ACP Intensive Insulin Therapy Guidelines Criticized

March 1, 2011

The American College of Physicians argues against the use of intensive insulin therapy in hospitalized patients and many have taken issue.

The American College of Physicians argues that “while most doctors make efforts to prevent and control hyperglycemia in hospital settings, the use of intensive insulin therapy and optimal blood glucose range to target in hospitalized patients has been uncertain.”

Accordingly, ACP issued a set of guidelines in the February 15 issue of Annals of Internal Medicine instructing clinicians on the management of glycemic control in this setting.

To develop their recommendations, ACP conducted a wide-ranging literature search reaching back to 1950 and focusing on “short-term mortality and hypoglycemia.”

They arrived at the following conclusions:

  1. ACP recommends not using intensive insulin therapy to strictly control blood glucose in non—surgical intensive care unit (SICU)/medical intensive care unit (MICU) patients with or without diabetes mellitus (Grade: strong recommendation, moderate-quality evidence).
  2. ACP recommends not using intensive insulin therapy to normalize blood glucose in SICU/MICU patients with or without diabetes mellitus (Grade: strong recommendation, high-quality evidence).
  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 (Grade: weak recommendation, moderate-quality evidence)

“The evidence shows that targeting normal glucose levels of 80 to 110 mg in ICU patients does not lead to better outcomes,” said Amir Qaseem, MD, PhD, MHA, FACP, director of clinical policy for ACP. “Some studies showed an increase in death with intensive insulin therapy.”

The reaction from the medical community was decidedly mixed.

The American Association of Clinical Endocrinologists and the American Diabetes Association addressed this issue in their “2009 Consensus Statement on Inpatient Glycemic Control,” which recommended “for most patients a blood glucose target of 140-180 mg/dL...and appropriate use of insulin is the preferred approach for achieving safe, optimal glucose control.”

In a joint response, the two organizations comment that “the recent ACP guidelines are for the most part consistent with the AACE/ADA recommendations,” however they maintain that “the upper limit of 180 mg/dl is safe and justified by data on benefits of glycemic control and the harms of uncontrolled hyperglycemia.”

“Hyperglycemia in hospitalized patients is common and associated with increased risk of infection, mortality, and increased cost,” said AACE President Daniel Einhorn, MD, FACP, FACE. “Although near normalization of glucose in these patients appears to be of no greater benefit than moderate glycemic targets, ignoring hyperglycemia in this population is no longer acceptable.”

“Both over treatment and under treatment of hyperglycemia in hospitalized patient are patient safety issues,” said Robert R. Henry, MD, President, Medicine and Science for the American Diabetes Association. “Coordinated, interdisciplinary teams have been shown to achieve both safe and effective control of hyperglycemia in hospitalized patients.”

Responses from other parties were far less diplomatic.

Anthony Furnary, MD, senior cardiothoracic surgeon, Starr Wood Cardiac Group chastised the group for only analyzining two randomly-controlled trials that included coronary artery bypass patients (CABG) with diabetes, and called for the guidelines to be pulled and re-examined.

“All of the remaining studies considered in the meta-analysis excluded cardiac surgical patients by design,” Dr. Furnary claims. “To dilute the positive effects of these two cardiac surgical RCTs with 12 medical/non-cardiac surgical studies of intensive insulin therapy-directed tight glycemic control (IIT-TGC), which were ineffective in reducing mortality and infection, and then broadly claim that IIT-TGC should not be performed in all patients - including diabetes CABG patients -- is both irresponsible and dangerous.”

Etie Moghissi, MD, FACP, FACE, co- chair of the AACE Inpatients Diabetes Taskforce and the American College of Endocrinology’s Consensus Development Conference on Inpatient Diabetes and Metabolic Control, and Mary Korytkowski, MD, director of the Center for Diabetes and Endocrinology at the University of Pittsburgh Medical Center, write of their concern “that variability in recommendations for glycemic targets by different professional organizations can result in both confusion and clinical inertia among those who deliver this care.” They believe that “publications such as the ACP Clinical Guideline has the potential for misinterpretation with a weakening of current efforts to achieve reasonable glycemic goals that have been demonstrated to reduce risks of undertreated hyperglycemia in hospitalized patients.”

Gauranga C. Dhar, an assistant professor at Bangladesh Institute of Family Medicine & Research at the Institute of the University of Science & Technology Chittagong believes that the guidelines are overly broad and that even if “IIT is used, may not be fixed but should be individualized which depends upon patient's present condition, age, duration of diabetes, existing medications and concomitant illness.”

Rajesh Garg, MD, assistant professor of medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, finds that the guidelines only explain “what should not be done,” and are not explicit enough about “what should be done.” What are the alternatives to intravenous insulin infusion if IIT is not recommended in or out of the ICU setting? If a physician considers “multiple subcutaneous insulin injections” to be an IIT, does that mean patients should “be given only sliding scale insulin”?

No response thus far from the ACP.

HCPLive wants to know:

On their face, do you find the ACP guidelines to be all that different from those of the AACE/ADA?Are there aspects of ACP’s guidelines that you find to be clinically insightful?Do you find fault with them as some of the critics listed here have? Are the guidelines vague or dangerous as they suggest?What do you feel would be the best means of addressing the shortfalls of these guidelines? Is there a need to “start over” as Anthony Furnary, MD believes?