21 February 2011

ACP Discourages Intensive Insulin Therapy

The American College of Physicians (ACP) may be doing a good thing. The new clinical guideline for glycemic control in hospitalized patients does not want the use of intensive insulin therapy. What they are trying to stop is the errors in insulin dosage which causes many cases of severe hypoglycemia.

The hypoglycemia is because many doctors and most nurses are not familiar with insulin and its proper use. They have fixed and inflexible ideas about proper dosage and often do not check that they are using the correct syringes or even the correct insulin. Most people attending in ICUs do not know how to count carbohydrates, or account for IV solutions, and match insulin requirements. And it seems no amount of training affects their decisions.

I do have to wonder why the guideline is set so high. They recommend a blood glucose level of 7.8 to 11.1 mmol/L. This equates to 140 to 200 mg/dl. I do question why there is nothing mentioned about allowing patients monitoring their own insulin use once they are able to communicate and/or capable of care. Oh, I forgot, this is the ICU and we are not able to make decisions while in this setting and our advocates are to keep their place.

Surprise! The American Diabetes Association and the American Association of Clinical Endocrinologists are not totally in agreement. The ADA spokesperson said that the new guideline is basically consistent with the ADA recommendations. The upper limit is higher that the 180 mg/dl recommended as this is the point at which the kidneys start to spill glucose. Patients could become dehydrated above this level.

The ACP guideline is expected to be for everyone, diabetes specialists, hospitalists, critical care specialists, and primary care providers. The ADA spokesperson also stated that some may still want to use the lower range of the ADA recommendations of 110 to 140 mg/dl.

Several noted that the ACP guideline applies only to patients in the ICU and that they were concerned about what the goals should be for non-ICU patients. Also of concern is developing better systems to prevent hypoglycemia.

Read the article here and an article by the ADA and AACE here.

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