Correspondence

Hyperglycemia in the Hospital Setting

N Engl J Med 2007; 356:753February 15, 2007

Article

To the Editor:

I would like to draw attention to two special situations that were not specifically mentioned in the review of management of hyperglycemia in the hospital setting by Dr. Inzucchi (Nov. 2 issue).1 One is the effect of renal insufficiency on determination of the starting dose of insulin. Since insulin clearance is decreased in patients with renal insufficiency, reducing the starting dose of insulin is essential to avoid hypoglycemia. The second situation is the case of patients who are receiving glucocorticoids. Through increasing insulin resistance, glucocorticoids cause hyperglycemia mainly in the postprandial state. Therefore, these patients frequently require higher prandial doses of insulin than basal doses; the rule of a 1:1 ratio between basal and bolus insulin doses frequently does not apply.

Fadi A. Nabhan, M.D.
Loyola University Medical Center, Maywood, IL 60153
fnabhan@lumc.edu

1 References

1. 1

   Inzucchi SE. Management of hyperglycemia in the hospital setting. N Engl J Med 2006;355:1903-1911
   Full Text | Web of Science | Medline

Author/Editor Response

Dr. Nabhan raises two important points. Patients with acute and chronic kidney diseases undergo several metabolic alterations that predispose them to hypoglycemia. In addition to altered insulin clearance, patients with azotemia frequently have anorexia, and the contribution of the kidney as a gluconeogenetic organ is often underrated. Accordingly, such patients are at high risk for hypoglycemia in the hospital, and insulin should be administered cautiously. It is well known that hyperglycemia frequently develops in patients receiving glucocorticoids, even in the absence of a history of diabetes. My colleagues and I have reported that the use of glucocorticoids in the intensive care unit increases the risk of hyperglycemia by a factor of more than five in both diabetic and nondiabetic patients.1 Dr. Nabhan's point regarding postprandial glucose is an excellent one. Indeed, the fasting glucose level is often not substantially affected, especially in patients receiving glucocorticoids once daily in the morning. Therefore, appropriate attention must be paid to sufficient insulin doses at mealtimes, which may indeed exceed the dose of basal insulin required. Other risk factors for hyperglycemia in hospitalized patients include hyperalimentation, continuous tube feeding, and pressor therapy.1

Silvio E. Inzucchi, M.D.
Yale University School of Medicine, New Haven, CT 06520-8020
silvio.inzucchi@yale.edu

1 References

1. 1

   Inzucchi SE, Goldberg PA, Dziura JD, et al. Risk factors for poor glycemic control in a medical intensive care unit. Diabetes 2003;52:Suppl 2:A96-A96
   Web of Science

Citing Articles (2)

Citing Articles

1. 1

   František Duška, Michal Anděl. (2008) Intensive blood glucose control in acute and prolonged critical illness: endogenous secretion contributes more to plasma insulin than exogenous insulin infusion. Metabolism 57:5, 669-671
   CrossRef

2. 2

   Subbulaxmi Trikudanathan, Graham T McMahon. (2008) Optimum management of glucocorticoid-treated patients. Nature Clinical Practice Endocrinology & Metabolism 4:5, 262-271
   CrossRef