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Three Part Question

Should [asymptomatic adults with mild to moderate uncomplicated hyperglycemia] be treated in the emergency department with [insulin replacement therapy in addition to supportive therapy] to achieve [normalization in glucose level]?

Clinical Scenario

A 40-year-old male with a history of hypertension and tobacco abuse presents to the emergency department (ED) complaining of chest pain. Workup is completed including a metabolic profile which is remarkable for a blood glucose of 294. He has no history of diabetes or hyperglycemia. The remainder of the workup reveals no abnormalities and undetectable troponin. The patient’s pain resolves after a dose of antacid in the ED. As you prepare discharge instructions, you wonder if you need to correct his hyperglycemia prior to sending him home.

Search Strategy

Medline 1966-05/20 using PubMed, Cochrane Library (2020), and Embase

[(exp hyperglycemia/therapy OR exp glycemic control OR exp insulin/therapy) AND (exp emergency service, hospital)]

Search Outcome

26 studies were identified: three studies addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Driver BE, et al Dec 2016 United States	422 patients presenting to the ED with glucose greater than 400 mg/dl and subsequently discharged	Retrospective Cohort Study	7-day outcomes of repeat ED visit for hyperglycemia or hospitalization for any reason and occurrence of DKA or HHS	Discharge glucose was not associated with 7-day adverse outcome	Retrospective; treatment not standardized; outcome assessors were not blinded to study outcomes
Driver BE, et al July 2019 United States	110 patients with hyperglycemia randomly assigned to a discharge glucose goal, less than 350 mg/dL (moderate control) or less than 600 mg/dL (loose control).	RCT	ED length of stay with secondary outcomes of repeat ED visit for hyperglycemia, hospitalization for hyperglycemia, and hospitalization for any reason	No significant difference in ED length of stay or secondary outcomes between loose and moderate glucose goals	Small sample size, length of stay as primary outcome subject to many confounders; significant loss to follow up
Johnson-Clauge M, et al May-Jun 2016 United States	161 patients with a history of diabetes and a blood glucose of greater than 200 mg/dl treated with subcutaneous insulin therapy	Retrospective Cohort Study	Hospital length of stay in patients receiving correction to end glucose of less than 200 mg/dl vs greater than 200 mg/dl.	No significant difference between hospital length of stay when comparing full and partial glycemic correction groups	Retrospective; small sample size; all patients received insulin therapy

Comment(s)

Asymptomatic hyperglycemia is frequently identified in the emergency department in patients with and without a history of diabetes, either as a chief complaint or incidentally during other laboratory investigations. Despite this, this there is no consensus as to optimal management. There has been research conducted on this topic in order to develop an evidence-based approach; however, the current research is limited by a scarcity of studies, the lack of a clear definition of moderate hyperglycemia, small sample sizes, and short follow up periods. In order to better establish evidence-based guidelines for the ED treatment of asymptomatic hyperglycemia, future research should establish a clear cutoff for moderate hyperglycemia, include a larger participant groups, and follow up at longer intervals to identify delayed sequalae of different management strategies.

Clinical Bottom Line

In adult patients with asymptomatic hyperglycemia, treatment with insulin therapy to achieve a specific glucose level prior to discharge does not decrease the risk of adverse events in short term follow up. These findings suggest that achieving specific glucose levels before sending patients home may not provide as much benefit as optimizing the patient’s outpatient glycemic control.

References

1. Driver BE, Olives TD, Bischof JE, Salmen MR, Miner JR. Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia Ann Emerg Med. 2016 Dec;68(6):697-705
2. Driver BE, Klein LR, Cole JB, Prekker ME, Fagerstrom ET, Miner JR. Comparison of two glycemic discharge goals in ED patients with hyperglycemia, a randomized trial Am J Emerg Med. 2019 Jul;37(7):1295-1300
3. Johnson-Clague M1, DiLeo J, Katz MD, Patanwala AE Effect of Full Correction Versus Partial Correction of Elevated Blood Glucose in the Emergency Department on Hospital Length of Stay Am J Ther 2016 May-Jun;23(3):e805-9