From the Guidelines
In sepsis, it is recommended to hold most diabetes medications, especially metformin, SGLT2 inhibitors, and sulfonylureas, due to the risk of lactic acidosis, dehydration, and hypoglycemia, and instead use insulin therapy for glycemic control. The management of diabetes in the hospital setting, particularly in critically ill patients, involves individualized antihyperglycaemic therapy, as outlined in a 2021 study published in The Lancet Diabetes and Endocrinology 1. According to this study, metformin might be associated with lactic acidosis in high-risk patients, such as those with sepsis, shock, renal or liver failure. Additionally, a 2023 consensus recommendation published in the American Journal of Kidney Diseases 1 suggests that metformin, SGLT2 inhibitors, and other medications should be temporarily stopped in patients with volume depletion or other signs of illness. Some key points to consider when managing diabetes in sepsis include:
- Discontinuing metformin due to the risk of lactic acidosis
- Stopping SGLT2 inhibitors to avoid worsening dehydration and increasing the risk of euglycemic diabetic ketoacidosis
- Holding sulfonylureas to prevent hypoglycemia in patients with decreased oral intake
- Discontinuing GLP-1 agonists to avoid worsening nausea and decreasing oral intake
- Using insulin therapy, typically administered as an intravenous infusion in critically ill patients or as subcutaneous basal-bolus regimens in less severe cases, to allow for more precise glucose management. Once the patient stabilizes and begins eating regularly, their usual diabetes medications can be gradually reintroduced based on kidney function and overall clinical status, as recommended by the consensus panel 1.
From the Research
Holding Diabetes Medicines in Sepsis
- The decision to hold diabetes medicines in sepsis is complex and depends on various factors, including the type of diabetes, the severity of sepsis, and the patient's overall health status 2, 3.
- Some studies suggest that tight glycemic control with intensive insulin therapy may not be beneficial for patients with severe sepsis and septic shock, and may even increase the risk of hypoglycemia 2.
- However, other studies suggest that diabetes patients with sepsis may benefit from continued treatment with insulin, metformin, and thiazolidinediones, which may be associated with lower incidence and mortality from sepsis 3.
- The presence of diabetes does not appear to significantly influence the outcome of severe sepsis, but admission hyperglycemia in nondiabetic patients is associated with increased mortality 4.
- The use of sulfonylureas, a type of diabetes medication, may be beneficial in certain patients with type 2 diabetes, but their role in the treatment of sepsis is not well established 5.
- The immune system in diabetic patients is compromised, which can contribute to the progression of sepsis, and insulin may have beneficial effects on the immune response in a glycemic control-dependent and independent manner 6.
Key Considerations
- The management of diabetes in patients with sepsis requires careful consideration of the patient's individual needs and health status.
- The goal of glycemic control in sepsis is to avoid hypoglycemia and hyperglycemia, while also considering the potential benefits and risks of different diabetes medications 2, 3.
- Further research is needed to determine the optimal approach to managing diabetes in patients with sepsis, including the role of different diabetes medications and the potential benefits of glycemic control 3, 6.