Rationale for Achieving Glycemic Control

Clinical Evidence for Glucose Control in the Inpatient Setting

Key Points

  • Epidemiologic studies show that glucose control in hospitals is woefully inadequate.

    • Approximately 30% of hospitalized patients have blood glucose values >180 mg/dL.

      • As glucose levels rise, so does mortality risk, as well as the risk of dehydration, hypotension, eventual renal shutdown, poor healing, and impaired immune system function.

    • Another 6% to 7% of patients have glucose values in the hypoglycemic range (<70 mg/dL) and are at risk for neuroglycopenia, brain dysfunction, and cardiac arrhythmias, which can prove fatal in vulnerable populations.

  • Although definitive data on optimal glucose targets for hospitalized patients are lacking due to a small number of trials, some conclusions can be drawn:

    • Good glucose control (blood glucose 140-180 mg/dL) is likely to be sufficient to improve clinical outcomes in the critical care setting, while near-normal control (blood glucose <110 mg/dL) increases risks for most inpatients in most hospitals.

    • Hyperglycemia and hypoglycemia are markers of poor outcomes in critically ill and noncritically ill patients.

    • Recent studies do not endorse a casual approach to inpatient glucose control.

  • Consensus guidelines have been issued by the American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) for all hospitalized patients and separately by The Endocrine Society (TES) for noncritically ill patients.

    • Blood glucose targets for critically ill inpatients (AACE/ADA)

      • Treatment threshold: >180 mg/dL

      • Goal <140-180 mg/dL for most patients

      • Lower threshold of 110 mg/dL for selected, low-risk patients

      • Hypoglycemia defined as <70 mg/dL or <100 mg/dL (TES)

    • Blood glucose targets for noncritically ill inpatients (AACE/ADA and TES)

      • Treatment threshold: >180 mg/dL

      • Goal <140 mg/dL for most patients

      • Hypoglycemia defined as <70 mg/dL (AACE/ADA) or

  • AACE, ADA, and TES all strongly discourage use of sliding scale insulin, which has been shown to lead to undesirable levels of both hypoglycemia and hyperglycemia relative to basal-bolus insulin approaches.

Suggested Reading

Clinical Guidelines

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Deedwania P, Kosiborod M, Barrett E; American Heart Association Diabetes Committee of the Council on Nutrition, Physical Activity, and Metabolism. Hyperglycemia and acute coronary syndrome: a scientific statement from the American Heart Association Diabetes Committee of the Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2008;117:1610-1619.

Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15:353-69.

Qaseem A, Humphrey LL, Chou R, Snow V, Shekelle P. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2011;154:260-267.

Society of Hospital Medicine. The case for supporting inpatient glycemic control programs now: the evidence and beyond. 2008.

Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97:16-38.

Key Prospective Studies, Reviews, and Meta-analyses

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Bailon RM, Partlow BJ, Miller-Cage V, et al. Continuous subcutaneous insulin infusion (insulin pump) therapy can be safely used in the hospital in select patients. Endocr Pract. 2009;15:24-29.

Bernard JB, Munoz C, Harper J, Muriello M, Rico E, Baldwin D. Treatment of inpatient hyperglycemia beginning in the emergency department: a randomized trial using insulins aspart and detemir compared with usual care. J Hosp Med. 2011;6:279-284.

Finfer S, Heritier S. The NICE-SUGAR (Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation) Study: statistical analysis plan. Crit Care Resusc. 2009;11:46-57.

Griesdale DE, de Souza RJ, van Dam RM, et al. Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ. 2009;180:821-827.

Hirsch IB. Inpatient diabetes: review of data from the cardiac care unit. Endocr Pract. 2006;12(suppl 3):27-34.

Kansagara D, Fu R, Freeman M, Wolf F, Helfand M. Intensive insulin therapy in hospitalized patients: a systematic review. Ann Intern Med. 2011;154:268-282.

McDonnell ME, Umpierrez GE. Insulin therapy for the management of hyperglycemia in hospitalized patients. Endocrinol Metab Clin North Am. 2012;41:175-201.

Moghissi ES. Reexamining the evidence for inpatient glucose control: new recommendations for glycemic targets. Am J Health Syst Pharm. 2010;67(16 Suppl 8):S3-S8.

NICE-SUGAR Study Investigators. Hypoglycemia and risk of death in critically ill patients. N Engl J Med. 2012;367:1108-1118.

NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283-1297.

Pittas AG, Siegel RD, Lau J. Insulin therapy and in-hospital mortality in critically ill patients: systematic review and meta-analysis of randomized controlled trials. J Parenter Enteral Nutr. 2006;30:164-172.

Queale WS, Seidler AJ, Brancati FL. Glycemic control and sliding scale insulin use in medical inpatients with diabetes mellitus. Arch Intern Med. 1997;157:545-552.

Umpierrez GE, Hor T, Smiley D, et al. Comparison of inpatient insulin regimens with detemir plus aspart versus neutral protamine hagedorn plus regular in medical patients with type 2 diabetes. J Clin Endocrinol Metab. 2009;94:564-569.

Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care. 2007;30:2181-2186.

Umpierrez GE. Basal versus sliding-scale regular insulin in hospitalized patients with hyperglycemia during enteral nutrition therapy. Diabetes Care. 2009;32:751-753.

Umpierrez GE, Smiley D, Jacobs S, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care. 2011;34:256-261.

Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006;354:449-461.

Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359-1367.

Vlasselaers D, Milants I, Desmet L, et al. Intensive insulin therapy for patients in paediatric intensive care: a prospective, randomised controlled study. Lancet. 2009;373:547-556.

Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008;300:933-944.

Prevalence Data

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Arinzon Z, Shabat S, Shuval I, et al. Prevalence of diabetes mellitus in elderly patients received enteral nutrition long-term care service. Arch Gerontol Geriatr. 2008;47:383-393.

Bartnik M, Ryden L, Ferrari R, et al. The prevalence of abnormal glucose regulation in patients with coronary artery disease across Europe. The Euro Heart Survey on diabetes and the heart. Eur Heart J. 2004;25:1880-1890.

Boord JB, Greevy RA, Braithwaite SS, et al. Evaluation of hospital glycemic control at US academic medical centers. J Hosp Med. 2009;4:35-44.

Conaway DG, O'Keefe JH, Reid KJ, et al. Frequency of undiagnosed diabetes mellitus in patients with acute coronary syndrome. Am J Cardiol. 2005;96:363-365.

Palacio A, Smiley D, Ceron M, et al. Prevalence and clinical outcome of inpatient hyperglycemia in a community pediatric hospital. J Hosp Med. 2008;3:212-217.

Swanson CM, Potter DJ, Kongable GL, Cook CB. Update on inpatient glycemic control in hospitals in the United States. Endocr Pract. 2011;17:853-861.

Wexler DJ, Meigs JB, Cagliero E, Nathan DM, Grant RW. Prevalence of hyper- and hypoglycemia among inpatients with diabetes: a national survey of 44 U.S. hospitals. Diabetes Care. 2007;30:367-369.

Additional Reading

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