Insulin Therapy While Hospitalized   (February 26, 2011)

It's interesting when one belongs to several organizations, and finds that two of them disagree with a guidance written by a third. That has happened earlier this month, when two diabetes organizations, the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA), issued a joint statement decrying a Clinical Guideline authored by a third organization, the American College of Physicians (ACP).

Back in 2009, the AACE and ADA organizations issued a joint Consensus Statement On Inpatient Glycemic Control, which advocated intensive glycemic control programs for hospitalized patients, indicating "substantial cost savings...; fewer inpatient complications; decreased ventilator days; and reductions in ICU and hospital LOS [length of stay]." (They also opined that "Noninsulin antihyperglycemic agents are not appropriate in most hospitalized patients who require therapy for hyperglycemia.")

The recent joint AACE/ADA statement has the somewhat misleading title Insulin Therapy for Hospitalized Patients Should Not Be Abandoned. I think the title is misleading as the ACP never suggested abandoning insulin therapy while patients are hospitalized.

The ACP Guideline itself has the title Use of Intensive Insulin Therapy for the Management of Glycemic Control in Hospitalized Patients -- another misleading title, as they recommend not using IIT. The ACP looked at earlier studies of intensive insulin therapy (IIT) for hospitalized patients, and came to the conclusion that IIT has risks as well as benefits (surprise, surprise!). The ACP came up with three specific recommendations. The first two essentially say to not use IIT anyplace in a hospital, the third clearly indicates insulin therapy is appropriate if it's needed. Their advice:

"Recommendation 1: ACP recommends not using intensive insulin therapy to strictly control blood glucose in non-SICU/MICU patients with or without diabetes mellitus...
Recommendation 2:  ACP recommends not using intensive insulin therapy to normalize blood glucose in  SICU/MICU patients with or without diabetes mellitus...
Recommendation 3:  ACP recommends a target blood glucose level of 7.8 to 11.1 mmol/L (140 to 200 mg/dL) if insulin therapy is used in SICU/MICU patients..."

Nowhere in the ACP document can I find anything that even remotely sounds like a recommendation not to use insulin therapy if it's needed to control hyperglycemia. So it was a bit of a surprise to me to see the title of the joint AACE/ADA statement, which (to me, anyway!) implied that ACP was somehow advocating completely abandoning insulin therapy for hospitalized patients. Perhaps the joint AACE/ADA statement is missing one word: perhaps it should have been  titled "Intensive Insulin Therapy for Hospitalized Patients Should Not Be Abandoned."

But in any case, all three organizations agree on a fundamental point. Whether a hospitalized patient has previously been diagnosed with diabetes or not, the target blood glucose levels while hospitalized should be maintained in the general range from 140 to about 180 or 200 mg/dL. The reason for the recommendation to keep the blood glucose values above 140 is to avoid the risk of severe hypoglycemia which can result from overuse of insulin. The highest target values (180 per AACE/ADA advice, and 200 for the ACP guideline) were set to avoid the increased risks such as prolongation of hospitalization and increased cost that are associated with hyperglycemia.

The takeaway message from all three organizations is straightforward: If it takes insulin therapy to control hyperglycemia in the hospital, use it. And don't worry about whether the three organizations have a snit about the precise wording of their recommendations or titles of their press releases: physicians should use insulin if needed to control high blood glucose, but not get overly aggressive to the point of risking severe hypoglycemia.