From the Guidelines
For a 71-year-old patient with diabetes mellitus, hypertension, chronic pancreatitis, and an infected foot ulcer, the optimal glycemic target should be between 7.8 to 10 mmol/L (140 to 180 mg/dL) to balance the need for glycemic control with the risk of hypoglycemia, as recommended for most noncritical and critically ill patients 1. The patient's advanced age, multiple comorbidities, and active infection necessitate a moderately relaxed glycemic target to avoid the risks of hypoglycemia, which can be particularly dangerous in older adults.
- Key considerations in managing this patient include:
- Controlling the infection with appropriate antibiotics and wound care
- Providing adequate glycemic control with insulin therapy, potentially using a basal-bolus regimen
- Monitoring blood glucose levels frequently, such as 4 times daily, during the acute phase
- Considering pancreatic enzyme replacement therapy if not already prescribed due to the potential for pancreatic exocrine insufficiency from chronic pancreatitis The immediate management should focus on controlling the infection and providing adequate wound care, while also managing blood glucose levels to prevent hyperglycemia and hypoglycemia, as these are associated with adverse outcomes, including death 1.
- The choice of antihyperglycemic agents and the specific glycemic targets may need to be adjusted based on the patient's response to treatment and the presence of any complications, such as hypoglycemia or worsening of the foot ulcer. Inpatient glucose targets of 7.8 to 10 mmol/L (140 to 180 mg/dL) are recommended for most noncritical and critically ill patients, and this target range is appropriate for this patient given their clinical presentation 1.
- It is essential to regularly reassess the patient's condition and adjust the treatment plan as needed to ensure the best possible outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Optimal Glycemic Target for a 71-year-old Patient with Diabetes Mellitus, Hypertension, and Chronic Pancreatitis with an Infected Foot Ulcer
- The optimal glycemic target for a patient with diabetes mellitus (DM) and an infected foot ulcer is not clearly established, but several studies suggest that reasonable glycemic control can facilitate wound healing 2.
- A study published in 2019 found that a hemoglobin A1c (HbA1c) level between 7.0% and 8.0% during treatment was associated with a higher wound healing rate compared to HbA1c levels less than 7.0% or greater than 8.0% 2.
- Another study published in 2018 found that low HbA1c variability was associated with faster wound healing in patients with diabetic foot ulcers, and that time to healing was more dependent on the mean HbA1c than the variability in HbA1c 3.
- A randomized controlled trial protocol published in 2022 aims to assess the role of intensive glycemic management in comparison to conventional glucose control for healing of diabetic foot ulcers, with glycemic targets of fasting blood glucose (FBG) <130 mg/dL, postprandial BG <180 mg/dL, and HbA1c <8% 4.
- A systematic review published in 2016 found that there was no conclusive evidence on the effects of intensive glycaemic control compared to conventional control on the outcome of foot ulcers in people with diabetes, but suggested that intensive glycaemic control may reduce the risk of limb amputation 5.
Glycemic Targets
- Fasting blood glucose (FBG) <130 mg/dL 4
- Postprandial blood glucose (BG) <180 mg/dL 4
- Hemoglobin A1c (HbA1c) <8% 4 or between 7.0% and 8.0% 2
Considerations
- The patient's age, comorbidities, and presence of an infected foot ulcer should be taken into account when determining the optimal glycemic target 4, 5, 3, 2.
- The patient's ability to achieve and maintain the target glycemic levels should also be considered, as well as the potential risks and benefits of intensive glycemic control 4, 5, 6.