Glycemic targets in hospital and barriers to attaining them.

The importance of glycemic control in hospitalized patients has been a relatively recent revelation. There is somewhat contradictory evidence concerning the optimal glycemic target in critically ill patients. There is only indirect evidence in non-critically ill patients. This article reviews the evidence for glycemic targets in hospitalized patients. It also investigates which hospital-based treatments can act as barriers to attaining optimal blood glucose levels in hospital and system barriers to attaining those optimal levels. The systematic approach to and evaluation of in-hospital diabetes management has a short history. The first large clinical trial, the DIGAMI trial of peri-myocardial infarction insulin therapy, was published in 1995 (1). The first guideline discussion of in-hospital diabetes management occurred briefly in 2003, more fully in 2008 and 2013 (2-4) by the Canadian Diabetes Association; in 2005 and annually since then by the American Diabetes Association (5,6). Recently, there have been many more publications on the topic. A recent PubMed search, limited to the last 5 years, "hospital" and "diabetes" as a Medical Subject Headings (MeSH) major topic, revealed more than 5000 English-language clinical trials (PubMed.gov; accessed 6 Oct 2013). Still, relatively little is certain about appropriate glycemic targets in hospital. This has left us, in 2014, with consensus recommendations only for glycemic targets in non-critically ill patients from both the Canadian Diabetes Association Clinical Practice Guidelines (4) and the American Diabetes Association Standards of Medical Care in Diabetes (6). This article reviews recommended glycemic targets in various in-hospital populations and the barriers to obtaining them.