Glucose control in and out of the ICU

Current recommendations from the ADA (guideline) and Surviving Sepsis Campaign (guideline) advocate for tight glucose control in ICU patients, although this had been a contentious issue. The landmark RCT of surgical ICU patients found signficantly lower mortality, LOS, and organ dysfunction in tight control (BS goal 80-110 mg/dL) (van den berghe) but a similar study in medical ICU patients did not find a mortality difference overall. It did find higher mortality in those with LOS <3 days and lower mortality in those with LOS > 3days. They also found a 3X higher rate of hypoglycemia in the intensive control group (van den berghe). A recently published meta-analysis of 29 controlled trials from 8432 ICU patients did not find a mortality benefit in tight control versus usual care (abstract). Tight control was associated with lower risk of septicemia (RR 0.76, CI 0.59-0.97) but markedly increased risk of hypoglycemia (BS <40 mg/dL, RR 5.13, CI 4.09-6.43). The NICE-SUGAR trial will randomize >5000 ICU patients to tight (80-110) versus conventioal (140-180) control and will hopefully settle this issue (NIH site). For non-ICU patients, there is no evidence that tight control is superior, and for now we should follow the ADA guidelines of fasting targets <126 and non-fasting targets <180 for hospitalized patients (ADA website)

Danielle Scheurer

Dr. Scheurer is a clinical hospitalist and the Medical Director of Quality and Safety at the Medical University of South Carolina in Charleston, South Carolina, and is Assistant Professor of Medicine. She is a graduate of the University of Tennessee College of Medicine, completed her residency at Duke University, and completed her Masters in Clinical Research at the Medical University of South Carolina. She also serves as the Web Editor and Physician Advisor for the Society of Hospital Medicine.

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