Essential Guidelines and Reviews

American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control
Diabetes Care. 2009 June;32(6):1119-1131. (published online May 8, 2009).Consensus: Inpatient Hyperglycemia, Endocr Pract. 2009;15(No. 4):1-17.

The 2009 ADA/AACE guidelines were published online recently. The guidelines address the following questions:

1. Does improving glycemic control improve clinical outcomes for inpatients with hyperglycemia?
2. What glycemic targets can be recommended in different patient populations?
3. What treatment options are available for achieving optimal glycemic targets safely and effectively in specific clinical situations?
4. Does inpatient management of hyperglycemia represent a safety concern?
5. What systems need to be in place to achieve these recommendations?
6. Is treatment of inpatient hyperglycemia cost- effective?
7. What are the optimal strategies for transition to outpatient care?
8. What are areas for future research?

Most clinicians want to know the new recommended BG targets:

Copied from the documented "Once IV insulin therapy has been initiated, the glucose level should be maintained between 140 and 180 mg/dL (7.8 and 10.0 mmol/L), and greater benefit may be realized at the lower end of this range. Although strong evidence is lacking, somewhat lower glucose targets may be appropriate in selected patients. Targets less than 110 mg/dL (6.1 mmol/L), however, are not recommended."

The AACE/ADA recommendations – teaching material for busy clinicians:

• A target of 140-180 mg/dl is preferable for MOST patients. 
• A target of 110-140 mg/dl may be appropriate in SELECTED patients (patients treated in sites with extensive experience and appropriate support: perhaps CABG surgical patients, sites with low rates of hypoglycemia, patients  on TPN etc). 
• A target > 180 mg/d/ or < 110 mg/dl is NOT recommended.

Future research needs to elucidate those patients who may benefit from 110-140 mg/dl, and who qualifies in the list of “SELECTED” populations.

ACE Position Statement and Consensus Conference Reviews
Garber AJ, Moghissi ES, Bransome ED Jr, et al. American College of Endocrinology Position Statement on Inpatient Diabetes and Metabolic Control. Endocr Pract. 2004;10 Suppl 2:4-9. PMID: 15251633   
The American College of Endocrinology, American Association of Clinical Endocrinologists, and cosponsoring organizations (including SHM) outlined the evidence supporting inpatient glycemic control, and endorsed the need for early detection of hyperglycemia, and aggressive management to achieve glycemic targets.
The upper limits for glycemic targets:
•  in the ICU setting: 110 mg/dL
•  for non-critical care units: a preprandial glucose of 110 mg/dL, and a maximal glucose of 180 mg/dL.

ACE / ADA Inpatient Diabetes and Glycemic Control Consensus Statement
Garber A, Moghissi E, et al. American College of Endocrinology and American Diabetes Association Consensus statement on inpatient diabetes and glycemic control: a call to action.  Diabetes Care. 2006 Aug;29(8):1955-62. PMID:16873812 also published in Endocrine Practice. 2006 July / Aug 12 (4) 458-68. PMID: 16983798.
This recent conference updated an evidence review supporting inpatient glycemic control, and also outlined essential elements that institutions need to put successful glycemic control programs in place. These essential elements formed the core outline for the SHM Workbook to Optimize Glycemic Control and Reduce Hypoglycemia, which can be found here on the website.

ADA Technical Review
Clement S, Braithwaite SS, Magee MF et al; American Diabetes Association Diabetes in Hospitals Writing Committee. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-91. PMID: 14747243
An indispensable review full of practical information, as well as a well articulated review of the literature on the topic. Insulin strategies for patients in special situations and with varied forms of nutritional intake are outlined, and policy / educational issues for institutions are also addressed.

ADA Standards for Diabetes
Standards of Medical Care in Diabetes--2008
Dora JM, Kramer CK, Canani LH. Diabetes Care 31:S12-S54, 2008. PMID: 18165335
The language around glycemic targets has softened in the 2008 version of the ADA Standards.
·  Diabetes care in the hospital: Glycemic goals have been modified slightly:

• Critically ill patients: blood glucose levels should be kept as close to 110 mg/dl (6.1 mmol/l) as possible and generally <140 mg/dl (7.8 mmol/l). (A) These patients require an intravenous insulin protocol that has demonstrated efficacy and safety in achieving the desired glucose range without increasing risk for severe hypoglycemia. (E)
• Non–critically ill patients: there is no clear evidence for specific blood glucose goals. Because cohort data suggest that outcomes are better in hospitalized patients with fasting glucose <126 mg/dl and all random glucoses <180–200 mg/dl, these goals are reasonable if they can be safely achieved. Insulin is the preferred drug to treat hyperglycemia in most cases.(E)

ASHP Recommendations for Safe Use of Insulin in Hospitals
American Society of Health-System Pharmacists and the Hospital and Health-System Association of Pennsylvania: Recommendations for Safe Use of Insulin in Hospitals.
Accessed as a pdf at: http://www.ashp.org/s_ashp/docs/files/Safe_Use_of_Insulin.pdf  (April 23, 2009).

Improving Care of the Hospitalized Patient with Hyperglycemia and Diabetes From the SHM Glycemic Control Task Force
SHM Glycemic Control Task Force J Hosp Med. 2008 Sept;3(5 Suppl):S1-83.

The case for supporting inpatient glycemic control programs now: The evidence and beyond 
Braithwaite SS, Magee M, Sharretts JM, Schnipper JL, Amin A, Maynard G; Society of Hospital Medicine Glycemic Control Task Force.  J Hosp Med. 2008 Sep;3(5 Suppl):6-16. PMID: 18951385

Hyperglycemia and acute coronary syndrome: a scientific statement from the American Heart Association Diabetes Committee of the Council on Nutrition, Physical Activity, and Metabolism.
Deedwania P, Kosiborod M, Barrett E, Ceriello A, Isley W, Mazzone T, Raskin P; American Heart Association Diabetes Committee of the Council on Nutrition, Physical Activity, and Metabolism.Circulation. 2008 Mar 25;117(12):1610-9. Epub 2008 Feb 25. PMID: 18299505

Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline.
Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, Service FJ; Endocrine Society. J Clin Endocrinol Metab. 2009 Mar;94(3):709-28. Epub 2008 Dec 16. PMID: 19088155.