For several years the leaders of the endocrine community have been advocating “tight” control of blood sugars in diabetics particularly for hospitalized patients. For hospitalized diabetics, tight control means keeping the blood sugar in the normal “non-diabetic” range 24 hours, seven days a week. For diabetics not in hospital the goal is a glycohemoglobin A1c level of less than 6%, which is considered the dividing line between diabetic and normal blood sugars.
For hospitalized diabetic patients with an enormous range of illnesses, stresses, diets and requirements for diagnostic procedures, instituting tight control requires a special nurse for each patient and creates a logistical nightmare for the hospital. The call for tight glucose control in hospitalized patients was founded on a few small studies with questionable study design. The movement among the academic community for tight control had gone so far that a special credentialing committee and curriculum was being organized to create a super-subspecialty of endocrinologists who would manage this new brand of in-hospital diabetes care. This would give physicians with this new credential a virtual monopoly on in-hospital diabetes care. The focus on creating this monopoly seemed to me a more powerful incentive than to address the need to create a valid new super-subspecialty.
The science behind the call for this degree of blood sugar control for diabetics, particularly of hospitalized patients, was flimsy at best. It defied the common knowledge that it takes over 10 years to see physical evidence of high blood sugars on body organs. In addition, clinicians with years of experience treating diabetes in hospitalized patients had seen first that non-ideal blood sugars rarely had any clinical impact on their patients out-comes. In an editorial last year, I had called upon the endocrine community to give up their quest to formalize diabetes care around unrealistic demands for tight glycemic control http://www.metabolism.com/2008/05/25/a-year-of-stumbles-for-diabetes-care-in-the-us-part-ii/
Fortunately, recent major studies have proven that not only does this rigorous degree of tight control not benefit hospitalized and non-hospitalized diabetics but the mortality (death) and complication rates were even higher for tight control patients. Most notably the NIH recently called for the end of the ACCORD study which examined the response to “tight” glycemic control of out-patient diabetics with high risk of heart disease and stroke. The ACCORD study was ended early when it became clear that “tight” glycemic control resulted in a worse outcome for diabetics than conventional glucose control. As far as studies of diabetics in the intensive care unit, back as far as 2003 a UK study revealed worse outcomes with tight control. Hopefully putting an end to the quest for this seemingly ill conceived goal are the results of the NICE-SUGAR study just published in the New England Journal of Medicine showing increased death rates for diabetics receiving tight glycemic control in the intensive care unit.
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