Seas of Change for Inpatient Glucose Management

September 4, 2009
Anita Ramsetty

Making the transition from outpatient to inpatient has been thankfully only a slightly “bumpy” road, but it is amazing looking back on how our approach to inpatient diabetes care and hyperglycemia on the whole has changed over the past 10 years.

During the past two weeks I started a new job at another hospital. This job, unlike my other, is limited to inpatient care (which I LOVE). The majority of consults for us, as an endocrine consult service, consists of diabetes management and the bulk of our patients are headed to surgery or just out from it. Making the transition from outpatient to inpatient has been thankfully only a slightly “bumpy” road, but it is amazing looking back on how our approach to inpatient diabetes care and hyperglycemia on the whole has changed over the past 10 years.

In the midst of my residency a now-landmark article led by Dr. Van den Berghe was published in 2001. It discussed the issue of hyperglycemia and intensive insulin therapy in the critically ill, making an astoundingly strong argument for more aggressive insulin regimens in many inpatient settings. I recall the atmosphere in academia right then, buzzing with a new awakening, with everyone looking at the data and looking for more “data.” For me, it was one of the peaks in the last two decades of the rise of evidence-based medicine (the WHI was another massive peak. Wow, the impact a study can have!). Soon the field of studies looking at inpatient glycemic control, in particular surgical settings, started becoming full with other studies, some confirming then later questioning the original Van Den Berghe study. We ran with strict glucose control for several years, using data to back up one group of patients while extending it to others who had not been directly studied. We started feeling like we had a handle on this, with data showing decreases in sternal wound infections, fewer hospital days and better outcomes overall.

Then, as science and life tend to do, we were stopped and humbled.

During the past 3-4 years a new crop of studies have begun to emerge, more strongly questioning the original data about how aggressively we should be controlling patient’s blood glucose levels. The additional interesting thing about these studies is that they criss-cross over various patient populations, diseases and settings including both inpatient AND outpatients. Two years ago the endocrine and medical field as a whole started having the equivalent of seismic activity with sequential release of protocol-altering studies like Nissen’s meta-analysis of the effects of Avandia on cardiovascular morbidity and mortality, the ADVANCE, VADT, and ACCORD trials. What had become almost commonplace for a few years was now strongly in question again. Our patients took notice, constantly fed by media frenzy and access to the Internet, and put us on the spot in clinics, at hospital bedsides, and at casual interactions in the grocery stores. Many of us were not sure what to say to these patients, even though in our gut we knew what we had to do—press on, but be careful.

And so with my new job consisting mainly of inpatient glucose management consults, I am back in the fray. Just this past year several studies were released questioning how tightly our glucose targets should be in patients with a prior history of cardiovascular disease. Hospitals already have protocols in place, for heaven’s sake! But this is where my teams comes in, I guess. We, and all of you as colleagues, are here to bend and stretch the protocols when they fall behind, as they all do in this ever-changing sea of medicine. All hail to evidence-based medicine! But please given us 2 seconds to catch our breath as we keep pace with change, and keep a close watch on our patients all the while.