Conditions: Hyperglycemia
Keywords: stress hyperglycemia blood glucose
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 80
Healthy volunteers: no

Brief summary:
The purpose of this study is to compare sitagliptin with a placebo for the prevention of high glucose after general surgery.

Detailed description:
Approximately 30-40% of hospitalized patients will develop stress hyperglycemia (high glucose in response to surgery or illness). High glucose is linked to an increased risk of hospital complications including wound infection, kidney failure and death. Patients with high glucose are treated with insulin given through an arm vein or by frequent insulin injections under the skin. Recent studies have found that inpatient therapy with oral dipeptidyl peptidase-4 inhibitor (DPP4-I) is an effective alternative to insulin in improving glycemic control with low risk of hypoglycemia in general medicine and surgical patients.

Sitagliptin is an oral medication approved by the Food and Drug Administration (FDA) to treat patients with diabetes. The aim of this study is to determine whether treatment with sitagliptin once daily can prevent the development of stress hyperglycemia during the postoperative period in non-diabetic patients undergoing general surgery.

Arms:
arm 1: Participants will receive sitagliptin beginning the day prior to surgery and continuing daily during hospitalization (up to 10 days post-surgery).

Point of care (POC) testing will be done four times daily, before meals and at bedtime, or every 6 hours for patients who are not eating (NPO). Patients developing hyperglycemia during or after surgery will be treated with insulin per standard of care.

Patients with fasting and/or premeal blood glucose levels \>180 mg/dl will receive supplemental insulin provided on a sliding scale. Patients with two consecutive fasting and/or premeal blood glucose levels \>180 mg/dl, or with average daily blood glucose levels \>180 mg/dl will be started on rescue therapy with subcutaneous insulin once daily plus correction doses by a sliding scale. arm 2: Participants will receive a placebo tablet beginning the day prior to surgery and continuing daily during hospitalization (up to 10 days post-surgery).

Point of care (POC) testing will be done four times daily, before meals and at bedtime, or every 6 hours for patients who are not eating (NPO). Patients developing hyperglycemia during or after surgery will be treated with insulin per standard of care.

Patients with fasting and/or premeal blood glucose levels \>180 mg/dl will receive supplemental insulin provided on a sliding scale. Patients with two consecutive fasting and/or premeal blood glucose levels \>180 mg/dl, or with average daily blood glucose levels \>180 mg/dl will be started on rescue therapy with subcutaneous insulin once daily plus correction doses by a sliding scale.

Interventions: intervention 1: Sitagliptin intervention 2: Placebo intervention 3: Supplemental insulin (insulin lispro) intervention 4: Supplemental insulin (insulin aspart) intervention 5: Long acting basal insulin (insulin detemir) intervention 6: Long acting basal insulin (insulin glargine)
Intervention descriptions: intervention 1: Participants will take 100 mg/day for patients with glomerular filtration rate (GFR) \> 50 and 50 mg/day for GFR 30 - 49, beginning on the day prior to surgery and continuing through hospitalization, up to 10 days. intervention 2: Participants will take one pill daily beginning on the day prior to surgery and continuing through hospitalization, up to 10 days. intervention 3: Supplemental insulin lispro will be administered before meals, in addition to scheduled insulin dose, following the supplemental insulin scale protocol. At bedtime, half of supplemental sliding scale insulin starting at blood glucose (BG) \>240 mg/dL will be given. If a patient is unable to eat, supplemental insulin will be administered every 6 hours with the lowest number of units for that appropriate BG level.

For subjects receiving supplemental insulin lispro with BG levels greater than 180 mg/dL, the supplemental insulin scale is as follows:

* BG between 181-220 mg/dL; 2-4 units of insulin lispro
* BG between 221-260 mg/dL; 3-5 units of insulin lispro
* BG between 261-300 mg/dL; 4-6 units of insulin lispro
* BG between 301-350 mg/dL; 5-7 units of insulin lispro
* BG between 351-400 mg/dL; 6-8 units of insulin lispro
* BG \> 400 mg/dL; 7-9 units of insulin lispro intervention 4: Supplemental insulin aspart will be administered before meals, in addition to scheduled insulin dose, following the supplemental insulin scale protocol. At bedtime, half of supplemental sliding scale insulin starting at blood glucose (BG) \>240 mg/dL will be given. If a patient is unable to eat, supplemental insulin will be administered every 6 hours with the lowest number of units for that appropriate BG level.

For subjects receiving supplemental insulin aspart with BG levels greater than 180 mg/dL, the supplemental insulin scale is as follows:

* BG between 181-220 mg/dL; 2-4 units of insulin lispro
* BG between 221-260 mg/dL; 3-5 units of insulin lispro
* BG between 261-300 mg/dL; 4-6 units of insulin lispro
* BG between 301-350 mg/dL; 5-7 units of insulin lispro
* BG between 351-400 mg/dL; 6-8 units of insulin lispro
* BG \> 400 mg/dL; 7-9 units of insulin lispro intervention 5: Long acting basal insulin therapy will be provided as needed, and will be given once daily, at the same time of day. Participants with blood glucose (BG) \>180 mg/dL= start detemir at 0.2 units per kg weight per day and will follow the following adjustment schedule:

* Fasting and pre-meal BG between 100-180 mg/dl without hypoglycemia the previous day: no change
* Fasting and pre-meal BG between \>180-240 mg/dl: increase detemir or glargine dose by 10% every day
* Fasting and pre-meal BG \>241 mg/dl: increase detemir or glargine dose by 20% every day
* Fasting and pre-meal BG \<100 mg/dl: reduce detemir or glargine by 20% or stop if patient is already on less than 0.1 units/kg of body weight intervention 6: Long acting basal insulin therapy will be provided as needed, and will be given once daily, at the same time of day. Participants with blood glucose (BG) \>180 mg/dL= start detemir at 0.2 units per kg weight per day and will follow the following adjustment schedule:

* Fasting and pre-meal BG between 100-180 mg/dl without hypoglycemia the previous day: no change
* Fasting and pre-meal BG between \>180-240 mg/dl: increase detemir or glargine dose by 10% every day
* Fasting and pre-meal BG \>241 mg/dl: increase detemir or glargine dose by 20% every day
* Fasting and pre-meal BG \<100 mg/dl: reduce detemir or glargine by 20% or stop if patient is already on less than 0.1 units/kg of body weight

Protocol document:
Prot_SAP_000.pdf: 
 
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Title: Prevention of stress hyperglycemia with the use of DPP-4 inhibitors in non-diabetic patients 
undergoing non-cardiac surgery, a Pilot Study (SITA-SURGERY PILOT TRIAL). 
 
Principal Investigator:    
Maya Fayfman, M.D.  
Instructor of Medicine 
                                     
Department of Medicine/Endocrinology 
                                     
Emory University School of Medicine 
 
Co-Investigators: 
 
Department of Medicine: 
Guillermo Umpierrez, MD, Priyathama Vellanki, MD, David Reyes, MD, Georgia Davis, MD, Saumeth 
Cardona, David Chachkhiani, Clementina Ramos Garrido, David Alfa, and Maria Urrutia  
 
Department of Surgery: 
Sheryl Gabram-Mendola and MD, Mara Schenker, MD 
 
Department of Anesthesiology  
Elizabeth Duggan, MD, Jay Sanford MD and Joanna Schindler MD 
 
School of Public Health 
Limin Peng, PhD 
 
Investigator-Sponsor: Guillermo Umpierrez, MD. Division of Endocrinology, Department of Medicine 
 
ABSTRACT 
    
Approximately 51.4 million surgical procedures are performed in the United States each year.1 Over 40% of 
patients both with and without diabetes (DM) develop stress hyperglycemia (defined as a BG >140 mg/dl) after 
general surgery.2,3 Compared to patients without DM, those with DM have higher rates of complications that 
include wound infections,4,5 acute renal failure,6 longer hospital stay,7,8 and perioperative mortality.8,9 However, 
non-DM patients with stress hyperglycemia have poor surgical outcome after cardiac surgery with even higher 
rates of complications and mortality compared to those with DM.10,11 Few observational studies looking at non-
cardiac patients have found that stress hyperglycemia is associated with higher rates of complications including 
mortality and length of stay compared to either normoglycemia12 or known DM.2,13 Although there is no 
consensus on optimal glycemic targets, there is strong agreement that improvement in glycemic control reduces 
complications and inpatient mortality,14-16 with better apparent response in subjects with stress hyperglycemia 
compared to those with known DM.17 In the GLUCO-CABG trial,18 we reported no differences in a composite of 
complications between intensive and conservative insulin regimens in patients with DM; however, we observed 
a significant reduction in hospital complications in patients with stress hyperglycemia treated with intensive 
glucose control (see preliminary results). These data clearly indicate that stress hyperglycemia is an independent 
risk factor of morbidity and mortality in cardiac and general surgery.4,7,19-21  
 
Our group recently reported that inpatient therapy with oral dipeptidyl peptidase-4 inhibitor (DPP4-I) is an 
effective alternative to insulin in improving glycemic control with low risk of hypoglycemia in general medicine 
and surgical patients.22 In addition, our preliminary studies indicate that sitagliptin is effective in preventing the 
need for subcutaneous insulin therapy during the transition period from the ICU to regular floors in patients with 
stress hyperglycemia (see preliminary data). To our knowledge, no prospective studies have determined best 
treatment to prevent and/or treat stress hyperglycemia among non-DM patients undergoing non-cardiac surgery. 
Therefore, this proposal will address the following 3 important clinical questions: 1) can stress hyperglycemia be 
safely prevented with the use of a DPP4-inhibitor, a commonly used drug for the treatment of patients with type 
2 diabetes with no increased risk of hypoglycemia?, 2) Can treatment with a DPP4-inhibitor reduce the need for 


 
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insulin therapy and reduce risk of hypoglycemia?, and 3) does prevention of stress hyperglycemia reduce 
perioperative complications during the perioperative period?. 
 
SPECIFIC AIM 
To determine whether treatment with sitagliptin once daily can prevent the development of stress 
hyperglycemia during the postoperative period in non-diabetic patients undergoing general surgery. 
Hypothesis: We hypothesize that sitagliptin, an oral DPP4-inhibitor, will prevent the development of 
perioperative hyperglycemia and its complications in non-diabetic patients undergoing non-cardiac surgery.  
 
BACKGROUND REVIEW 
Stress hyperglycemia in the hospital.  Stress hyperglycemia is reported in over 30-40% of medicine and surgery 
patients in the hospital,2,23,24 and in up to 80% after cardiac procedures.3,6,25 Large cohort studies have identified 
hyperglycemia and DM as independent risk factors of poor outcome after surgery compared to patients with 
normoglycemia, specifically higher perioperative mortality,8,9 deep sternal wound infections,4,5 renal failure,6 
postoperative strokes,7,26 longer hospital stays,7,8 and higher health care resource utilization.27-29 In patients 
undergoing non-cardiac (general) surgery, diabetes as well as hyperglycemia in non-DM patients are associated 
with up to 4-fold increase in complications and over a 2-fold increase in death compared to patients with 
normoglycemia.12,30,31 Solid evidence indicates that stress hyperglycemia in non-DM patients is associated with 
worse clinical outcome compared to patients with a known history of DM.2,10,11,13,32-34 The severity of 
hyperglycemia positively correlates with the rates of complications among non-DM patients but not in those with 
DM.30 The risk of post-operative infections increase incrementally with worsening hyperglycemia, independent 
of DM status.35 Despite the relationship between stress hyperglycemia in non-DM patients and poor outcomes, 
few non-DM patients with stress hyperglycemia are treated with either oral agents or insulin.13 
 
Glycemic control in surgery and critically ill patients. The results of several clinical trials in critically ill and 
surgery patients indicate that improvement of glycemic control reduces LOS, risk of multi-organ failure and 
systemic infections,5,14,36 as well as mortality in patients with stress hyperglycemia and diabetes.14,37 The Portland 
Diabetic Project, a prospective, non-randomized study of diabetic patients who underwent CABG5 reported that 
the use of continuous insulin infusion (CII) to achieve a BG target between 150-200 mg/dl compared with SQ 
regular insulin resulted in a lower mortality rate (2.5% vs. 5.3%) and reduced rate of deep sternal wound infection 
by 66%.38 In the GLUCO-CABG trial (see preliminary results) we found no differences in a composite of 
complications between intensive and conservative regimens in patients with DM; however, we observed a 
reduction in hospital complications in patients with stress hyperglycemia treated with intensive glucose control.18 
Similarly, a subgroup analysis by Van den Berghe et al39 of surgical and medical ICU patients reported that while 
glucose lowering effectively reduced mortality in those without a previous history of diabetes, no significant 
benefit from treatment was observed in patients with diabetes. The Surgical Care and Outcomes Assessment 
Program performed a retrospective review if 11,633 patients with and without DM undergoing surgery and found 
that glycemic control with insulin treatment reduced the rates of complications.31,40  
 
Stress hyperglycemia: mechanisms and consequences. The ADA/AACE and Endocrine Society guidelines on 
inpatient hyperglycemia defined stress hyperglycemia or hospital-related hyperglycemia as any BG concentration 
>140-180 mg/dl without evidence of previous diabetes. In most patients stress hyperglycemia resolves as the 
acute illness or surgical stress abates; however ~30% to 60% of patients have impaired carbohydrate intolerance41 
or unrecognized diabetes.42 Stress hyperglycemia results from the acute metabolic and hormonal changes 
associated with the response to injury and stress.43,44 Acute illness, surgery, and trauma raise levels of 
counterregulatory hormones such as glucagon, epinephrine, cortisol, and growth hormone. This, in turn, results 
in a number of alterations in carbohydrate metabolism, including insulin resistance, increased hepatic glucose 
production, impaired peripheral glucose utilization, and relative insulin deficiency.45,46 The development of 
hyperglycemia leads to generation of reaction oxygen species (ROS), lipid peroxidation, and elevated 
inflammatory markers. It also increased pro-inflammatory cytokine such as tumor necrosis factor-alpha (TNF-α), 
interleukin (IL)-6, and IL-1, which ultimately alter the immune system, 43,47-49 as well as altered hemostasis, 


 
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increased platelet activation, adhesion and aggregation,
50 reduced plasma fibrinolytic activity and increased 
plasminogen activator inhibitor-1 (PAI-1) activity.51   
 
Hospital Use of DPP-4 Inhibitors. We recently completed two randomized trials determined the safety and 
efficacy of treatment with sitagliptin alone or in combination with basal insulin in general medicine and surgery 
patients with T2D (see preliminary results).22 In the first study, we demonstrated that the use of sitagliptin alone 
or in combination with basal insulin was well tolerated and resulted in no significant differences in daily BG, 
frequency of hypoglycemia or in the number of treatment failures compared to basal bolus regimen. DPP4 therapy 
is associated with low-risk of hypoglycemia, and these agents are ideal for the management of hyperglycemia and 
diabetes in the hospital setting.  In a larger prospective, four-center randomized study in 280 patients we found 
that the use of sitagliptin plus a single dose of basal insulin (glargine) resulted in similar improvement in glucose 
control and complications, but in significant less insulin dosage and less number of injections compared to basal 
bolus regimen. These studies indicate that the use of sitagliptin is well tolerated and effective in maintaining good 
metabolic control avoiding or reducing insulin doses with low levels of hypoglycemia.  
 
 
Significance and Innovation.   
Approximately 30-40% of hospitalized patients will develop stress hyperglycemia.2,23,24 Numerous studies have 
found that diabetes and hyperglycemia in non-DM patients are associated higher rates of complications and 
mortality.12,30,31 There is increasing evidence indicates that stress hyperglycemia in non-DM patients is associated 
with worse clinical outcome compared to patients with a known history of DM.2,10,11,13,32-34 Clinical guidelines 
recommend treating patients with hyperglycemia in the hospital with subcutaneous insulin protocols used in 
patients with DM,52 but this can be labor intensive and costly. Furthermore, it is a retroactive approach and does 
not target prevention of hyperglycemia and the associated with increased risk of hypoglycemia. Our preliminary 
studies have shown that treatment with DPP4-inhibitors represent an alternative treatment to insulin therapy in 
improving glycemic control with low risk of hypoglycemia in a general inpatient population
22 and in preventing 
the need for subcutaneous insulin therapy after stopping CII in cardiac surgery patients with stress hyperglycemia. 
This proposal is an extension of previous work and will test whether 1) can stress hyperglycemia can be prevented 
or ameliorated with DPP4-inhibitors, and 2) can DPP4-inhibitors therapy, by preventing stress hyperglycemia 
lead to reduction in perioperative complications.  
 
 
Preliminary Results  
Our research team has extensive clinical and research experience in inpatient management of hyperglycemia and 
has published several RCTs in medical/surgery patients in ICU and non-ICU settings.13,18,22,53-56  
 
RABBIT 2 Surgery Trial. This multicenter RCT compared the efficacy 
and safety of a basal/bolus regimen to sliding scale insulin (SSI) in non-
ICU patients undergoing general surgery. Study outcomes included 
differences in daily BG levels and a composite of hospital complications 
including postoperative wound infection, pneumonia, respiratory failure, 
acute renal failure, and bacteremia. A total of 211 patients were 
randomized to glargine once daily + glulisine before meals or to SSI 
given 4 times/day. The mean daily glucose concentration after the 1st day 
of basal bolus and SSI was 145±32 mg/dl and 172±47 mg/dl, 
respectively, p<0.01. There were reductions with basal bolus as 
compared with SSI in the composite outcome (24.3% and 8.6%, OR: 3.39 (95% CI: 1.50-7.65); p=0.003).  SSI 
had higher number of wound infection (2.9% vs. 10.3%), pneumonia (0% vs. 2.8%), and acute renal failure (3.8% 
vs. 10.3%) than basal bolus regimen.  In addition, SSI treatment had higher number of post-surgery ICU 
admissions (12.5% vs. 19.6%, p=0.159) and ICU length of stay (1.2±0.6 vs. 3.2±2 days, p=0.003). 
 
 We concluded 
that treatment with basal bolus improved glycemic control and reduced hospital complications compared to SSI 
in surgery patients with T2DM.  
P=0.003 
P=NS 
P=0.05 
P=0.10 
P=0.24
 
Glargine+Glulisine 
Sliding Scale Insulin 
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011 
* Composite of hospital complications: wound infection, pneumonia, respiratory 
failure, acute renal failure, and bacteremia. 


 
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Sitagliptin Inpatient Pilot Study.22   In a two-center open label randomized pilot trial we recently determined 
differences in glycemic control between sitagliptin alone or in combination with basal insulin and basal bolus 
regimen in medicine and surgery patients with T2D.  In this study, 90 patients with a BG between 140-400 
mg/dl treated with diet, OAD or low-dose insulin (≤ 0.4 U/kg/day) were randomized to sitagliptin once daily 
(n=30), sitagliptin and basal insulin (n=30) or to a basal bolus (n=30) 
regimen. Patients in the sitagliptin group received a daily dose of 
100 mg or 50 mg as per renal function. Those in the sitagliptin plus 
glargine received sitagliptin and glargine starting at 0.25 U/kg once 
daily. Patients in the basal bolus group were started at 0.5 U/kg, 
given half as glargine once daily and half as lispro before meals.  All 
groups received correction doses of lispro before meals and bedtime 
for BG >140 mg/dl.  We found that treatment with sitagliptin alone 
or in combination with glargine resulted in similar glycemic control 
compared to basal bolus regimen (Figure 2). There were no differences in mean daily BG, number of BG 
readings within target, hypoglycemia, frequency of treatment failures, hospital LOS or complications.  In 
addition, treatment with sitagliptin had less daily insulin requirements and lower number of insulin injections, 
both, p<0.001. The study shows that use of a DPP4 inhibitor is a safe and effective for treatment of inpatient 
hyperglycemia. 
 
We recently completed a second large, multi-center, prospective, open-label, randomized clinical trial to 
determine the safety and efficacy of sitagliptin plus basal insulin for the management of general medicine and 
surgery patients with T2D. 280 patients with T2D were included 
with (BG) ranging between 140-400 mg/dl. They were randomized 
to receive sitagliptin plus glargine once daily (SITA-GLA) or a 
basal bolus insulin regimen with daily glargine and rapid-acting 
insulin before meals (BB). There were no differences between 
treatment groups in the mean daily BG (170±49 vs. 169±48 mg/dl, 
p=0.96) (Figure 3), percentage of BG readings within target range 
of 70-180 mg/dl (57% vs. 60%, p=0.58), or in the number of 
patients with hypoglycemia (BG <70 mg/dl, 9% vs. 12%, p=0.45). 
None of the patients developed severe hypoglycemia. The number 
treatment failures (defined as more than 2 consecutive BG >240 
mg/dl or a mean daily BG >240 mg/dl) were similar between SITA-GLA and BB groups (16% vs. 19%, p=0.54), 
as were the number of hospital complications of acute kidney injury, wound infection, stroke, acute myocardial 
infarction, respiratory failure, reoperation, or pneumonia (9% vs. 7%, p=0.52). There were also no differences in 
length of stay [median (IQR): 4 (3-8) vs. 4 (3-8) days, p=0.54]. The total daily insulin dose was significantly 
lower in the SITA-GLA group (0.23±0.14 vs. 0.33±0.16 U/kg) as were the number of daily insulin injections 
(2.2±1.0 vs. 2.9±0.9), both p<0.001.  
 
GLUCO-CABG TRIAL18 
This randomized controlled trial aimed to determine whether 
intensive BG control (intensive, target: 100-140 mg/dl) reduces 
perioperative complications compared to conservative BG 
control (conservative, 141-180 mg/dl) in hyperglycemic patients 
undergoing CABG. After ICU care, subjects were transitioned to 
a single treatment regimen targeting a BG<140 mg/dl before 
meals during the hospital stay and 90 days post discharge. The 
primary outcome was differences in a composite score of 
complications including mortality, wound infection, pneumonia, 
bacteremia, respiratory failure, acute renal failure, and major cardiovascular events. A total of 302 patients were 
randomized to intensive (n=151) or conservative (n=151) glucose control following a computerized insulin 
Intensive (BG 100-140 mg/dl) 
Conservative (BG 100-140 mg/dl) 
Figure 2: Mean Daily BG during Treatment
Rand
1
2
3
4
5
6
7
8
9
10
80
120
160
200
240
Blood glucose (m g/dL)
Sitagliptin + Basal
Basal Bolus
Duration of treatm ent (days)
 
Figure 3: Mean Daily BG during Treatment 


 
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infusion algorithm. The mean ICU daily BG was 132±14 mg/dl (IQR 124-139) in the intensive and 154±20 
mg/dl (IQR 142-164) in the conservative group (p<0.001). Overall, we observed a similar number of patients in 
the intensive and conservative groups experiencing ≥ 1 complications (42% vs. 52%, p=0.08). There were no 
differences in the composite or on individual complications in patients with DM; however, the composite of 
complications was lower in non-DM patients (stress hyperglycemia) in the intensive compared to the 
conservative group (p=0.008) (Figure 4). 
 
In summary, during the past decade our group has provided novel and important information to guide health care 
providers in the hospital management of patients with hyperglycemia and diabetes. Our preliminary studies 
indicate that stress hyperglycemia is common and associated with increased rate of complications.  The proposed 
studies will determine if DPP4 agents are effective in the prevention and management of stress hyperglycemia in 
patients undergoing non-cardiac surgery. 
 
 
 


 
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METHODOLOGY 
 
Aim: To determine whether treatment with sitagliptin once daily can prevent the development of stress 
hyperglycemia during the postoperative period in non-diabetic patients undergoing general surgery. 
 
Rationale: 
Approximately 30% of non-diabetic patients undergoing general non-cardiac surgery will develop stress 
hyperglycemia (BG > 140-180 mg/dl) and require treatment with insulin during the perioperative period.6,14,57,58 
Few trials have investigated the impact of hyperglycemia in general non-cardiac surgery patients.2,12 The current 
standard of care according national medical associations is to treat stress hyperglycemia with insulin, with up to 
4 injections per day.52,59 This, however, is costly and requires significant nursing resources and is associated with 
up to 20-30% risk of hypoglycemia.
56,60 We have shown that a DPP-4 inhibitor can be used to reduce 
hyperglycemia safely and effectively in diabetic patients in the hospital with relatively low risk of hypoglycemia 
(preliminary results).
22 Our study aims to safely reduce the risk of developing postoperative hyperglycemia and 
associated complications with the use of a once daily oral medication.  
 
METHODS: 
This pilot randomized, placebo-controlled, intent-to-treat trial will be conducted in 100 subjects between 18-80 
years of age, without a known history of diabetes and with normoglycemia [BG<126 mg/dl or random BG ≤ 140 
mg/dl] undergoing non-cardiac surgery. Subjects will be consented either prior to hospitalization at the pre-
operative clinic visit or during hospitalization before surgery.  Subjects will be randomized to receive either 
sitagliptin or placebo starting one day prior to surgery and continued daily during hospitalization to determine if 
stress hyperglycemia, defined as a BG >140 mg/dL can be prevented or reduced with the use of a DPP4-inhibitor.  
 
 
Treatment Groups: 
 
Primary outcome:  
 To determine whether treatment with sitagliptin once daily can prevent the development of stress hyperglycemia 
during the postoperative period in non-diabetic patients undergoing general surgery. 
 
Secondary outcomes:  
1. Total daily dose of insulin dose for patients requiring insulin 
2. Length of hospital stay 
3. Number of patients requiring SC insulin, either SSI or basal 
4. Hypoglycemic events (BG < 70 mg/dl); severe hypoglycemia (BG < 40 mg/dl)  
5. Transfer to the ICU (immediately after surgery or during hospitalization) and number of days in the 
ICU 
6. Hospital readmission and Emergency room visit after discharge. 
7. Individual and composite of the following complications:  
 Wound infection 
 Respiratory failure 
 Pneumonia 
 Acute kidney injury (defined by increase in creatinine by 0.5 meq/L above preoperative value) 
 Major adverse cardiac events  


 
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 Bacterial septic infection 
 Death 
Study population: Patients between 18-80 years of age, without a known history of diabetes and with 
normoglycemia [fasting BG<126 mg/dl dl or random BG ≤ 140 mg/dl] planned for non-cardiac surgery will 
undergo screening at their preoperative clinic visit or during hospitalization prior to surgery.  
The screening and recruitment will occur in 2 different scenarios.  For patients who undergo pre-anesthesia and 
surgery screening (elective cases) will be screened for inclusion/exclusion criteria and will be invited to 
participate by a study coordinator and/or investigator. If accepted to participate, the patient will be given a 
sitagliptin or placebo tablet and instructed to take the medication the day before and the day of surgery (see graph 
in page 6).  
For hospitalized patients without pre-anesthesia visit, which we anticipate will be about half of the patients, we 
will approach and invite to participate if no history of diabetes and with a fasting BG < 126 mg/dL or random BG 
≤ 140 mg/dL.  
Inclusion criteria:   
1. Men and women between the ages of 18 and 80 years undergoing non-cardiac surgery.   
2. No previous history of diabetes or hyperglycemia 
3. Randomization fasting BG <126 mg/dl or random ≤ 140 mg/dl. 
 
 
Exclusion criteria:  
1. Patients with hyperglycemia (fasting BG ≥ 126 or random BG >140mg/dl)  
2.  Patients with prior history of diabetes with HbA1c ≥ 6.5% or previous treatment with oral antidiabetic 
agents or insulin.  
3. Patients undergoing cardiac surgery. 
4. Patients anticipated to require ICU care following surgery. 
5. Severely impaired renal function (GFR < 30 ml/min) or clinically significant hepatic failure. 
6. Moribund patients and those at imminent risk of death (brain death or cardiac standstill).  
7. Subjects with gastrointestinal obstruction or adynamic ileus or those expected to require gastrointestinal 
suction. 
8. Patients with clinically relevant pancreatic or gallbladder disease.  
9. Treatment with oral (equivalent to prednisone> 5 mg/day) or injectable corticosteroid. 
10. Mental condition rendering the subject unable to understand the nature, scope, and possible consequences of 
the study 
11. Pregnancy or breast-feeding at time of enrollment. 
Procedures  
   A total of 100 patients will be consented during their surgery clinic visit or during hospitalization.  
Medication: 
 The study drug (sitagliptin or placebo) will be started one day prior to surgery and continued once daily in a 
blinded fashion for up to 8 days postoperatively.  
 Patients with normal renal function will receive two 50 mg tablets sitagliptin (total of 100 mg) or two placebo 
tablets. 
 Patients with GFR of <50 ml/min will receive one 50 mg tablet of stiagliptin (total of 50 mg) or one placebo 
tablet. 
 If a patient’s GFR changes during hospitalization, the dose of sitagliptin will be adjusted accordingly. If GFR 
is ≥ 50mL/min, the dose will be 100 mg; If GFR is <50 and ≥30 mL/min, the dose will be adjusted to 50 mg; 
if the GFR decreases to <30, the dose will be changed to 20 mg. 
 During hospitalization after surgery, patients will have point of care (POC) testing done 4 times daily; for 
patients who are eating, POC testing will be done before meals and at bedtime; for patients not eating (NPO), 


 
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POC testing will be every 6 hours.  One blood glucose check will also be done during surgery to assess 
predictive value of intraoperative hyperglycemia in developing sustained hyperglycemia postoperatively.  
 Patients who develop hyperglycemia during surgery or in the recovery unit, will be treated with insulin as per 
institution protocol (standard of care). 
 Patients with fasting and/or premeal BG >180 mg/dl will receive coverage with sliding scale insulin 
(supplements).  Those with 2 consecutive fasting and/or premeal BG >180 mg/dl, or with average daily BG 
>180 mg/dl will be started on rescue therapy with SC detemir or glargine insulin once daily plus correction 
doses by sliding scale. 55  
 
Supplemental (correction) insulin.  Supplemental (lispro or aspart) insulin will be administered following 
standard “sliding scale” protocol outlined below. 
Supplemental Sliding Scale Insulin (number of units) - administer dose before meals.   
 
Blood Glucose 
  
(mg/dL) 
                  Sensitive            Usual  
     Resistant             
 
181-220 
 
 
2 
 
   3 
 
 
4 
221-260 
 
 
3 
 
   4 
 
 
5 
261-300 
 
 
4 
 
   5 
 
 
6 
301-350 
 
 
5 
 
   6 
 
 
7 
351-400 
 
 
6 
 
   7 
 
 
8 
> 400  
 
 
7 
 
   8 
 
 
9 
______________________________________________________________ 
** Check appropriate column below and cross out other columns 
 
At bedtime, give according to Bedtime Supplemental Sliding Scale Insulin starting at BG >220 mg/dl: 
 
Blood Glucose 
  
(mg/dL) 
                  Sensitive            Usual  
     Resistant             
 
221-260 
 
 
1 
 
   2 
 
 
3 
261-300 
 
 
2 
 
   3 
 
 
4 
301-350 
 
 
3 
 
   4 
 
 
5 
351-400 
 
 
4 
 
   5 
 
 
6 
> 400  
 
 
5 
 
   6 
 
 
7 
______________________________________________________________ 
** Check appropriate column below and cross out other columns 
 
The numbers in each column indicate the number of units of aspart or lispro insulin per dose. If a patient is able 
and expected to eat all or most of his/her meals, supplemental insulin will be administered before each meal 
following the “usual” column dose.  Supplemental insulin at bedtime = half of premeal insulin dose at BG > 
220 mg/dl.  If a patient is not able to eat (NPO), supplemental insulin will be administered every 6 hours (6-12-
6-12) following the “sensitive” column dose.  
Initiation of subcutaneous insulin  
Patients with fasting and/or premeal BG >180 mg/dl will receive coverage with sliding scale insulin 
(supplements).  Those with 2 consecutive fasting and/or premeal BG >180 mg/dl or with average daily BG >180 
mg/dl, will be started on detemir or glargine insulin once daily as basal plus correction or on basal bolus insulin 
regimen plus supplements with rapid-acting insulin analog. The study drug-sitagliptin or placebo will be 
continued once daily in all patients independently of the need for insulin therapy. 
 
Basal insulin therapy with Detemir or Glargine: 
 Continue study drug (sitagliptin or placebo) once daily.  


 
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 Patients with averageBG between >180 mg/dL= start detemir or glargine at 0.2 units per kg weight per day. 
 Patients with GFR <50 or over the age of 70= start detemir or glargine at 0.1 units per kg weight per day. 
 Basal insulin will be given once daily, at the same time of day.   
 
Insulin adjustment.  The total detemir or glargine daily insulin dose will be adjusted as follow:  
 Fasting and pre-meal BG between 100-180 mg/dl without hypoglycemia the previous day: no change  
 Fasting and pre-meal BG between >180-240 mg/dl: increase detemir or glargine dose by 10% every day 
 Fasting and pre-meal BG >241 mg/dl: increase detemir or glargine dose by 20% every day  
 Fasting and pre-meal BG <100 mg/dl: reduce detemir or glargine by 20% or stop if patient is already on less 
than 0.1 units/kg of body weight 
 
Data collection and data entry.  The study coordinators will enter baseline and daily data for this study into 
data collection paper forms and into an electronic database provided by the Emory Research Information 
Technology Department. Baseline data will include demographics/history form (subject gender, date of birth, 
ethnicity, dates of hospitalization and operation, history of diabetes, type of treatment of diabetes and comorbid 
conditions, body weight, BMI, type of surgery. Daily information will be collected on treatment (insulin dosage, 
antibiotics), nutrition support, BG and laboratory values, hospital complications and adverse events, and length 
of ICU and hospital stay. 
 
 
STATISTICAL ANALYSIS  
 
To determine whether treatment with sitagliptin once daily can prevent the development of stress 
hyperglycemia during the postoperative period in non-diabetic patients undergoing general surgery. 
 
Analysis of Primary Endpoint: The primary endpoints in this study are to determine differences between 
sitagliptin and placebo treatment on the frequency of stress hyperglycemia during surgery who require therapy 
with SC insulin. We will first use two-sided Chi-square test or Fisher’s exact test to compare primary endpoints 
between treatment groups. Next, we will perform multivariate logistic regression to estimate the difference in 
the occurrence rate of the primary endpoint while adjusting for other relevant covariates such as age and gender. 
Stepwise, backward, or forward model selection strategy will be adopted to determine the variables to be 
included in the final model. Standard diagnostic and model checking procedures, such as deviance residual plot 
and Hosmer-Lemeshow test, will be applied to examine the fit of the developed predictive model. 
 
Sample Size Calculation and Power Analysis:  
We have performed sample size and power calculations based on our preliminary data on retrospective chart 
review, which showed that 29% of non-DM patients develop stress hyperglycemia following general surgery. 
We anticipate that sitagliptin will reduce the rate of hyperglycemia by 50-80% (corresponding to odds ratio 
(OR) in the range of 0.42-0.15). We calculate the sample size based on the OR estimate of 0.42 and provide the 
power for the larger treatment effects represented by OR=0.42, 0.3, 0.2, 0.15 (see Table). More specifically, 
conservatively using two-sided Fisher’s exact test, two-sided, with alpha=0.05, the sample size required for 
80% power to detect the conjectured treatment effect of OR=0.42 (ie. 29.0% vs 14.5%) would be 143 patients 
per study group. Accounting for 15-20% attrition rate, recruiting 179 patients will need to be recruited in each 
group.  A total of 358 patients (179 patients per group) will need to be recruited. In this pilot study, we will 
recruit a total of 100 patients (50 per group). 
 
Table. Power computed based on two-sided Fisher’s exact test with alpha=0.05 and sample, 143 per group  
Effect Size: 
Odds ratio  
0.42 
0.3 
0.2 
 
0.15 
Primary endpoint: Stress hyperglycemia in  the hospital 
Event rates 
29% vs. 14.5% 
29% vs. 10.9% 
29% vs. 
7.6% 
29% vs. 5.8% 


 
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Analysis of Secondary Endpoints: The secondary outcomes of interest can be a binary outcome (eg. indicator 
for whether patients require transfer to the ICU), or a count outcome (eg. number of perioperative 
complications), or a continuous outcome (eg. mean daily BG concentration). We will adopt the same strategy 
proposed for the primary endpoint to analyze any binary secondary outcomes. For secondary endpoints 
measured as counts, we plan to use nonparametric tests such as Krustal-Wallis tests to compare them between 
the two study groups. Univariate Poisson regression (or Negative Binomial regression) will be performed to 
estimate the marginal treatment effect. In addition, we will also conduct multivariate Poisson regression (or 
Negative Binomial regression) to assess the outcome differences between the two study groups with potential 
confounders taken into account. For secondary endpoints, which produce continuous outcomes, we will use 
two-sample t-tests or nonparametric Wilcoxon tests to compare them between the two study groups. 
Transformations will be applied if normality violation is detected.  Multivariate linear regression will be further 
conducted to assess the difference in continuous secondary outcomes between the two groups while accounting 
for other potential confounders. We will use standard model selection and model checking procedures for 
Poisson regression (or Negative Binomial regression) and linear regression to decide the final models and assess 
their fits to the data. 
  
Data and Safety Monitoring Plan (DSMP): The Data and Safety Monitoring Plan (DSMP) will include 2 
independent reviewers monitor on safety, treatment compliance, and evaluate the efficacy of the intervention 
being studied in this clinical trial. The DSMP will meet at 6-month intervals and report on study progress to the 
IRB.  
Interim Analysis and Stopping Rules:  We plan to perform one interim analysis on the primary endpoint 
every 6 months and when half of the subjects have been randomized.  The trial will be stopped if there is 
evidence beyond a reasonable doubt of a difference in hospital complications (two-sided alpha level, <0.01) 
between the treatment groups.  
 
Future direction 
Using the pilot data collected from the proposed pilot study, I plan to develop a large-randomized-controlled 
trial investigating whether stress hyperglycemia and associated complications can be prevented.  
 
HUMAN SUBJECTS 
 
Inform consent and randomization: All patients scheduled to undergo surgery will be considered potential 
candidates in this study. Patients will be consented during the preoperative clinic evaluation or on admission to 
the surgical service at least 24 hours prior to scheduled surgery. The investigators or study coordinators will 
review and explain the contents of the informed consent document to the eligible patient.  The potential subject 
will be informed of the purpose of the study, the randomization procedure, and the risks and benefits of 
participation.  The potential subject will also be informed that he/she may refuse to participate, and that even if 
he/she consents to participate he/she may withdraw from the study at any time.  
 
Study Site: This pilot study will be conducted at Emory University Hospital and Grady Memorial Hospital, 
Atlanta. 
 
Power  
80.2% 
96.1% 
99.6% 
99.9% 


 
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Risk associated with participation: 
 
Hypoglycemia: Hypoglycemia is the main adverse event and safety issue in the study. In our previous surgery 
study, we observed that mild (BG ≤70 mg/dL) hypoglycemia occurred in 20-30% and severe (BG ≤40 mg/dL) 
hypoglycemia occurred in 3-4% of patients treated with SC insulin.60 The use of insulin in combination with 
DPP4 inhibitors may increase the risk of hypoglycemia during the hospital stay.  The number of mild and 
severe hypoglycemia and clinical consequences (neurological and cardiovascular) will be compared across 
treatment arms.    
 
Treatment of hypoglycemia: Hypoglycemia, defined as a BG <70 mg/dL will be treated by a standard 
hypoglycemia protocol available at the institution.  In brief, Hypoglycemia, for BG < 70 mg/dL and patient is 
alert and can tolerate oral intake, give 20 grams of fast-acting carbohydrate (6 oz. fruit juice or regular soda, 
crackers); if patient is not alert and cannot tolerate oral intake, give 1ampule (50 mL) of D50. Check finger stick 
BG q 15 minutes and repeat above treatment until BG > 100 mg/dL. Once BG > 100 mg/dL, repeat finger stick 
BG 1 hour later and treat as follows: If BG < 70 mg/dL, call MD and follow hypoglycemia orders (above); if 
BG 70 – 100 mg/dL, give snack/scheduled meal and check BG q1 h until BG >100 mg/dl; if BG > 100, no 
further treatment needed. 
 
Hyperglycemia: It is possible that following the proposed protocol, patients randomized to the conventional 
treatment arm may develop higher numbers of hyperglycemic events (BG 180 mg/dl) which may lead to 
increased risk of complications.  We expect that ~20% of subjects will experience one or more episodes of 
hyperglycemia.  The frequency of severe hyperglycemia will be analyzed statistically.   
 
Protection against risks: Our strict inclusion and exclusion criteria for entry will help to minimize risks. In 
addition, we will carefully monitor capillary BG at the bedside using the hospital certified meter, b) only 
experienced nurses/or phlebotomist will draw blood samples, and c) no patients with history of significant 
pancreatic, renal or hepatic failure will be recruited in this study, d) study subjects will receive rescue therapy 
with insulin in the event of hyperglycemia.     
 
Potential benefits to the subject: We believe that all subjects will benefit from this study.  Intensified blood 
glucose monitoring and blood glucose control has been shown to significantly reduce hospital complications 
associated with hyperglycemia and hypoglycemia.   
 
Inclusion of women:  We anticipate that ~50% of the study subjects will be female.  No patients under the age 
of 18 and no pregnant women will be included in the study.   
 
Inclusion of minorities: Patients will not be excluded based on race or ethnic origin.  We anticipate that half of  
the patients will be African Americans or Hispanics, and the rest Caucasians.   
 
Inclusion of children: No patients under the age of 18 will be recruited in this study. 
 
Confidentiality: Informed consent will follow the procedure of Emory University Institutional Review Board.   
Every participant will be informed in writing and verbally with the important and key points of the study.   The 
investigators or the research coordinators will obtain a witnessed informed consent prior to inclusion into the 
study.  Data collection records with personal identifiers will be stored in locked file cabinets.  All data 
maintained in the computerized database will be accessible only with a login and protected password. After the 
study is completed, all data will be kept in a locked file. Presentation of the study results at regional or scientific 
meetings or in publications will not identify subjects.   
 


 
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Payment for participation: Participation in this study is voluntary. Patients will receive fifty ($50) at the time 
of hospital discharge for participation in the study. If a participant should stop participation before completion, 
they will receive twenty five ($25.00) at the time of termination.  
 
Financial conflict of interests.     None of the investigators in this study have any activities that may represent 
a conflict of interest.  None of the investigators have an economic interest in an outside entity, or act as officers, 
directors, employees or consultants with such an entity, whose financial interest may be affected by this 
research study. 
 
Time Line: We anticipate completion of enrollment in the pilot study within 1 year with about 6 patients 
enrolled per month. 
 
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