Blood sugar control: In the ICU and for moms-to-be

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New recommendations and draft guidelines are being considered in two important areas related to blood sugar (glucose) control. The first relates to stringent (tight) glucose control in the intensive care unit and the second relates to screening recommendations for gestational diabetes in pregnant women.

According to a scientific statement released by the American College of Physicians, clinicians should not use intensive insulin therapy to regulate blood sugar in the ICU and they should make sure not to let blood sugar levels fall below 140 mg/dL for fear of increasing risk of hypoglycemia (low blood sugar). The recommendations go further to specify that if insulin therapy is used, clinicians should aim to keep blood sugar levels between 140 mg/dL and 200 mg/dL.

According to Dr. Amir Qaseem, director of clinical policy for the American College of Physicians, The current evidence does not support that the benefits of insulin therapy outweigh its harms. And he goes on to say, Clinicians caring for hospitalized patients must keep the harms of hypoglycemia in mind when managing hyperglycemia and should avoid aggressive glucose management.

In contrast, the United States Preventive Services Task Force has released draft guidelines recommending that all pregnant women even those not experiencing symptoms of diabetes be screened for the disease after 24 weeks gestation. Support for the new guideline comes from a literature review which included five randomized, controlled trials and six cohort studies. Analysis of the data showed that dietary changes, glucose monitoring and insulin therapy had the potential to result in fewer incidences of preeclampsia (high blood pressure and protein in the urine), shoulder dystocia (abnormal or difficult childbirth), and macrosomia (overly large babies). And although there was inconclusive evidence in terms of long-term metabolic benefits for both mother and baby, the only minor downside would be increased frequency of prenatal visits.

These new guidelines are in agreement with the recommendations of the American Diabetes Association to screen asymptomatic women at 24 to 28 weeks, and with the American College of Obstetricians and Gynecologists which recommends screening all women, except those at low risk of gestational diabetes.

ACSH s Dr. Gilbert Ross says, In terms of the screening recommendations for gestational diabetes, when we see something that clearly has no downside and could potentially be quite beneficial for pregnant women, it seems like a no-brainer to go ahead and issue the new guidelines. But I d really hope that most doctors are doing these screenings already.