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A Numbers Game


 

New guidelines from the American College of Physicians (ACP) on the use of intensive insulin therapy (IIT) for glycemic control of hospitalized patients have prompted a backlash from physicians, including an SHM mentor, who think the rules could lead to needless confusion on best practices.

The guidelines, issued in February, recommend against using IIT to strictly control or normalize blood glucose in nonsurgical or medical ICU patients with or without diabetes. It also recommends a target blood-glucose level of 140 mg to 200 mg if insulin therapy is used in those patients.

Hospitalist Pedro Ramos, MD, assistant clinical professor of medicine at the University of California at San Diego and a mentor with SHM’s Glycemic Control Mentored Implementation (GCMI) program, says the first two guidelines are in line with current practice, as laid out by a 2009 consensus statement from the American Association of Clinical Endocrinologists and the American Diabetes Association.

The guideline on glucose levels, however, has generated harsh feedback, with one cardiothoracic surgeon calling for ACP to pull the recommendations. Dr. Ramos doesn’t go that far, but he wonders whether that guideline was necessary, as he believes there is little strong evidence on outcomes from 180 mg to 200 mg.

The third guidelin "didn't really add much, other than confusion," Dr. Ramos says.

Dr. Ramos says it's too early to draw best practices from SHM's GCMI program, but the initiative is drawing attention to the issue. He hopes the ACP guidelines won't impede that growth.

"I want [hospitalists] not to focus on the numbers: 140 to 180, 140 to 200," Dr. Ramos explains. "What I want them to take from it is we need control ... we need safe targets and they need to be achievable."

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