Tuesday, May 26, 2009

The unsweeteness of inpatient glycemic control

Recent data has linked stringent glucose control, especially hypoglycemia, with increased mortality. Therefore, a thorough review of the current evidence was done in a joint fashion by both ADA and AACE. (You can access the guildelines if you click over the title of this post). They did not discover "the philosophal stone" but summarized the existent evidence in both critical care and non care settings. They suggest that in the critical care setting a target of 140 to 180 mg/dL should be aimed, and in the non-critical care setting a preprandial glucose of less than 140 mg/dL and a random glucose less than 180 mg/dL.

Most likely, although these glucose limits may help some practitioners, it is unlikely that this will be the last word in inpatient glycemic management and an ongoing long term debate will continue.

An interesting point is when the common sense and an expected outcome linked to hypoglycemia is converted into "evidence". It is reasonable to think that although the patients in the hospital and critical care setting need strict glucose control, they still need to have enough substrate to permit an adequate metabolic functioning and therefore low glucose levels may be potentially related to poor outcomes, even death. But now, we have "evidence" that show us that glucose below 110 can be potentially dangerous.

The interest is to increase patients' safety and better outcomes. More than just look into numbers is to determine what is the best practice to do so. Perhaps, the best measure is to individualize our patient glucose management, taking into consideration all the involved factors that can affect the glucose levels (sepsis or infections, steroid use, medications such as beta-agonists or quinolones, etc.) Establishing a basal insulin dose along with preprandial insulin coverage should be advocated, and the use of an insulin sliding-scale as a sole measure for glucose control should be discouraged.

We are aiming into "reasonable" goals of glucose levels for determining the maximum tolerated glucose level (180) mixed with "strictly evidence-based" glucose levels to determine how low we can aim (not less than 110), although the guidelines were not explicit about establishing a lower limit.

As always...primum non nocere.

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