Tight Glycemic Control-A Review

Multiple recent studies have started to validate an extension of the philosophy of the Diabetes Control and Complications Trial in terms of the need for tight glycemic control from the diabetic population to the acute inpatient diabetic and nondiabetic population. The studies have been based on patients in acute care situations such as intensive care (surgical and medical), intraoperative, and post-myocardial infarction. The overall conclusion of all studies has been a reduction in morbidity and/or mortality in patients when glucose levels were controlled to some degree. The pathophysiology of hyperglycemic impairment is thought to be linked to glycemic toxicity at the cellular level secondary to derangements in normal protein structure and function. However, the actual biochemical link of increased morbidity and mortality to hyperglycemia has not yet been ascertained. The studies disagree on several major points; namely, what is the best glycemic threshold, what role does insulin play (harmful or helpful), and is there a connection between hyperglycemia and morbidity/mortality or is it an epiphenomenon. Despite the disagreements, intensive glycemic control is good medical "common sense" based on the wealth of knowledge already associated with diabetes and diabetic complications. Additional studies are pending, and more will follow that will further define how best to tightly control glycemic levels.