Tuesday, June 22, 2010

Glycemic targets in hospitalized patients

---varies with patient characteristics and whether or not the patient is in the critical care unit. This article in Hospitalist News offers some pointers.

For critically ill patients, intravenous insulin infusion protocols are better for achieving and maintaining glycemic control, she said. Many hospitals further subdivide the protocol for critically ill patients to have different glycemic targets for surgical and nonsurgical ICU patients, added Dr. Korytkowski, professor of medicine at the University of Pittsburgh's Center for Diabetes and Endocrinology.

A 2009 consensus statement from the American Association of Clinical Endocrinologists and the American Diabetes Association recommended maintaining glucose levels between 140 and 180 mg/dL in most critically ill patients, but added that glucose levels of 110-140 mg/dL may be appropriate in some, such as those in cardiothoracic intensive care...

In noncritically ill inpatients, the consensus statement recommends targeting premeal glucose levels of 100-140 mg/dL and random glucose test results below 180 mg/dL (Endocr. Pract. 2009;15:353-69 and Diabetes Care 2009;32:1119-31).

Prolonged therapy with “sliding scale” insulin alone is not recommended, Dr. Korytkowski stressed. “This whole idea of putting patients on sliding-scale insulin and continuing it for the duration of their hospitalization independent of what their blood sugar levels are needs to be stopped,” she said.

The whole discussion about sliding scale insulin is confusing. The statement above may have a valid point if I could understand it. The dosing of sliding-scale insulin, after all, is dependent on what the patient's blood sugar is. What's more, titratable insulin drips, widely advocated by the same diabetes mavens who decry sliding-scales, are nothing more than sliding-scale insulin modified as to timing of monitoring and route of administration. Short acting “correction” insulin, also recommended by the diabetes mafia, is just sliding-scale insulin made more confusing by administering it on top of a fixed amount of short acting insulin.

The rationale against simple sliding-scale insulin (why wait for the patient to go out of control before giving insulin?) is sound but I am not aware of evidence that it is associated with worse clinical outcomes. Reading between the lines of that the experts say, I can glean the following principles, with which I am in general agreement:

Simple sliding-scale insulin by it self is not enough in many circumstances where patients need basal coverage.

Correction short acting insulin on top of a fixed amount of pre-meal short acting insulin is more physiologic than simple sliding-scale coverage.

The most rational coverage would be basal-bolus insulin. This may not be practical for all hospitalized patients because achieving suitable control may be a stepwise process taking days, according to the article. For patients with very short hospital stays who will be NPO a good portion of the time, sliding-scale coverage is appealing.

Some resources cited in the article can be found here and here.

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