College of Pharmacy and Health Sciences, Mercer University, Atlanta, GA 30341, USA.
Am J Health Syst Pharm. 2010 May 15;67(10):798-805. doi: 10.2146/ajhp090211.
The current evidence on intensive glycemic control in the inpatient and outpatient settings and its implications to practice are reviewed.
Poor glycemic control in patients with diabetes is associated with microvascular and macrovascular complications. Various clinical trials involving patients with type 1 and type 2 diabetes have revealed the benefits of intensive glycemic control in delaying the onset and progression of microvascular complications of diabetes. However, while long-term epidemiologic trials and a meta-analysis have shown a benefit of intensive glycemic control in reducing the incidence of macrovascular complications, recent clinical trials have not found similar benefits. The American Diabetes Association (ADA), American College of Endocrinology (ACE), and American Association of Clinical Endocrinologists recommend intensive control of glycosylated hemoglobin and plasma glucose at specified goals. Hyperglycemia in the inpatient setting is associated with increased morbidity and mortality. ACE and ADA recommend the use of an i.v. insulin infusion in critically ill inpatients with hyperglycemia. In noncritically ill inpatients, basal and bolus doses of insulin are recommended. The use of sliding-scale insulin as the sole therapy for inpatient hyperglycemia is discouraged. However, caution must be exercised to ensure a balance between controlling hyperglycemia and reducing the risk of hypoglycemia.
While intensive glycemic control is known to prevent or delay the occurrence of microvascular complications of diabetes, macrovascular benefits are still uncertain. Current evidence suggests that intensive glycemic control should be initiated as soon as possible after diagnosis of type 1 or type 2 diabetes in order to maximize potential long-term macrovascular benefits. Inpatient hyperglycemia should be managed appropriately to reduce morbidity and mortality, with great care taken to avoid and appropriately treat hypoglycemia.
综述了住院和门诊环境中强化血糖控制的现有证据及其对实践的影响。
糖尿病患者血糖控制不佳与微血管和大血管并发症有关。涉及 1 型和 2 型糖尿病患者的各种临床试验表明，强化血糖控制可延迟糖尿病微血管并发症的发生和进展。然而，虽然长期的流行病学试验和荟萃分析表明强化血糖控制可降低大血管并发症的发生率，但最近的临床试验并未发现类似的益处。美国糖尿病协会（ADA）、美国内分泌学会（ACE）和美国临床内分泌医师协会建议将糖化血红蛋白和血浆葡萄糖控制在特定目标范围内。住院患者的高血糖与发病率和死亡率增加有关。ACE 和 ADA 建议在患有高血糖的重症住院患者中使用静脉内胰岛素输注。对于非重症住院患者，建议使用基础和推注剂量的胰岛素。不鼓励将静脉滴注胰岛素作为住院高血糖症的唯一治疗方法。然而，必须谨慎行事，以确保在控制高血糖和降低低血糖风险之间取得平衡。
虽然强化血糖控制已知可预防或延迟糖尿病微血管并发症的发生，但大血管的益处仍不确定。目前的证据表明，应在诊断 1 型或 2 型糖尿病后尽快开始强化血糖控制，以最大限度地发挥潜在的长期大血管益处。应适当管理住院患者的高血糖症，以降低发病率和死亡率，同时要特别注意避免和适当治疗低血糖症。
