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Precision Medicine, Glycemic Control and the Problems of Identifying Friend from Foe
Mark E. Nunnally, MD, FCCM, New York University Langone Medical Center

“Friendly fire” is a military concept that describes risks to troops from their own weaponry during combat operations. In broad terms, knowing the target and hitting the target are key principles in avoiding collateral damages. Medicine will never be combat, but similar principles apply when one cannot identify and treat the things that matter most in disease.

The lessons of tight glycemic control in the intensive care unit are still being learned. The promise of a simple, inexpensive and initially promising therapy have devolved into uncertainties about harm. Enthusiasm for tight protocols in response to large effect sizes in a randomized, controlled trial could not be replicated in larger studies. Explanations for the irreproducibility and the suggestion of harm focused on hypoglycemia and plasma glucose level variability. As enthusiasm waned, interest shifted from maximizing benefits from tight control to minimizing the harms of permissive hyperglycemia. More>

Safety and Efficacy of Personalized Glycemic Control

in Critically Ill Patients: A 2 year Before and After Interventional Trial
James S Krinsley MD, FCCM; Jean-Charles Preiser MD, PhD; Irl B. Hirsch MD

Our understanding of the relationship of glycemia to outcomes of critically ill patients has evolved considerably in the 15 years since publication of the first randomized trial of intensive insulin therapy. Observational and randomized trial data have demonstrated that hyperglycemia, hypoglycemia and increased glucose variability are independently associated with mortality. In addition, an emerging body of literature has highlighted differences in the relationship of glucose metrics to outcomes when comparing patients with and without diabetes and a review of the interventional trials of intensive insulin therapy suggested greater benefit of treatment among patients without diabetes.

Observational data has underscored the importance of preadmission glycemia. Among a cohort
of critically ill diabetic patients, those with A1C levels > 7% had higher probability of... More >

Use of a Computer-Guided Glucose Management System to Improve Glycemic Control and Address National Quality Measures

A 7-Year Retrospective Observational Study at a Tertiary Care Teaching Hospital
Robert J. Tanenberg, MD, FACP; Sandra Hardee, PharmD, CDE; Caitlin Rothermel, MA,
MPH; Almond J Drake, 3rd, MD, FACE


Inpatient hyperglycemia, hypoglycemia, and glucose variability are associated with increased
mortality. The use of electronic Glucose Management Systems (eGMS) to guide intravenous
(IV) insulin infusion have been found to significantly improve blood glucose (BG) control. This
retrospective observational study evaluated the 7-year (1/2009-12/2015) impact of the
EndoTool® eGMS in intensive and intermediate units at Vidant Medical Center, a 900-bed
tertiary teaching hospital. More >

A Liberal Glycemic Target in Critically Ill Patients with Poorly Controlled Diabetes?
Jan Gunst, Greet Van den Berghe, Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium

Due to severe physical stress, critically ill patients commonly develop hyperglycemia. Multiple observational studies have shown a U-shaped association between glycemic levels in the intensive care unit (ICU) and the risk of death, with the lowest risk of death associated with glucose levels that are normal for age. Three landmark randomized controlled trials (RCTs) performed in Leuven and several subsequent single-center studies found that treating pronounced hyperglycemia [>215 mg/dL (11.9 mmol/L)] with insulin to target age-adjusted normoglycemia [80–110 mg/dL (4.4–6.1 mmol/L) for adults, 60–100 mg/dL (3.9–5.6 mmol/L) for children, 50–80 mg/dL (2.8–4.4 mmol/L) for infants] reduced morbidity and mortality for both critically ill adults and children.

Soon after these landmark RCTs, many ICUs worldwide adopted tight glycemic control (TGC) as part of their standard of care. Unfortunately, worldwide implementation of some degree of glycemic control impeded the design of a repeat multicenter RCT. Subsequent multicenter RCTs no longer compared TGC to severe hyperglycemia, but to an intermediate glycemic target, in general <180 mg/dL (10 mmol/L). Compared to an intermediate target, these multicenter trials did not find an outcome benefit from targeting normoglycemia and the NICE-SUGAR study even found harm. Therefore... More >

Glycemic Outcomes Three Years After Implementation of a Perioperative Glycemic Control Algorithm in a Academic Institution
Lindsay M. Arnold PharmD, BCPS, Mufaddal Mahesri MD, MPH , Marie E. McDonnell MD;. Sara M. Alexanian MD

While hyperglycemia in the postoperative setting has been linked to an increase in surgical
complications, limited data is available to inform the management of patients with diabetes (DM) in the operating room and the immediate perioperative period. We describe the results of a perioperative glycemic control program that standardized intravenous insulin with a target glucose (BG) range of 120- 180 mg/dL for patients with DM presenting with a BG level > 180mg/dL and included transition to subcutaneous insulin. More >

Trends in Drug Utilization, Glycemic Control, and Rates of Severe Hypoglycemia, 2006-2013
www.ncbi.nlm.nih.gov,  Diabetes Care. 2016 Sep 22. pii: dc160985.

The full text of the article only available with a subscription. More >

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