommendations at the American Association of Clinical Endocrinologists 18th Annual Meeting and Clinical Congress.

“Over the past 18 months, new evidence began to suggest that the targets of 80 mg/dL to 110 mg/dL may not be necessary” in critically ill patients in the ICU, Moghissi said. Recent studies that attempted to intensively manage glucose targets in the ICU setting have yielded inconsistent results in patient outcomes.

The consensus panel has deemed the new recommended targets “reasonable, achievable and safe.”

No randomized, controlled trials have examined the effect of intensive glycemic control on outcomes in non-critically ill hospitalized patients. Thus, the panel recommended that these patients be treated with a premeal blood glucose target of ≤140 mg/dL with random blood glucose values ≤180 mg/dL.

Inconsistent study results

The consensus panel members wrote that intervention to normalize glycemia has yielded inconsistent results. “Moreover, recent randomized, controlled trials have highlighted the risk of severe hypoglycemia resulting from such efforts. These outcomes have contributed to confusion regarding specific glycemic targets and the means for achieving them,” they wrote.

These trials include the recently published Normoglycemia in Intensive Care Evaluation — Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial, which included 6,104 critically ill patients. Results from the NICE-SUGAR trial demonstrated that intensive glucose control (80 mg/dL to 110 mg/dL) increased the risk for death by 10%. Further, 90-day mortality was significantly higher in the intensively vs. conventionally treated group (27.5% vs. 24.9%) in both surgical and medical patients.

In April, Donald E. G. Griesdale, MD, MPH, and colleagues reported the results from a meta-analysis of 26 trials (n=13,567) that examined intensive vs. conventional glucose control. The researchers concluded that intensive insulin therapy significantly increased the risk for hypoglycemia and provided no overall mortality benefit for critically ill patients (RR=0.93).

“Despite some inconsistencies in clinical trial results, it would be a serious error to conclude that judicious control of glycemia in hospitalized patients is not warranted,” Moghissi said in a press release.

Interpreting new recommendations

“What needs to be emphasized over and over is that we really have to consider each individual situation and individual status of the patient,” Moghissi said.

The panel recommended IV insulin infusions as the preferred method for achieving and maintaining glycemic control with frequent glucose monitoring and also called for validated insulin infusion protocols with demonstrated safety and efficacy.

“The responsibility for management of hyperglycemia shifts from the health care team to the patient following hospital discharge. It is therefore important that patients receive the information necessary to safely manage this aspect of their care once they are at home,” Mary Korytkowski, MD, ADA chair of the Inpatient Glycemic Control Consensus Panel, said in a press release.

The consensus statement was published in Diabetes Care and Endocrine Practice. – by Katie Kalvaitis

I am concerned that we not allow the pendulum to swing too far back to where we were and allow patients to have average glucose levels that are above 180 mg/dL or even above 200 mg/dL. The recommendation to treat patients and try to keep glucose levels in the 140 mg/dL to 180 mg/dL range may be okay, but I would prefer to see it towards the lower part of that range, as long as we can protect against hypoglycemia. The NICE-SUGAR study was conducted in many centers, and intensive glucose control was found to cause more hypoglycemia and some increase in mortality. It is important to note that only 37% of the patients were surgical patients and only 12-13% had undergone elective surgery. The previous reports suggest that benefits may be greater in surgical patients. What concerns me most about NICE-SUGAR is that patients in the standard glucose control group had an average glucose of 144 mg/dL. If we target glucose levels to the 140 mg/dL to 180 mg/dL range, the average glucose levels will be significantly higher than 144 mg/dL.

– Glenn R. Cunningham, MD

Endocrine Today Editorial Board member