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glycemic control

Control of blood glucose. Also see dysglycemia. Benefit/risk: - tight glycemic control (blood glucose 72-135 mg/dL) - no benefit immediately after ischemic stroke [29] - number needed to harm = 7 hypoglycemia [29] - tight glycemic control HgbA1c = 6.5-7.0% for 5 years for type 2 diabetes - no benefit for reducing risk of stroke, MI, renal failure or death [30] - number needed to treat (NNT) to prevent 1 limb amputation = 250 [30] - number needed to harm = 6 (hospitalization for severe hypoglycemia) - tight glycemic control < HgbA1c of 6.5% not associated with lower risks for retinopathy or microalbuminuria, but does increase risk for hypoglycemia [53] - tight glycemic control risky in cognitively impaired nursing home residents [54] - both hypoglycemia & hyperglycemia associated with cognitive impairment [52] * also see management Laboratory: - screening for dysglycemia - oral glucose tolerance test is superior to hemoglobin A1c (HbA1c) for detecting dysglycemia in patients with coronary artery disease [1] - strongest predictors of cardiovascular outcomes are 2-hour post-load glucose levels >= 9 mmol/L & HbA1c >= 5.9% - hemoglobin A1c & blood glucose for monitoring patients with diabetes mellitus Management: === General === - avoiding episodes of hypoglycemia assume highest priority [20] - self glucose monitoring not recommended for patients with type 2 diabetes not on insulin or other drug associated with hypoglycemia [51] - outpatients with type 2 diabetes on QHS glargine or other long-acting insulin - target morning preprandial glucose < 150 mg/dL - hemoglobin A1c targets: - < 7% healthy young adults - < 7.5% healthy older adults - < 8% older adults with with multiple chronic illnesses [56] === hospitalized, non-critical care patients === - all patients serum glucose on admission [15,57] - hemoglobin A1c levels if not measured within 2-3 months (diabetics) - point-of-care blood glucose testing a) enteral or parenteral nutrition or glucocorticoids - before meals & QHS - every 4-6 hours if NPO or continuous enteral feeding b) in patients without diabetes, discontinue testing when blood glucose <140 mg/dL without insulin for at least 24-48 hours - insulin parenteral including basal & preprandial insulin [20] - discontinue oral hypoglycemic medications in hospitalized patients - avoid hypoglycemia - target blood glucose for hospitalized patients with diabetes mellitus is 140-200 mg/dL [21] - tight glycemic control (80-110 mg/dL) may increase mortality [20] - nutrition consult for all patients with hyperglycemia - all diabetics treated with insulin as outpatient should receive scheduled subcutaneous insulin in the hospital - avoid sole &/or prolonged use of insulin sliding-scale [20] - 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 - an inpatient virtual glucose management service (uses EMR) may improve glycemic control & prevent some episodes of hypoglycemia [46] === Glycemic control in ICU patients === === 1) insulin infusion may be preferred 2) intensive glycemic control not recommended a) reduced mortality (15% vs 21%) [1]*; b) increased mortality (25% vs 27%) [7]; c) no benefit in mortality [6]; d) no benefit in pediatric patients after cardiac surgery [17] e) reduced new cases of renal failure (3 vs 12) [1], or need for renal replacement therapy [59] f) reduced need for blood transfusion (excluding GI bleed) (21% vs 25%) [1] g) shortened median ICU stay (1.6 vs 1.9 days) [1]; no differencs in median ICU stay [7] h) beneficial for ICU stays > 3 days, but may be harmful for short ICU stays < 3 days (reason unclear) [4] i) no difference in days of mechanical ventilation [7] j) increased incidence of hypoglycemia [6,7] - incidence of severe hypoglycemia < 1% [59] 3) goal for blood glucose is 140-200 mg/dL [10]; 140-180 mg/dL [20] - ACP guidelines - no mortality benefit for targeting lower levels 4) hypoglycemia associated with increased mortality [18] 5) tight glycemic control not indicated in pediatric patients a) hypoglycemia associated with increased mortality b) non-cardiac surgery patients - less likely to become hypoglycemic - may have lower costs & shorter hospital stays with tight glycemic control - tight glycemic control does not improve mortality [23] 6) ICUs slow to adapt to recommendations against tight glycemic control in the ICU [31] 7) tight glycemic control 80-110 mg/dL of no benefit in critically ill children [45] 8) critically ill diabetic patients not harmed by glucose targets of 180-250 mg/dL [50] * Re-evaluation suggests hyperglycemia a risk factor for ICU mortality only in previously unrecognized diabetics [2,3] Notes: Continuous glucose monitoring may be useful for resolving inconsistencies in plasma glucose & hemoglobin A1c [20] Postprandial plasma glucose may be useful for - preprandial plasma glucose - HgbA1c discrepancies [20] - preprandial plasma glucose at target, but HgbA1c not at goal [20] - preprandial plasma glucose at not at target, but HgbA1c at goal [20] - measure post postprandial glucose to adjust mealtime insulin rather than increase long-acting insulin [20] 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 relation between perioperative mortality & HbA1c [47] intensive glycemic control in patients with type 1 diabetes may not be apparent in patients with type 2 diabetes - intensive glycemic control reduces need for eye surgery in patients with type 1 diabetes [33] 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 - fewer non-fatal acute coronary events despite higher cardiovascular & all-cause mortality [28] - higher mortality with intensive glycemic control seen primarily in patients with chronic kidney disease [32] - no benefit in preventing microvascular complications (diabetic nephropathy, diabetic retinopathy ..) - no benefit in preventing diabetic nephropathy [16] - 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] 6 years of intensive glycemic control in veterans with long-standing type 2 diabetes is not associated with cardiovascular benefit, but after an additional 4 years of standard glycemic control, cardiovascular events were reduced 0.86% in the intensive glycemic control group (NNT to prevent 1 cardiovascular event = 116); no mortality benefit [34] Intensive glycemic control (Hgb A1c < 6.5%) in patients with type 2 diabetes lowers risk of end-stage renal disease (ESRD) - number needed to treat to prevent one case of ESRD = 430 [19] Intensive glycemic control is common among elderly with type 2 diabetes is common & associated with increased risk of hypoglycemia [41,49] better glycemic control, even within the normal range, is correlated with better memory & hippocampal structure in the elderly [22] A low glycemic diet supplemented with canola oil is associated with slightly better glycemic control that a diet rich in whole grains in patients with diabetes mellitus type 2 [27] fasting until noon associated with higher blood glucose after lunch & dinner in patients with type 2 diabetes [36] white wine (150 mL daily) associated with reduced fasting plasma glucose (17.2 mg/dL) in patients with type 2 diabetes [42] - only slow ethanol metabolizers benefit extra virgin olive oil - lowers post-prandial serum glucose & LDL cholesterol [43] - no change in serum glucose or lipid profile [44] brief interruptions of prolonged sitting with standing or light exercise improves postprandial glycemic control in prediabetic postmenopausal women [37] gut microbiome influences glycemic control [40] indoor light environment modulates postprandial substrate handling, energy expenditure & thermoregulation of insulin-resistant diabetics in a time-of-day-dependent manner [55] - evening plasma glucose pre- & post-prandial lower by ~ 5 mg/dL after exposure to bright light during the daytime [55] a text message based, self management support program may result in modest improvements in glycemic control in adults with poorly controlled diabetes [48]

Related

continuous glucose monitor (Dexcom G5 CGM; G4 Platinum CGM System with Dexcom Share system, Flash glucose monitoring system, Eversense) diabetes mellitus glucose in serum/plasma glucose monitor hemoglobin A1c in red blood cells (Tina-quant HbA1cDx) hyperglycemia hypoglycemia

Specific

impaired glycemic control

References

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