Introduction: Hypoglycemia in critically ill patients increases morbidity and mortality. Subcutaneous long-acting insulin (LAI) in patients without diabetes is associated with hypoglycemia in the SICU. However, limited evidence exists in patients with diabetes. Methods: This was a single-center, retrospective cohort study evaluating patients with T2DM who were admitted to the SICU for 24 h and received LAI in combination with sliding scale insulin (LAI + SSI) or sliding scale insulin (SSI) alone. The primary outcome was the incidence of hypoglycemia (BG < 70 mg/dL) in patients who received LAI + SSI or SSI. Secondary outcomes evaluated the number of glucose values across defined categories: hypoglycemia (54-70 mg/dL), severe hypoglycemia (<54 mg/dL), euglycemia (70-180 mg/dL), hyperglycemia (>180 mg/dL) and glycemic variability.
Results: A total of 228 patients were included in the final analysis. The incidence of hypoglycemia occurred in 17.5% of patients in the LAI + SSI cohort and 18.4% in the SSI cohort (p = .86). After controlling for confounders, no differences were observed with LAI + SSI versus SSI for hypoglycemia (OR 1.09, 95% CI 0.46-2.6, p = .85). Secondary outcomes demonstrated no difference in total hypoglycemia (37 vs 31, p = .80), severe hypoglycemia (15 vs 34, p = .17) and euglycemia (1622 vs 1780, p = .22) in the LAI + SSI cohort compared to SSI alone. Hyperglycemia occurred more frequently with LAI + SSI. However, after adjusting for confounders there was no difference in hyperglycemia (OR 1.8, 95% CI 0.7-4.6, p = .22). No difference was observed in glycemic variability between LAI + SSI and SSI (26.5 vs 24.5, p = .21).
Conclusion and Relevance: The addition of LAI to SSI in SICU patients with T2DM was not associated with an increased risk of hypoglycemia.
UmpierrezGEIsaacsSDBazarganNYouXThalerLMKitabchiAE. Hyperglycemia: An independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab.2002;87(3):978–982.
2.
GaleSCCrnpCSReillyPMSchwabCWGraciasVH. Poor glycemic control is associated with increased mortality in critically ill trauma patients. Am Surg.2007;73(5):454–460.
3.
LongCAFangZBHuFY, et al.Poor glycemic control is a strong predictor of postoperative morbidity and mortality in patients undergoing vascular surgery. J Vasc Surg.2019;69(4):1219–1226.
4.
CritchleyJACareyIMHarrisTDeWildeSHoskingFJCookDG. Glycemic control and risk of infections among people with type 1 or type 2 diabetes in a large primary care cohort study. Diabetes Care. 2018;41(10):2127–2135.
5.
FalcigliaM. Causes and consequences of hyperglycemia in critical illness. Curr Opin Clin Nutr Metab Care. 2007;10(4):498–503.
6.
YehHFChaoWCWuCLChanMC. Hypoglycemia and hospital mortality in critically ill patients. Sci Rep.2025;15(1):2642.
7.
McCowenKCMalhotraABistrianBR. Stress-induced hyperglycemia. Crit Care Clin.2001;17(1):107–124.
8.
RobinsonLEvan SoerenMH. Insulin resistance and hyperglycemia in critical illness: Role of insulin in glycemic control. AACN Adv Crit Care.2004;15(1):45–62.
9.
KrinsleyJSGroverA. Severe hypoglycemia in critically ill patients: Risk factors and outcomes. Crit Care Med.2007;35(10):2262–2267.
10.
HonarmandKSirimaturosMHirshbergEL, et al.Society of critical care medicine guidelines on glycemic control for critically ill children and adults 2024. Crit Care Med.2024;52(4):e161–e181.
11.
ElSayedNAMcCoyRGAleppoG, et al.16. Diabetes care in the hospital: Standards of care in diabetes—2025. Diabetes Care. 2025;48(Supplement_1):S321–S334.
12.
AronAWangJCollierBAhmedNBrateanuA. Subcutaneous versus intravenous insulin therapy for glucose control in non-diabetic trauma patients. A randomized controlled trial. J Clin Pharm Ther.2013;38(1):24–30.
13.
CavalcantiABSilvaEPereiraAJ, et al.A randomized controlled trial comparing a computer-assisted insulin infusion protocol with a strict and a conventional protocol for glucose control in critically ill patients. J Crit Care.2009;24(3):371–378.
14.
De BlockCManuel-y-KeenoyBVan GaalLRogiersP. Intensive insulin therapy in the intensive care unit: Assessment by continuous glucose monitoring. Diabetes Care. 2006;29(8):1750–1756.
15.
TranKKKibertJLTelfordEDFranckAJ. Intravenous insulin infusion protocol compared with subcutaneous insulin for the management of hyperglycemia in critically ill adults. Ann Pharmacother.2019;53(9):894–898.
16.
DhatariyaKUmpierrezGE. Management of diabetes and hyperglycemia in hospitalized patients. Endotext [Internet], 2024.
17.
UmpierrezGCardonaSPasquelF, et al.Randomized controlled trial of intensive versus conservative glucose control in patients undergoing coronary artery bypass graft surgery: GLUCO-CABG trial. Diabetes Care. 2015;38(9):1665–1672.
18.
ClementSBraithwaiteSSMageeMF, et al.Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27(2):553–591.
19.
SmileyDDUmpierrezGE. Perioperative glucose control in the diabetic or nondiabetic patient. South Med J.2006;99(6):580–591.
20.
GearhartJDuncanJReplogleWForbesRWalleyE. Efficacy of sliding-scale insulin therapy: A comparison with prospective regimens. Fam Pract Res J.1994;14(4):313–322.
21.
HirschIB. Sliding scale insulin—time to stop sliding. Jama. 2009;301(2):213–214.
22.
UmpierrezGESmileyDHermayerK, et al.Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: Basal plus trial. Diabetes Care. 2013;36(8):2169–2174.
23.
UmpierrezGESmileyDJacobsS, et al.Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care. 2011;34(2):256–261.
24.
VellankiPCardonaSGalindoRJ, et al.Efficacy and safety of intensive versus nonintensive supplemental insulin with a basal-bolus insulin regimen in hospitalized patients with type 2 diabetes: A randomized clinical study. Diabetes Care. 2022;45(10):2217–2223.
25.
MasseJGiulianoCABrownSPaxtonRA. Association between the use of long-acting insulin and hypoglycemia in nondiabetic patients in the surgical intensive care unit. J Intensive Care Med.2018;33(5):317–321.
