American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control.

P eople with diabetes are more likely to be hospitalized and to have longer durations of hospital stay than those without diabetes. A recent survey estimated that 22% of all hospital inpatient days were incurred by people with diabetes and that hospital inpatient care accounted for half of the 174 billion USD total U.S. medical expenditures for this disease (1). These findings are due, in part, to the continued expansion of the worldwide epidemic of type 2 diabetes. In the U.S. alone, there are 1.6 million new cases of diabetes each year, with an overall prevalence of 23.6 million people (7.8% of the population, with one-fourth of the cases remaining undiagnosed). An additional 57 million American adults are at high risk for type 2 diabetes (2). Although the costs of illness-related stress hyperglycemia are not known, they are likely to be considerable in light of the poor prognosis of such patients (3–6). There is substantial observational evidence linking hyperglycemia in hospitalized patients (with or without diabetes) to poor outcomes. Cohort studies as well as a few early randomized controlled trials (RCTs) have suggested that intensive treatment of hyperglycemia improved hospital outcomes (5–8). In 2004, this evidence led the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE), in collaboration with the American Diabetes Association (ADA) and other medical organizations, to develop recommendations for treatment of inpatient hyperglycemia (9). In 2005, the ADA added recommendations for treatment of hyperglycemia in the hospital to its annual Standards of Medical Care (10). Recommendations from the ACE and the ADA generally endorsed tight glycemic control in critical care units. For patients in general medical and surgical units, where RCT evidence regarding treatment targets was lacking, glycemic goals similar to those advised for outpatients were advocated (9,10). In 2006, the ACE and the ADA partnered on a joint “call to action” for inpatient glycemic control, addressing a number of systematic implementation barriers in hospitals (11). These efforts contributed to a growing national movement viewing the management of inpatient hyperglycemia as a quality-of-care measure. Although hyperglycemia is associated with adverse patient outcomes, intervention to normalize glycemia has yielded inconsistent results. Indeed, recent trials in critically ill patients have failed to show a significant improvement in mortality with intensive glycemic control (12,13) or have even shown increased mortality risk (14). Moreover, these recent RCTs have highlighted the risk of severe hypoglycemia resulting from such efforts (12– 17). These outcomes have contributed to confusion regarding specific glycemic targets and the means for achieving them in both critically ill and noncritically ill patients. Recognizing the importance of glycemic control across the continuum of care, the AACE and the ADA joined forces to develop this updated consensus statement on inpatient glycemic management. The central goals were to identify reasonable, achievable, and safe glycemic targets and to describe the protocols, procedures, and system improvements needed to facilitate their implementation. This document is addressed to health care professionals, supporting staff, hospital administrators, and other stakeholders focused on improved management of hyperglycemia in inpatient settings. Consensus panel members extensively reviewed the most current literature and considered the following questions: