Hyperglycemic Crises in Adult Patients With Diabetes

Kitabchi, Abbas E.; Umpiérrez, Guillermo E.; Murphy, Mary Beth; Kreisberg, Robert A.

doi:10.2337/dc06-9916

Cited by 446 publications

(302 citation statements)

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“…Further inclusion criteria included diabetes treatment with either diet alone or any combination of oral antidiabetic agents and the absence of diabetic ketoacidosis (18). Exclusion criteria included subjects without a known history of diabetes, intensive care unit patients, the use of corticosteroid therapy, subjects expected to undergo surgery during the hospitalization course, patients with clinically relevant hepatic disease, serum creatinine Ն3.0 mg/dl, pregnancy, and any mental condition rendering the subject unable to understand the scope and possible consequences of the study.…”

Section: Research Design and Methods -In This Multicentermentioning

confidence: 99%

Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT 2 Trial)

et al. 2007

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OBJECTIVE -We sought to study the optimal management of hyperglycemia in nonintensive care unit patients with type 2 diabetes, as few studies thus far have focused on the subject.RESEARCH DESIGN AND METHODS -We conducted a prospective, multicenter, randomized trial to compare the efficacy and safety of a basal-bolus insulin regimen with that of sliding-scale regular insulin (SSI) in patients with type 2 diabetes. A total of 130 insulin-naive patients were randomized to receive glargine and glulisine (n ϭ 65) or a standard SSI protocol (n ϭ 65). Glargine was given once daily and glulisine before meals at a starting dose of 0.4 units ⅐ kg Ϫ1 ⅐ day Ϫ1 for blood glucose 140 -200 mg/dl or 0.5 units ⅐ kg Ϫ1 ⅐ day Ϫ1 for blood glucose 201-400 mg/dl. SSI was given four times per day for blood glucose Ͼ140 mg/dl. RESULTS -The mean admission blood glucose was 229 Ϯ 6 mg/dl and A1C 8.8 Ϯ 2%. A blood glucose target of Ͻ140 mg/dl was achieved in 66% of patients in the glargine and glulisine group and in 38% of those in the SSI group. The mean daily blood glucose between groups ranged from 23 to 58 mg/dl, with an overall blood glucose difference of 27 mg/dl (P Ͻ 0.01). Despite increasing insulin doses, 14% of patients treated with SSI remained with blood glucose Ͼ240 mg/dl. There were no differences in the rate of hypoglycemia or length of hospital stay.CONCLUSIONS -Treatment with insulin glargine and glulisine resulted in significant improvement in glycemic control compared with that achieved with the use of SSI alone. Our study indicates that a basal-bolus insulin regimen is preferred over SSI in the management of non-critically ill, hospitalized patients with type 2 diabetes. Diabetes Care 30:2181-2186, 2007H yperglycemia in hospitalized patients is a common, serious, and costly health care problem with profound medical consequences. Increasing evidence indicates that the development of hyperglycemia during acute medical or surgical illness is not a physiologic or benign condition but is a marker of poor clinical outcome and mortality (1-3). Extensive evidence from observational studies, including our own, indicates that in hospitalized patients with critical illness, hyperglycemia is associated with an increased risk of complications and mortality (3-9). Prospective randomized trials in critically ill patients have shown that intensive glucose control reduces the risk of multiorgan failure, systemic infections, and short-and longterm mortality. Effective management of hyperglycemia is also associated with a decreased length of intensive care unit and hospital stay (4,6,8 -10) and decreased total hospitalization cost (11). The importance of glycemic control on outcome is not limited to patients in critical care areas but also applies to patients admitted to general surgical and medical wards. In such patients, the presence of hyperglycemia has been associated with prolonged hospital stay, infection, disability after hospital discharge, and death (1,5,12). In general surgery patients, the relative risk for serious postopera...

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Section: Research Design and Methods -In This Multicentermentioning

confidence: 99%

Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT 2 Trial)

et al. 2007

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“…These have already led to the re-emergence of the use of fixedrate intravenous insulin infusions in adults in the USA and international paediatric practice [8,11,12]. It is, however, recognized that the fixed rate may need to be increased in insulin-resistant states if metabolic targets are not being met.…”

Section: Insulin Therapy and Metabolic Treatment Targetsmentioning

confidence: 99%

“…There are several existing national and international guidelines for the management of diabetic ketoacidosis in both adults and children [8][9][10][11][12]. The Joint British Diabetes Societies guidelines take into account developments in technology and changes in the presentation of diabetic ketoacidosis over the last few years.…”

Section: Introductionmentioning

confidence: 99%

Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis

Savage

Dhatariya²,

Kilvert³

et al. 2011

Diabetic Medicine

281

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The Joint British Diabetes Societies guidelines for the management of diabetic ketoacidosis (these do not cover Hyperosmolar Hyperglycaemic Syndrome) are available in full at: This article summarizes the main changes from previous guidelines and discusses the rationale for the new recommendations. The key points are: Monitoring of the response to treatment (i) The method of choice for monitoring the response to treatment is bedside measurement of capillary blood ketones using a ketone meter.(ii) If blood ketone measurement is not available, venous pH and bicarbonate should be used in conjunction with bedside blood glucose monitoring to assess treatment response.(iii) Venous blood should be used rather than arterial (unless respiratory problems dictate otherwise) in blood gas analysers.(iv) Intermittent laboratory confirmation of pH, bicarbonate and electrolytes only.Insulin administration (i) Insulin should be infused intravenously at a weight-based fixed rate until the ketosis has resolved.(ii) When the blood glucose falls below 14 mmol ⁄ l, 10% glucose should be added to allow the fixed-rate insulin to be continued.(iii) If already taking, long-acting insulin analogues such as insulin glargine (Lantus Ò

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“…A lthough positive therapeutic responses to low-dose insulin therapy have been established in adult patients with diabetic ketoacidosis (DKA) (1)(2)(3)(4)(5)(6)(7)(8), none of these studies and guidelines for the treatment of DKA, including the American Diabetes Association (ADA) Consensus and Position Statements, has ever assessed or addressed the use of a continuous insulin infusion without a loading dose of insulin (9). In the current study, we used a dose of 0.14 unit ⅐ kg Ϫ1 ⅐ h Ϫ1 without a loading dose instead of the recommended 0.1 unit ⅐ kg Ϫ1 ⅐ h Ϫ1 with a loading dose.…”

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Is a Priming Dose of Insulin Necessary in a Low-Dose Insulin Protocol for the Treatment of Diabetic Ketoacidosis?

et al. 2008

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OBJECTIVE—The purpose of this study was to assess the efficacy of an insulin priming dose with a continuous insulin infusion versus two continuous infusions without a priming dose. RESEARCH DESIGN AND METHODS—This prospective randomized protocol used three insulin therapy methods: 1) load group using a priming dose of 0.07 units of regular insulin per kg body weight followed by a dose of 0.07 unit · kg−1 · h−1 i.v. in 12 patients with diabetic ketoacidosis (DKA); 2) no load group using an infusion of regular insulin of 0.07 unit · kg body weight−1 · h−1 without a loading dose in 12 patients with DKA, and 3) twice no load group using an infusion of regular insulin of 0.14 · kg−1 · h−1 without a loading dose in 13 patients with DKA. Outcome was based on the effects of insulin therapy on biochemical and hormonal changes during treatment and recovery of DKA. RESULTS—The load group reached a peak in free insulin value (460 μU/ml) within 5 min and plateaued at 88 μU/ml in 60 min. The twice no load group reached a peak (200 μU/ml) at 45 min. The no load group reached a peak (60 μU/ml) in 60–120 min. Five patients in the no load group required supplemental insulin doses to decrease initial glucose levels by 10%; patients in the twice no load and load groups did not. Except for these differences, times to reach glucose ≤250 mg/dl, pH ≥7.3, and HCO3− ≥15 mEq/l did not differ significantly among the three groups. CONCLUSIONS—A priming dose in low-dose insulin therapy in patients with DKA is unnecessary if an adequate dose of regular insulin of 0.14 unit · kg body weight−1 · h−1 (about 10 units/h in a 70-kg patient) is given.

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Hyperglycemic Crises in Adult Patients With Diabetes

Cited by 446 publications

References 80 publications

Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT 2 Trial)

Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT 2 Trial)

Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis

Is a Priming Dose of Insulin Necessary in a Low-Dose Insulin Protocol for the Treatment of Diabetic Ketoacidosis?

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