Perspective:

The following are 10 points to remember about these guidelines on the use of intensive insulin therapy (IIT) for the management of glycemic control in hospitalized patients:

1. Hyperglycemia is a common finding among medical and surgical patients with or without known diabetes during hospital admission.

2. The purpose of this American College of Physicians (ACP) guideline is to address the management of hyperglycemia and evaluate the benefits and harm associated with the use of IIT to achieve tight glycemic control in hospitalized patients with or without diabetes mellitus.

3. The target audience for this guideline includes all clinicians, and the target patient population comprises all adults with hyperglycemia in a hospital setting.

4. Poorly controlled hyperglycemia is associated with increased morbidity, mortality, and worsening health outcomes in hospitalized patients. However, the optimal blood glucose range to target in hospitalized patients is uncertain.

5. A few studies show that IIT improves mortality, whereas most have shown that patients who receive IIT have no reduction in mortality and have a significantly increased risk for severe hypoglycemia.

6. The consequences of severe hypoglycemia in hospitalized patients have not been well studied. There is some evidence for excess mortality or extended length of stay among patients experiencing one or more episodes of hypoglycemia.

7. Based on current evidence, ACP recommends not using IIT to strictly control blood glucose in non–surgical intensive care unit (SICU)/medical intensive care unit (MICU) patients with or without diabetes mellitus.

8. ACP recommends not using IIT to normalize blood glucose in SICU/MICU patients with or without diabetes mellitus.

9. ACP recommends a target blood glucose level of 7.8-11.1 mmol/L (140-200 mg/dl) if insulin therapy is used in SICU/MICU patients.

10. Institutions that implement insulin therapy in patients in the ICU should incorporate quality improvement and training initiatives in order to achieve target glucose levels while minimizing rates of hypoglycemia.