Glycemic Control

From Anvita Health Wiki

Contents 1 Introduction 2 Management 3 Additional Terms 4 References

Introduction

• Control of blood glucose.

Management

• hosptalized, non- critical care patients [15]

• all patients serum glucose on admission
• hemoglobin A1c levels if not measured within 2-3 months ( diabetics)
• point-of-care blood glucose testing

• enteral or parenteral nutrition or glucocorticoids

• before meals & QHS
• every 4-6 hours if NPO or continuous enteral feeding

• in patients without diabetes, discontinue testing when blood glucose <140 mg/dL without insulin for at least 24-48 hours

• insulin therapy is preferred in hospitalized patients
• discontinue oral hypoglycemic medications in hospitalized patients
• premeal BG target is <140 mg/dL; random BG target is <180 mg/dL for most patients; targets can be modified higher or lower according to clinical status
• to avoid hypoglycemia

• reassess insulin therapy when blood glucose levels are <100 mg/dL
• modify insulin therapy when levels are <70 mg/dL

• nutrition consult for all patients with hyperglycemia
• all diabetics treated with insulin as outpatient should receive scheduled subcutaneous insulin in the hospital
• avoid prolonged use of insulin sliding-scale
• transition all diabetic patients to subcutaneous insulin at least 1-2 hours before discontinuation of intravenous insulin infusion
• all surgical patients with diabetes mellitus type 1 & most with diabetes mellitus type 2 should receive subcutaneous insulin or insulin infusion to prevent hyperglycemia
• at hospital discharge, provide patients, family, & caregivers with easy-to-understand written & oral instructions

• Intensive glycemic control in ICU patients

• reduced mortality (15% vs 21%) [1]*; increased mortality (25% vs 27%) [7]; no benefit in mortality [6]
• reduced new cases of renal failure (3 vs 12) [1]
• reduced need for blood transfusion (excluding GI bleed) (21% vs 25%) [1]
• shortened median ICU stay (1.6 vs 1.9 days) [1] no differencs in median ICU stay [7]
• beneficial for ICU stays > 3 days, but may be harmful for short ICU stays < 3 days (reason unclear) [4]
• no difference in days of mechanical ventilation [7]
• increased incidence of hypoglycemia [6,7]
• goal for blood glucose is 140-200 mg/dL [10]

• ACP guidelines
• no mortality benefit for targeting lower levels
  

• * Re-evaluation suggests hyperglycemia a risk factor for ICU mortality only in previously unrecognized diabetics [2,3]
  
• Patients undergoing CABG (& presumably other surgery)

• tight glycemic control ( serum glucose 90-120 mg/dL) increases the incidence of hypoglycemic events & does not result in any significant improvement in clinical outcomes relative to moderate glycemic control ( serum glucose 120-180 mg/dL) [14]
  

• No benefit for intensive glucose control in patients with long-standing diabetes mellitus type 2 (see VADT trial) [5], & ACCORD trial [11,12]

• no benefit in preventing cardiovascular events
• no benefit in preventing microvascular complications ( diabetic nephropathy, diabetic retinopathy ..)
• no benefit in life expectancy
• no benefit in quality of life [12]
  

• Meta-analysis of 13 trials fails to show benefit of intensive glycemic control, finds reduction in non-fatal MI ( HR-0.85) & microalbuminuria ( HR-0.90) with intensive glucose control, but not stroke, congestive heart failure, diabetic retinopathy, peripheral vascular disease or mortality [8,13]

Additional Terms

• diabetes mellitus
• glucose in serum/plasma
• hemoglobin A1c in red blood cells
• hyperglycemia
• hypoglycemia

References

1. Journal Watch 24(18):124, 2004 Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2004 Aug;79(8):992-1000. PMID: [1]
2. Rady MY et al, Influence of individual characteristics on outcome of glycemic control in intensive care unit patients with or without diabetes mellitus Mayo Clin Proc 2005; 80:1588 PMID: [2]
   - Bellmon R & Egi M Glycemic control in the intensive care unit: Why should we wait for NICE-SUGAR Mayo Clin Proc 2005; 80:1546 PMID: [3]
3. Whitcomb BW et al, Impact of admission hyperglycemia on hospital mortality in various intensive care unit populations Crit Care Med 2005; 33:2774 PMID: [4]
   - Angus DC & Abrahan E. Intensive insulin therapy in critical illness: When is the evidence enough? Am J Crit Care Med 2005; 172:1358 PMID: [5]
4. Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H, Bouillon R. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006 Feb 2;354(5):449-61. PMID: [6]
   - Malhotra A. Intensive insulin in intensive care. N Engl J Med. 2006 Feb 2;354(5):516-8. No abstract available. PMID: [7]
5. Duckworth W et al for the VADT Investigators Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009, 360:129 <PubMed> PMID: [8] <Internet> [9]
6. Arabi YM Intensive versus conventional insulin therapy: A randomized controlled trial in medical and surgical critically ill patients. Crit Care Med 2008, 36:3190 PMID: [10]
   - Oddo M et al, Impact of tight glycemic control on cerebral glucose metabolism after severe brain injury: A microdialysis study. Crit Care Med 2008, 36:3233 PMID: [11]
7. Finfer S et al for The NICE-SUGAR Study Investigators Intensive versus Conventional Glucose Control in Critically Ill Patients N Engl J Med. 2009 Mar 26;360(13):1283-97. Epub 2009 Mar 24. <PubMed> PMID: &dopt=Abstract <Internet> [12]
   - Kovalaske MA, Gandhi GY. Intensive glucose control increased risk for death and severe hypoglycemia in critically ill adults. ACP Journal Club. Ann Intern Med 2009 Aug 18;151(4):JC2-JC5. PMID: [13]
8. Ray KK et al Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials Lancet. 2009 May 23;373(9677):1765-72. PMID: [14]
9. Prescriber's Letter 16(6): 2009 Inpatient Management of Hyperglycemia Detail-Document#: [15] (subscription needed) [16]
10. Qaseem A et al Use of Intensive Insulin Therapy for the Management of Glycemic Control in Hospitalized Patients: A Clinical Practice Guideline From the American College of Physicians Annals of Internal Medicine Feb 14, 2011 [17]
11. The ACCORD Study Group. Long-term effects of intensive glucose lowering on cardiovascular outcomes. N Engl J Med 2011 Mar 3; 364:818 <PubMed> PMID: [18] <Internet> [19]
12. Anderson RT et al. Effect of intensive glycemic lowering on health-related quality of life in type 2 diabetes: ACCORD trial. Diabetes Care 2011 Apr; 34:807 PMID: [20]
13. Boussageon R et al. Effect of intensive glucose lowering treatment on all cause mortality, cardiovascular death, and microvascular events in type 2 diabetes: Meta-analysis of randomised controlled trials. BMJ 2011 Jul 26; 343:d4169 PMID: [21]
14. Lazar HL et al. Effects of aggressive versus moderate glycemic control on clinical outcomes in diabetic coronary artery bypass graft patients. Ann Surg 2011 Sep; 254:458 PMID: [22]
15. Umpierrez GE et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: An endocrine society clinical practice guideline. J Clin Endocrinol Metab 2012 Jan; 97:16. PMID: [23]
16. National Guideline Clearinghouse Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians. ngc-guideline: [24]

glycemic control