ACP recommends not using intensive insulin therapy in hospitalized patients

The American College of Physicians has released a clinical practice guideline with three recommendations on the use of intensive insulin therapy to treat hyperglycemia in hospitalized patients with or without diabetes.

“The issue is what is the optimal blood glucose range in the hospitalized patient,” guideline author Amir Qaseem, MD, PhD, MHA, of the American College of Physicians (ACP), told Endocrine Today. “Hyperglycemia is a common finding in both medical and surgical patients with or without diabetes, and can lead to increased morbidity and mortality, poor immune response, increased cardiovascular events, thrombosis and other problems.”

Qaseem and other members of the Clinical Guidelines Committee of the ACP addressed hyperglycemia management and evaluated the benefits and risks associated with intensive insulin therapy to achieve tight glucose control in patients with and without diabetes in the hospital setting. Generally, 80 mg/dL to 110 mg/dL is the target for intensive insulin therapy in the ICU setting; targets in non-ICU settings are usually more variable, around <200 mg/dL.

New recommendations

The ACP now recommends against using intensive insulin therapy to strictly control blood glucose in non-surgical ICU and non-medical ICU patients with or without diabetes.

“The reason behind this recommendation is that the data do not show any reduction in mortality when targeting a blood glucose level between 80 mg/dL and 180 mg/dL compared with a higher level,” Qaseem said. “Avoiding targets less than 140mg/dL should be a priority because harms increased when blood glucose targets were lower.”

The group also recommends restricting use of intensive insulin therapy to normalize blood glucose in patients with or without diabetes who are in the surgical ICU or the medical ICU.

“We found that the evidence does not show any mortality benefit when using intensive insulin therapy to target a normal blood glucose level between 80 mg/dL and 110 mg/dL,” Qaseem said. “In fact, some studies actually showed an increase in mortality associated with intensive insulin therapy and hypoglycemia.”

The third recommendation is that if intensive insulin therapy is used in patients in the surgical ICU or the medical ICU, the target blood glucose level should be 140 mg/dL to 200 mg/dL.

“To target a normal blood glucose level of 80 mg/dL to 100 mg/dL is not associated with improved health outcomes, and the mortality is similar to those patients treated to a blood glucose level of 140 mg/dL to 200 mg/dL” Qaseem said. “The advantage of targeting a higher blood glucose level is that there is lower risk for hypoglycemia.”

Departure from current practice

The optimal blood glucose level range is considered controversial. Some studies have shown that intensive insulin therapy improves mortality; others have shown that intensive insulin therapy does not reduce mortality and may be associated with increased risk for severe hypoglycemia.

In a related Annals of Internal Medicine article, Devan Kansagara, MD, from Portland Veterans Affairs Medical Center, and colleagues published results of a systematic review of intensive insulin therapy in hospitalized patients. Their meta-analysis included 21 trials in the ICU, perioperative care, myocardial infarction, stroke or brain injury settings. According to the results, intensive insulin therapy did not affect short-term mortality (RR=1.00; 95% CI, 0.94-1.07) and did not reduce long-term mortality, infection rates, length of stay or need for renal replacement therapy. In addition, the review showed no benefit of intensive insulin therapy in any hospital setting; however, the best evidence for lack of benefit was in the ICU setting, according to the researchers. Data combined from 10 trials linked intensive insulin therapy with high risk for severe hypoglycemia (RR=6.00; 95% CI, 4.06-8.87), and risk for therapy-associated hypoglycemia was increased in all settings.

“No consistent evidence demonstrated that intensive insulin therapy targeted to strict glycemic control compared with less strict glycemic control improves health outcomes in hospitalized patients.

“The consequences of severe hypoglycemia in hospitalized patients have not been well studied. However, given the lack of compelling evidence for benefit, the potential for serious harm should forestall efforts to routinely implement very strict targets for blood glucose control in hospitalized patients,” Kansagara and colleagues concluded. – by Emily Shafer

For more information:

• Kansagara D. Ann Intern Med. 2011;154:268-282.
• Qaseem A. Ann Intern Med. 2011;154:260-267.

Disclosure: Dr. Kansagara reports consulting fees or honorarium from the American College of Physicians. Dr. Qaseem reports no relevant financial disclosures.

The guideline in the current issue of Annals of Internal Medicine suggests that intensive glucose control is sufficiently likely to cause hypoglycemia and insufficiently likely to lead to benefit, and further highlights that earlier recommendations suggesting such an approach be adopted are now to be considered incorrect. The articles somewhat grudgingly suggest that glucose levels of 140 mg/dL to 200 mg/dL be considered in an endeavor to attain glycemic control in intensively treated patients.

The dilemma is that many — perhaps all — of the studies not showing benefit use capillary glucose monitoring with reagent strips, an approach that is increasingly recognized to be sufficiently inaccurate in that it may frequently fail to recognize low glucose levels, markedly increasing the risk of such treatment. The original Van der Berghe studies use arterial blood glucose measurements with highly accurate instruments, which appear to be required to adequately achieve the precise glucose control necessary for benefit. We, therefore, may simply be dealing with a problem in clinical chemistry testing, so that the hypothesis that glycemic control is of benefit remains tenable, and the present analysis appears somewhat premature in its blanket recommendations.

– Zachary T. Bloomgarden, MD
Endocrine Today Editorial Board member

Disclosure: Dr. Bloomgarden has no relevant financial disclosures.

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