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January-A 2021, Volume 71, Issue 1

Recent Advances In Endocrinology

Approach to glucose control: The SECURE model

Hitesh Punyani  ( Department of Medicine, Chaitanya Cardio Diabetes Centre, New Delhi, India. )
Tejal Lathia  ( Department of Endocrinology, Fortis Hospital, Navi Mumbai, India )
Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal, India. )

Abstract

This communication describes a framework to help plan and implement glucose lowering strategies in hospitalized patients. Termed the SECURE model, it utilizes six clinical characteristics to decide intensity of insulin therapy. The SECURE rubric is more comprehensive than the conventional gluco-centric approach promoted by routinely used algorithms. SECURE promotes good clinical sense and pragmatic care in the critical care setting.

Keywords: Critical care, diabetes, hyperglycaemia, hypoglycaemia, insulin, intravenous insulin

 

Introduction

 

Euglycaemia is an important target in the management of persons with diabetes. Critical care protocols predominantly use intravenous insulin to manage hyperglycaemia.1 Most algorithms, however, base the intensity of initial dosing, monitoring and titration on a single parameter - the severity of hyperglycaemia. The gluco-centric approach views the patient’s health as a series of numbers, without considering the other aspects of health which influence glycaemic status. This approach may lead to suboptimal glucose control and outcomes.

In critically ill patients, the advantages of euglycaemia have to be assessed vis-a vis the risks of hypoglycaemia. The SECURE model proposes a holistic and comprehensive approach to hyperglycaemia management particularly in critically ill patients.

 

The Secure Model

 

The SECURE rubric suggests six person-specific aspects which must be considered while planning glucose-lowering treatment. These characteristics help decide glycaemic targets and goals. They also define the starting intensity of therapy, the frequency of glucose monitoring, and the degree of dose titration.

The six components of SECURE are listed in Table.

They include severity of hyperglycaemia, expected prognosis, concomitant medication, urgency of control, risk of hypoglycaemia, and environmental factors. Severity of hyperglycaemia and urgency of control are two factors which encourage aggressive treatment, while expected prognosis and risk of hypoglycaemia may call for a guarded approach. The other two factors, concomitant medication and environmental factors, underscore the need of a cautious approach towards glucose modulation in certain settings.

 

1) Severity

 

Severity of hyperglycaemia is judged, in the critical care setting, by repeated plasma glucose measurements.2,3 Urine and plasma ketone determination may be required at times. A baseline HbA1c helps differentiate between stress hyperglycaemia and previously undiagnosed diabetes. However HbA1c may show false values in anaemia and chronic kidney disease, which are common comorbid conditions in hospitalized patients. Assessment of this information informs targets of glycaemia, which in turn helps decide initial dosing of intravenous insulin.

 

2) Expected Prognosis

 

The expected prognosis of a particular patient is an important contributor to this decision-making process. A patient with a potentially curable acute illness or manageable chronic co-morbidity should be treated aggressively. On the other hand, a patient in end-of-life stage, or with poor prognosis due to underlying disease, should be managed with caution.4 In patients with poor prognosis, the risks of hypoglycaemia outweigh the benefits of intensive glycaemic control.

 

3) Concomitant Medication

 

Concomitant medication may influence glycaemic levels, and therefore, may impact attitudes to the degree and intensity of glucose-lowering. Concomitant use of drugs such as corticosteroids, dopamine and immunosuppresants should prompt usage of higher-dose algorithms, while administration of hypoglycaemia-related drugs like quinine and levofloxacin should call for caution.5,6

 

4) Urgency of Control

 

Urgency of control is another factor which impacts attitudes towards glycaemic management. Patients with life-threatening, organ-threatening or limb-threatening complications that may benefit from early restitution of glycaemia should be considered for aggressive glucose-lowering. This will include pre-operative and peri-operative patients as well.7

 

5) Risk of Hypoglycaemia

 

Patients with previous history of  hypoglycaemia, hepatic or renal impairment and those with cognitive impairment, adrenal or thyroid insufficiency should be managed cautiously.8 Mortality from hypoglycaemia will negate any benefits of intensive glucose control.

 

6) Environmental Factors

 

Caution should also be exercised if the environment is not conducive to safety. The nurse: patient ratio, experience of nurses, and availability as well as cost of glucose monitoring also influence glucose-lowering targets and therapy. Pragmatism must be exercised while planning therapy for patients. An insulin stewardship programme helps minimize errors and enhance productivity in hospital settings.9

 

Summary

 

The SECURE framework is a simple, yet comprehensive tool which guides approach to glucose management in hospitalized patients. It serves as learning and teaching tool in diabetes care as well.

 

References

 

1.      Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002; 87:978–82.

2.      Bajwa SS, Kalra S. Glycaemic control in ICU. Endocrine Soc India: Manual of Clin Endocrinol. 2012;1:115-23.

3.      Umpierrez GE, Pasquel FJ. Management of inpatient hyperglycemia and diabetes in older adults. Diabetes care. 2017; 40:509-17.

4.      Hussain S, Chowdhury TA. The impact of comorbidities on the pharmacological management of type 2 diabetes mellitus. Drugs. 2019; 79:231-42.

5.      Shea KE, Gerard SO, Krinsley JS. Reducing Hypoglycemia in Critical Care Patients Using a Nurse-Driven Root Cause Analysis Process. Critical care nurse. 2019;39:29-38.

6.      Braithwaite SS, Bavda DB, Idrees T, Qureshi F, Soetan OT. Hypoglycemia reduction strategies in the ICU. Curr Diab Rep. 2017;17:133.

7.      Kalra S, Khandelwal D, Singla R, Aggarwal S, Dutta D.Malaria and diabetes. J Pak Med Assoc. 2017; 67: 810-813

8.      Bajwa SJ, Baruah MP, Kalra S, Kapoor MC. Interdisciplinary position statement on management of hyperglycemia in peri-operative and intensive care. J. Anaesthesiol. Clin. Pharmacol. 2015; 31:155.

9.      Kalra S, Sahay R, Tiwaskar M. Need for Insulin Stewardship Programmes. J Assoc Physicians India. 2018;66:83–4.

 

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