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Relative Hypoglycemia and Lower Hemoglobin A1c-Adjusted Time in Band Are Strongly Associated With Increased Mortality

James S Krinsley1, Peter R Rule2, Gregory W Roberts3

  • 1Division of Critical Care, Department of Medicine, Stamford Hospital, and the Columbia Vagelos College of Physicians and Surgeons, Stamford, CT.

Critical Care Medicine
|February 8, 2022
PubMed

Insights

Critically ill patients with higher hemoglobin A1c (HbA1c) levels may benefit from individualized blood glucose (BG) targets. Relative hypoglycemia (BG 70-110 mg/dL) can increase mortality in patients with HbA1c ≥ 8.0%.

Area of Science:

  • Critical Care Medicine
  • Endocrinology
  • Metabolic Disorders

Background:

  • Glycemic control is crucial in critically ill patients.
  • Standard blood glucose (BG) targets may not be optimal for all patients, particularly those with varying hemoglobin A1c (HbA1c) levels.
  • The metric HbA1c-adjusted time in band (HA-TIB) offers a novel approach to assess glycemic control.

Purpose of the Study:

  • To investigate the association between relative hypoglycemia and HA-TIB with mortality in critically ill patients.
  • To explore the impact of individualized glycemic targets based on HbA1c levels on patient outcomes.
  • To re-evaluate the interpretation of intensive insulin therapy trials in light of these findings.

Main Methods:

  • Retrospective cohort study of 3,655 adult medical-surgical ICU patients.
  • Stratification by HbA1c levels (<6.5%, 6.5-7.9%, ≥8.0%) with corresponding BG target ranges.
  • Calculation of HA-TIB and relative hypoglycemia (BG 70-110 mg/dL for HbA1c ≥ 8.0%).
  • Severity-adjusted mortality assessed using the Observed:Expected Mortality Ratio (O:EMR).

Main Results:

  • Among non-diabetic patients, higher time in target BG range (70-140 mg/dL) correlated with decreased mortality.
  • HA-TIB ≥ 50% was associated with lower O:EMR across most groups.
  • For patients with HbA1c ≥ 8.0%, relative hypoglycemia was linked to significantly increased mortality, particularly with longer durations.

Conclusions:

  • BG values of 70-110 mg/dL may be detrimental for critically ill patients with HbA1c ≥ 8.0%.
  • Individualizing BG targets based on HbA1c levels is suggested.
  • Findings necessitate re-evaluation of past intensive insulin therapy trials and warrant further investigation through randomized trials.
Abstract

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