Tight Glycemic Control – The Debate Continues
When it comes to the “correct” glycemic control it seems as though everyone has an opinion as to exactly what that means. Recently there has been a great deal of debate as to whether there is a benefit to practicing tight glycemic control in a hospital setting. While this debate rages on there are some undisputable facts. First, the Portland Protocol is being adopted by a greater number of hospitals. Second, continuous glucose monitoring is an essential tool in the hospital and is the answer and not the problem with tight glycemic control.
There are two reasons Diabetic Investor brings this to your attention today. In the upcoming issue of JAMA (The Journal of the American Medical Association) there are two letters that address the controversy of tight glycemic control for critically ill patients; plus tomorrow at 4:30 pm EST Dexcom (NASDAQ:DXCM) will conduct their first quarter conference call.
Looking over the two letters in JAMA one line stood out among all others; “Since then, our study and others2 have provided additional evidence suggesting that normalization of blood glucose levels should not be a target, at least with tools available at the bedside.” This comment came from Djillali Annane, MD University of Versailles SQY Garches, France and Julie Lejeune, PharmD; Sylvie Chevret, MD
Hôpital Saint Louis, AP-HP Paris, France . (Diabetic Investor added highlighting, bold and underlining.) And just what are the tools available; in the majority of hospitals it’s a conventional finger stick glucose monitor, a monitor which is used by an ICU nurse who performs a test every hour on the hour. And as we learned from the recent FDA meeting on glucose monitor accuracy there are a host of factors which can lead to an inaccurate test result and drug interactions are only part of the problem. As many noted during this meeting human error is just as much a problem as GPH-PQQ.
The reality here is that CGM is not just a tool to measure glucose but an invaluable time saving, productivity enhancement tool. Anyone who has been in an ICU unit understands that ICU nurses are just a moment away from chaos. They should also understand the simple notion that the more frequently you give someone a chance to make a mistake the greater the probability a mistake will be made. Although it may not seem like administering a glucose test is all that complicated it amazing who often what is supposed to be a simple test gets screwed up.
The fact is CGM is critical in an ICU setting as it can preempt both hyperglycemia and hypoglycemia. The problem isn’t whether CGM fits within the hospital setting, it does. The real problem is physicians have yet to figure out just what “tight control” means and how to achieve tight control safely.
While this year’s AACE meeting was less than spectacular one point stood out above the rest in that diabetes is not a one size fits all disease and what’s good for one patient is not necessarily good for another. As the DCCT study and corresponding follow-up proved there are numerous benefits to lower glucose levels. However, other comprehensive studies have called into question the benefits of tighter control. The real question isn’t whether lower glucose levels are beneficial, they are. The issue is should we have a one size fits all standard for every situation, including patients in ICU and the answer is a resounding no.
As this debate rages on, which it surly will, and more data becomes available Diabetic Investor believes physicians will develop the correct range for patients in the ICU just as they do with everyday patients who are on insulin therapy. The fact is no two patients are exactly alike and while both may be on insulin therapy it does not mean both follow the exact same insulin regimen to reach the exact same glucose target. Given the problems with both hyper and hypoglycemia and the demands on an ICU nurse, CGM can be a life saving tool in the hospital setting. The fact is physicians need more and not less information to make informed decisions regarding patient care and CGM delivers this information.
We can debate all we want about the pros and cons of tight glycemic control in a hospital setting. However there is no debate that CGM will play a pivotal role in the hospital in the future. And when it comes to CGM systems and hospitals Dexcom is taking the lead.