What is the target blood glucose for noncritical care patients?

Case

A 65-year-old obese (100 kg) man with type 2 diabetes, hypertension, and a pack-a-day smoking habit is admitted with moderately severe bilobar pneumonia. His condition is manifest by fever, cough, chills, leukocytosis, and a modest oxygen requirement. You order oxygen, intravenous (IV) fluids, diet, and appropriate antibiotics while continuing the history and chart review. The patient uses metformin and glyburide, and his home glucose readings are generally in the 160 to 180 mg/dL range. An HbA1c level performed three months ago was 9.8, leading to an increased dose of glyburide. As you finish the history, the nurse reports a glucose reading of 198 mg/dL. What is the target blood glucose for noncritical care adult inpatients?

Overview

Diabetes mellitus is an epidemic in the United States. At least 9.3% of adults older than 20 (more than 20 million people) have diabetes. Approximately 30% are unaware they have diabetes.1 Concurrent with the increasing prevalence of diabetes in the U.S. from 1980 through 2003, the number of hospital discharges with diabetes as any listed diagnosis more than doubled between 1980 and 2003. These trends are expected to accelerate.2 Studies suggest 26% of inpatients have diabetes and 12% have pre-diabetes, previously undiagnosed diabetes, or stress hyperglycemia.3

Key Points

  1. The guideline recommended glycemic targets for noncritically ill inpatients are pre-prandial blood glucose levels of less than 110 mg/dL (AACE) or 90 to 130 mg/dL (ADA), and maximum random glucose levels of 180 mg/dL.
  2. These aggressive glucose target recommendations are not based on randomized controlled trials in noncritically ill inpatients. They are based on outpatient studies, a variety of critical care studies, and a large number of physiology and observational studies.
  3. Achieving aggressive glycemic targets safely requires institutional infrastructure, educational programs, and standardization of order sets and protocols.

The Bottom Line

The AACE recommended target glucose levels for noncritically ill inpatients are pre-prandial blood glucose levels of less than 110 mg/dL (90–130 mg/dL ADA), and maximum random glucose levels of 180 mg/dL. The glycemic target you and your institution choose should be similar to AACE/ADA targets but may reasonably be more conservative, dependent on patient and institutional factors.

Additional Reading

  • Clement S, Braithwaite SS, Magee MF, Ahmann A, Smith EP, Schafer RG, Hirsch IB, the Diabetes In Hospitals Writing Committee. Management of diabetes and hyperglycemia in hospitals (technical review). Diabetes Care 2004;27:553–591.
  • American College of Endocrinology and American Diabetes Association Consensus Statement on Inpatient Diabetes and Glycemic Control: A call to action. Diabetes Care. 2006;29(8):1955-1962.
  • SHM’s “Workbook for Improvement: Improving Glycemic, Preventing Hypoglycemic, and Optimizing Care of the Inpatient with Hyperglycemia and Diabetes.” Available at www.hospitalmedicine.org/

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Review of the Data

A full review of the evidence is beyond the scope of this article. What follows is a sampling of the most representative or influential critical care studies.

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