No. 26 October 2008 

Synthesis of the Evidence on Inpatient 

Hyperglycemia Management Finds Intensive 

Insulin Therapy Does Not Clearly Improve 

Health Outcomes

Hyperglycemia is a common finding in hospitalized patients and has been associated 

with negative outcomes in a variety of inpatient subpopulations. The use of insulin to 

control blood glucose has been advocated as a way to improve health outcomes in 

hospitalized patients with hyperglycemia, but the evidence for the efficacy of this 

approach and the thresholds for initiating insulin management are unclear. 

Recently, investigators at the Portland VA Medical Center conducted a systematic, 

comprehensive review of the literature on inpatient hyperglycemia management 

(published from 1950 to May 2008), and conducted a survey of active research. 

Investigators sought to address three questions: 

1. Does strict blood glucose control, compared to less strict control, improve final 

health outcomes in seven specific inpatient subpopulations? 

2. What, if any, are the negative consequences of strict blood glucose control within 

the given subpopulations? 

3. What are the most effective and safest means of normalizing blood glucose in the 

given subpopulations? 

Overall, investigators found that the literature regarding Question 1 showed very little 

intervention data available to help clearly define a glucose threshold that would prompt 

glucose-lowering efforts in the specified inpatient populations. Further, the benefits of 

achieving normal blood glucose using intensive insulin therapy seen in earlier singlecenter studies have not been confirmed in subsequent studies. Finally, the literature 

indicates that higher glucose targets can likely be relatively safely achieved in 

inpatients, however, the impact of this practice on health outcomes remains uncertain.

With regard to Question 2, there is considerable risk of hypoglycemia in medical ICU 

patients treated with intensive insulin protocols designed to normalize blood glucose. 

Literature addressing Question 3 showed that while a number of infusion protocols have 

been evaluated, comparative effectiveness data are lacking. 

Future research recommendations include: enrolling general medical and surgical ward 

patients in blood glucose management studies; developing studies that examine the 

efficacy of higher glucose targets; and initiating investigations designed to examine the 

safest and most effective ways to adapt insulin management in patients transitioning 

Please feel free to forward 

this information to others! 

Read past HSR&D 

Management e-Briefs on 

the HSR&D website. 

This Management e-Brief is 

provided to inform you 

about recent HSR&D 

findings that may be of 

interest. The views 

expressed in this article 

are those of the authors 

and do not necessarily 

reflect the position or 

policy of the Department 

of Veterans Affairs. If 

you have any questions or 

comments about this Brief, 

please email CIDER at 

CIDER.Boston@va.gov. 

The Center for Information 

Dissemination and 

Education Resources 

(CIDER) is a VA HSR&D 

Resource Center charged 

with disseminating 

important HSR&D findings 

and information to policy 

makers, managers, 

clinicians, and researchers 

working to improve the 

health and care of 

veterans. 
from one level of care to another. 

Conclusions

The authors note that the use of intensive insulin therapy to achieve normal blood 

sugar levels in critically ill patients does not clearly result in health outcome benefits 

and is associated with high rates of hypoglycemia. More moderate blood glucose control 

to targets above the normal range can likely be safely achieved, though the health 

outcome benefit of this practice has not been well studied.

To view the full reports, go to http://www.hsrd.research.va.gov/publications/esp/. 

This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP) established to provide timely 

and accurate syntheses of targeted health care topics of particular importance to VA managers and policymakers 

and to disseminate these reports throughout VA. 

http://vhabhscdr2/eml/email-working-folder/mgmt-e-brief-sept08/eBrief_2008_10.htm (2 of 2) [10/3/2008 9:56:16 AM]