How should glucose levels be managed in critically ill patients with type 2 diabetes mellitus (DM)?

Updated: Sep 27, 2021
  • Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
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Standard practice in intensively ill patients has been to provide tight glycemic control through intensive insulin therapy. Research evidence, however, has called this practice into question.

A meta-analysis found that in critically ill adult patients, tight glucose control is associated with an increased risk of hypoglycemia but not with significantly reduced hospital mortality. [365] A large, international, randomized trial among adults treated in an intensive care unit (ICU) found that intensive glucose control (target, 81-108 mg/dL) resulted in higher mortality than did a blood glucose target of 180 mg/dL or less. [366]

However, large, single-center studies using more accurate glucose measurements have shown a benefit to intensive glycemic control in critical illness. [367] This remains an area of important ongoing research.

Results of the Diabetes and Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial suggested improved outcomes in patients with type 2 diabetes with acute myocardial infarction or stroke who receive constant IV insulin during the acute phase of the event to maintain blood glucose values of approximately 100-150 mg/dL. [368] However, these results were not confirmed in the follow-up trial, DIGAMI-2. [369]

A post-hoc analysis of the DIGAMI-2 study revealed that glucose-lowering drugs impact prognosis differently. Insulin may be associated with increased risk of nonfatal cardiac events, whereas metformin seems to be protective against risk of death. [370]

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