I attended the annual meeting of the American Association of Clinical Endocrinologists (AACE), held from May 14th to 18th, 2009. Here’s a re-cap of the buzz about ICU glycemic control, prediabetes, and vitamin D.
Inpatient Glycemic Control
An AACE and ADA consensus group called for significant changes in the way that healthcare professionals treat hospitalized patients with high blood glucose levels. They recommended revised glucose targets of 140 to 180 mg/dL in the ICU setting and 100 to 180 mg/dL for most patients admitted to general medical-surgical wards. People were talking about this because of recent attempts to intensively manage glucose targets in the ICU setting. In addition, several recent randomized controlled studies failed to show improvement when trying to achieve near normal glucose levels and instead showed an increase in mortality.
Quick View: Managing blood glucose levels in the inpatient environment is complex.
Reacting Earlier to Prediabetes
New clinical recommendations include specific instructions for lifestyle intervention and medication. The opening session speaker, Dr. Alan Garber, MD, PhD, said, “Prediabetes is not a benign state. It is associated with an increased risk of cardiovascular complications and increased risk of small blood vessel and microvascular complications. The risks begin before diabetes is established, and, therefore, we need to treat it. Compliance with lifestyle interventions is usually poor. If lifestyle is not sufficient or if there is rapid beta cell failure, then aggressive pharmacology may be the best choice for first line therapy.”
AACE Vice President Daniel Einhorn, MD, FACP, FACE, also suggested a more aggressive approach to treating patients in high-risk groups, with medications, including metformin, TZDs, DDP4, and GLP1. He said, “These medications illustrate a specific ‘plan of attack’ for treating prediabetes. But it’s important that caution is exercised.” Dr. Einhorn suggested that A1c levels be considered as a diagnostic tool. “An A1c level of 6.0% to 6.5% indicates treatment for prediabetes, with certain caveats. Lifestyle intervention should be the cornerstone of treatment for all patients,” Einhorn said. “And it should be reinforced with each visit to the doctor.”
Quick View: Don’t take prediabetes lightly. Treat it as though it were diabetes. In time, we may be using the same diagnostic criteria for diabetes that we do now for prediabetes.
Dr. Neil Binkley, MD, Associate Professor in Geriatrics and Endocrinology at the University of Wisconsin, spoke about how low vitamin D levels are now endemic in the United States. He discussed the known relationship of vitamin D with bones, muscle, and cancer. He spoke of vitamin D’s relationship with other conditions as well, such as myocardial infarction, heart failure, blood pressure, mortality, cognition problems, and the list goes on. “National recommendations from the Food and Nutrition Board are 400 to 600 International Units (IU) a day. That’s simply not enough,” he said. “Experts recommend somewhere between 1,500 to 2,600 IU daily. It’s considered a very safe vitamin. One would need daily doses of 40,000 IU or higher before seeing negative side effects.”
Quick View: Casual sun exposure is not enough, and vitamin D inadequacy is common. It’s prudent to recommend vitamin D3, as we need at least 1,000 to 2,000 IU/day, and these higher doses are safe. Not everyone, however, needs the same dosage. Vitamin D adequacy will reduce osteoporotic fractures, falls, cancer and, potentially, other diseases.