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AACE: Following Glucose Control Protocol Superior for Hospitalized Diabetics


SEATTLE -- Aggressive glucose control with subcutaneous insulin in non-critically ill hospitalized patients results in better outcomes and may significantly reduce hospital stays, reported investigators here.

SEATTLE, April 16 -- Aggressive glucose control with subcutaneous insulin in non- critically ill hospitalized patients results in better outcomes and may significantly reduce hospital stays, reported investigators here.

In a study comparing individualized hyperglycemia management in non-critically ill hospitalized patients with a glucose-management protocol, the protocol-driven management resulted in better glycemic control than standard care, said Alicia Leung, M.D., of the John H. Stroger, Jr., Hospital of Cook County in Chicago.

Patients eligible were those hospitalized for surgical debridement of diabetic foot ulcers. Those who were randomly assigned to the protocol also had hospital stays that were shorter by 2.3 days than those of patients who received individualized glycemic management, but the study was not sufficiently large enough to show statistical significance, the authors reported in a poster presentation at the American Association of Clinical Endocrinologists annual meeting.

But when they looked at the cohort as a whole, the authors found that every 50 mg/dL drop in glucose levels was associated with a 1.5 day decrease in length of hospital stay, regardless of how that reduction was achieved, and this finding reached statistical significance..

Previous studies have shown that glucose control in surgical and medical ICUs is associated with reduced morbidity and mortality and better wound healing, but those studies involved intravenous insulin.

The current study suggests that a glucose-management protocol involving the use of subcutaneous rather than intravenous insulin can significantly improve care for hospitalized patients and, by standardizing the approach to glycemic management, may help to ease some of the burden on nurses caring for patients in post-surgical settings.

"Not every hospital can afford to have a diabetes team managing glucose throughout the hospital," commented co-author Rasa Kazlauskaite, M.D., at Cook County.

"Ours is a public hospital," she said, "an we showed that if we train the staff properly we can show the improvement of glycemic control, and it might be that we also reduce the hospital stay and hopefully improve the quality of life for those patients."

The authors randomized enrolled 23 patients with type 2 diabetes and blood glucose of more than 200 mg dL. Of the patients, all admitted for debridement of foot ulcers, 11 were assigned to individualized glycemic management from a medical consult team, and 12 were assigned to a protocol-driven subcutaneous twice-daily insulin therapy with NPH and regular insulin.

Blood glucose levels were evaluated with a bedside check four times daily, and were targeted to 70 to 120 mg/dL according to the Rush University insulin escalation protocol.

They found that glucose and hemoglobin A1c levels on admission were similar in both groups, but the average daily glucose in the protocol-driven management group was significantly lower than in the individual management groups, at 144 19 mg/dL, compared with 200 29 mg/dL (P<0.001).

In both groups, the patients on average went to surgery on their third day of hospitalization. But the patients in the protocol-managed group went into the operating room with significantly lower glucose, at 133 42 mg/dL, compared with patients in the individualized treatment group, whose day of surgery glucose was 214 41 mg/dL (P<0.01).

There were four episodes of hypoglycemia events (defined as glucose below 50 mg/dL) in the protocol group and one in the individualized group, but this difference was not significant.

The mean hospital stay was 8.7 days in the individualized glycemic control group and 6.3 days in protocol group, but this difference was not statistically significant (P=0.09). The authors noted that midway during the study the hospital adopted a similar glucose control protocol, thereby limiting the sample size before a significant between-group difference could be shown.

The authors found, however, when they pooled the two study groups, that there was a significant correlation between glucose control and hospital length of stay, with each 50 mg/dL decrease in glucose resulting in a 1.5 day shorter stay (P=0.02).

Dr. Leung and colleagues noted that the study was limited by its unblinded design, and by the fact that the patients were discharged at the discretion of podiatry team, basing decision on wound healing, independently of the extent of glycemic control achieved.

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