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Cao L, Zhang D, Zhao Y, Zhou N, Zhang P. Efficacy and safety of different insulin infusion methods in the treatment of total parenteral nutrition-associated hyperglycemia: a systematic review and network meta-analysis. Front Nutr 2023; 10:1181359. [PMID: 37674887 PMCID: PMC10479116 DOI: 10.3389/fnut.2023.1181359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/24/2023] [Indexed: 09/08/2023] Open
Abstract
Aims To systematically evaluate the efficacy and safety of different insulin infusion methods in the treatment of total parenteral nutrition (TPN)-associated hyperglycemia based on published literature and the data of completed clinical trials using a network meta-analysis. Methods A comprehensive search of PubMed, Elsevier, Web of Science, EMBASE, Medline, clinicaltrials.gov, Cochrane Library, and three Chinese databases (Wanfang Data, China National Knowledge Infrastructure, and SINOMED) up to December 15, 2022, was performed to collect information on different insulin infusion methods used for the treatment of TPN-associated hyperglycemia, and the Cochrane systematic review method was used to screen the literature, evaluate the quality of the included literature, and extract clinical characteristics for a network meta-analysis. Clinical outcomes included mean blood glucose (MBG), hypoglycemia, hospital length of stay, hyperglycemia, surgical site infection (SSI) and mean total daily insulin. Results A total of 21 articles, including 1,459 patients, were included to analyze 6 different routes of insulin infusion, including continuous intravenous insulin infusion (CVII), continuous subcutaneous insulin infusion (CSII), subcutaneous glargine insulin (s.c. GI), the addition of regular insulin to the PN mixture (RI-in-PN), multiple subcutaneous insulin injections (MSII) and 50% of insulin administered as RI-in-PN + 50% of insulin administered as s.c. GI (50% RI-in-PN + 50% s.c. GI). The results of the network meta-analysis showed that MSII was the least effective in terms of MBG, followed by CVII. The 6 interventions were basically equivalent in terms of the hypoglycemia incidence. In terms of the length of hospital stay, patients in the CVII group had the shortest hospital stay, while the MSII group had the longest. CVII was the best intervention in reducing the incidence of hyperglycemia. The incidence of SSI was the lowest in the CSII and CVII groups, and the mean daily insulin dosage was the lowest in the CVII group. Conclusion Current literature shows that for the treatment of TPN-associated hyperglycemia, CVII is the most effective, reducing the incidence of hyperglycemia and shortening the length of hospital stay without increasing the incidence of hypoglycemia. MSII has the worst efficacy, leading to a higher MBG and longer hospital stay, and RI-in-PN, CSII, s.c. GI and 50% RI-in-PN + 50% s.c. GI are better in terms of efficacy and safety and can be substituted for each other. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023439290.
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Affiliation(s)
| | | | | | - Nan Zhou
- Department of Pharmacy, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Peng Zhang
- Department of Pharmacy, Shaanxi Provincial People’s Hospital, Xi’an, China
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Mundi MS, Mohamed Elfadil O, Hurt RT, Bonnes S, Salonen BR. Management of long-term home parenteral nutrition: Historical perspective, common complications, and patient education and training. JPEN J Parenter Enteral Nutr 2023; 47 Suppl 1:S24-S34. [PMID: 36468330 DOI: 10.1002/jpen.2424] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 12/12/2022]
Abstract
Intestinal failure (IF) is a rare disease that requires ongoing intravenous supplementation to sustain growth and health. Advancements in parenteral nutrition (PN) and central venous access in the 1960s and 1970s transformed a life-limiting disease to a chronic one in which patients are able to administer hydration, electrolytes, micronutrients, and macronutrients in the comfort of their home. However, despite ongoing advancements in the field of home PN (HPN), complications-whether related to central venous catheters or PN itself-remain common and can be associated with significant morbidity and mortality. Central venous access can be associated with thrombosis, central line-associated bloodstream infection, or damage and can result in loss of access over time. PN can be associated with IF-associated liver disease or hyperglycemia. The key to preserving central venous access and quality of life and maintaining health for patients with chronic IF (CIF) is education focused on prevention and prompt management of CIF complications as they arise. This education typically takes place at the time of initiation of HPN, either in the hospital setting or in the patient's home. The present manuscript describes the historical progression of HPN, prevalence and characteristics of CIF, and an in-depth discussion of the most common catheter-related and PN-related complications and their management, along with a discussion of our education and training process.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara Bonnes
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bradley R Salonen
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Henry H, Goossens JF, Kouach M, Lannoy D, Seguy D, Dine T, Odou P, Foulon C. Behavior of Regular Insulin in a Parenteral Nutrition Admixture: Validation of an LC/MS-MS Assay and the In Vitro Evaluation of Insulin Glycation. Pharmaceutics 2022; 14:1081. [PMID: 35631667 PMCID: PMC9148014 DOI: 10.3390/pharmaceutics14051081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/14/2022] [Accepted: 05/17/2022] [Indexed: 02/01/2023] Open
Abstract
Parenteral-nutrition (PN)-induced hyperglycemia increases morbidity and mortality and must be treated with insulin. Unfortunately, the addition of insulin to a ternary PN admixture leads to a rapid decrease in insulin content. Our study's objective was to determine the mechanistic basis of insulin's disappearance. The literature data suggested the presence of a glycation reaction; we therefore validated an LC-MS/MS assay for insulin and glycated insulin. In a 24-h stability study, 20 IU/L of insulin was added to a binary PN admixture at pH 3.6 or 6.3. When the samples were diluted before analysis with a near-neutral diluent, insulin was fully stable at pH 3.6, while a loss of around 50% was observed at pH 6.3. Its disappearance was shown to be inversely correlated with the appearance of monoglycated insulin (probably a Schiff base adduct). Monoglycated insulin might also undergo a back-reaction to form insulin after acidic dilution. Furthermore, a second monoglycated insulin species appeared in the PN admixture after more than 24 h at high temperature (40 °C) and a high insulin concentration (1000 IU/L). It was stable at acidic pH and might be an Amadori product. The impact of insulin glycation under non-forced conditions on insulin's bioactivity requires further investigation.
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Affiliation(s)
- Heloise Henry
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France; (J.-F.G.); (M.K.); (D.L.); (T.D.); (P.O.); (C.F.)
| | - Jean-François Goossens
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France; (J.-F.G.); (M.K.); (D.L.); (T.D.); (P.O.); (C.F.)
| | - Mostafa Kouach
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France; (J.-F.G.); (M.K.); (D.L.); (T.D.); (P.O.); (C.F.)
| | - Damien Lannoy
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France; (J.-F.G.); (M.K.); (D.L.); (T.D.); (P.O.); (C.F.)
| | - David Seguy
- Univ. Lille, Inserm, CHU Lille, U1286-INFINITE-Institute for Translational Research in Inflammation, F-59000 Lille, France;
| | - Thierry Dine
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France; (J.-F.G.); (M.K.); (D.L.); (T.D.); (P.O.); (C.F.)
| | - Pascal Odou
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France; (J.-F.G.); (M.K.); (D.L.); (T.D.); (P.O.); (C.F.)
| | - Catherine Foulon
- Univ. Lille, CHU Lille, ULR 7365-GRITA-Groupe de Recherche sur les formes Injectables et les Technologies Associées, F-59000 Lille, France; (J.-F.G.); (M.K.); (D.L.); (T.D.); (P.O.); (C.F.)
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Henry H, Lannoy D, Maboudou P, Seguy D, Dine T, Pigny P, Odou P. Addition of Regular Insulin to Ternary Parenteral Nutrition: A Stability Study. Pharmaceutics 2021; 13:pharmaceutics13040458. [PMID: 33801784 PMCID: PMC8066181 DOI: 10.3390/pharmaceutics13040458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/20/2021] [Accepted: 03/24/2021] [Indexed: 01/16/2023] Open
Abstract
Background: Parenteral nutrition (PN) is a complex medium in which added insulin can become unstable. The aim of this study is, therefore, to evaluate the stability of insulin in PN and to identify influencing factors. Methods: A total of 20 IU/L of regular insulin was added to PN in either glass or Ethylene Vinyl Acetate (EVA) containers. A 24 h stability study was performed via an electrochemiluminescence immunoassay in different media: A ternary PN admixture, separate compartments of the PN bag and a binary admixture. This study was repeated in the absence of zinc, with the addition of serum albumin or tween and with pH adjustment (3.6 or 6.3). Insulin concentration at t time was expressed as a percentage of the initial insulin concentration. Analysis of covariance (ANCOVA) was applied to determine the factors that influence insulin stability. Results: In all PN admixtures, the insulin concentration ratio decreased, stabilising at a 60% and then plateauing after 6 h. At pH 3.6, the ratio was above 90%, while at pH 6.3 it decreased, except in the amino acid solution. ANCOVA (r2 = 0.68, p = 0.01) identified dextrose and pH as significant factors influencing insulin stability. Conclusion: A low pH level seems to stabilise insulin in PN admixtures. The influence of dextrose content suggests that insulin glycation may influence stability.
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Affiliation(s)
- Heloise Henry
- ULR 7365–GRITA–Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, F-59000 Lille, France; (H.H.); (T.D.); (P.O.)
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France
| | - Damien Lannoy
- ULR 7365–GRITA–Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, F-59000 Lille, France; (H.H.); (T.D.); (P.O.)
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France
- Correspondence: ; Tel.: +33-(0)3-20-96-40-29; Fax: +33-(0)3-20-95-90-09
| | - Patrice Maboudou
- Service de Biochimie Automatisée Protéines, CHU Lille, F-59000 Lille, France;
| | - David Seguy
- Service Endocrinologie Diabétologie Maladies Métaboliques et Nutrition, CHU Lille, F-59000 Lille, France;
- U 1286–Infinite–Institute for Translational Research in Inflammation, University of Lille, F-59000 Lille, France
- Inserm, U 1286, F-59000 Lille, France
| | - Thierry Dine
- ULR 7365–GRITA–Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, F-59000 Lille, France; (H.H.); (T.D.); (P.O.)
| | - Pascal Pigny
- Laboratoire de Biochimie & Hormonologie, Centre de Biologie Pathologie, CHU Lille, F-59000 Lille, France;
| | - Pascal Odou
- ULR 7365–GRITA–Groupe de Recherche sur les Formes Injectables et les Technologies Associées, University of Lille, F-59000 Lille, France; (H.H.); (T.D.); (P.O.)
- Institut de Pharmacie, CHU Lille, F-59000 Lille, France
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[Measurement of insulin in multilayer bags for parenteral nutrition]. NUTR HOSP 2021; 38:685-689. [PMID: 33829850 DOI: 10.20960/nh.03460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Introduction: it is common to add rapid-acting insulin to parenteral nutrition (NP) bags for the management of hyperglycemia. However, insulin can be adsorbed in NP bags due to electrostatic interactions. Objective: to determine the influence of the presence of lipids and of insulin concentration in NP bags on the adsorption of insulin in these bags, as well as its stability for 5 days. Method: seven NP bags were prepared with the same volume and with a similar composition except for the presence of lipids and micronutrients, and insulin concentration. Insulin was determined by electrochemiluminescent immunoassay. Samples of 2 mL were taken after preparation and on day 5. Results: on day 1, the mean loss of insulin was 15.26 % (± 7.08) in the bags with lipids and 18.45 % (± 5.67) (p = 0.60) in the bags without lipids. The percentage of insulin lost by day 5 in the PN bags with lipids was 30.13 % (± 4.14), and in the PN bags without lipids it was 44.71 % (± 12.94) (p = 0,052). No correlation was observed between the amount of insulin added to the PN bags and the percentage of insulin lost between day 1 (ρ = -0.407, p = 0.365) or day 5 (ρ = -0.295, p = 0.521). Conclusions: there is an increase in insulin adsorption in NP EVA bags over time. The presence of lipids in the bags decreases adsorption. Further studies are needed to demonstrate the factors associated with insulin adsorption in EVA bags.
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Laesser CI, Cumming P, Reber E, Stanga Z, Muka T, Bally L. Management of Glucose Control in Noncritically Ill, Hospitalized Patients Receiving Parenteral and/or Enteral Nutrition: A Systematic Review. J Clin Med 2019; 8:jcm8070935. [PMID: 31261760 PMCID: PMC6678336 DOI: 10.3390/jcm8070935] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 12/25/2022] Open
Abstract
Hyperglycemia is a common occurrence in hospitalized patients receiving parenteral and/or enteral nutrition. Although there are several approaches to manage hyperglycemia, there is no consensus on the best practice. We systematically searched PubMed, Embase, Cochrane Central, and ClinicalTrials.gov to identify records (published or registered between April 1999 and April 2019) investigating strategies to manage glucose control in adults receiving parenteral and/or enteral nutrition whilst hospitalized in noncritical care units. A total of 15 completed studies comprising 1170 patients were identified, of which 11 were clinical trials and four observational studies. Diabetes management strategies entailed adaptations of nutritional regimens in four studies, while the remainder assessed different insulin regimens and administration routes. Diabetes-specific nutritional regimens that reduced glycemic excursions, as well as algorithm-driven insulin delivery approaches that allowed for flexible glucose-responsive insulin dosing, were both effective in improving glycemic control. However, the assessed studies were, in general, of limited quality, and we see a clear need for future rigorous studies to establish standards of care for patients with hyperglycemia receiving nutrition support.
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Affiliation(s)
- Céline Isabelle Laesser
- Department of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Paul Cumming
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- School of Psychology and Counselling and IHBI, Queensland University of Technology, Brisbane, QLD 4059, Australia
| | - Emilie Reber
- Department of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Zeno Stanga
- Department of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Taulant Muka
- Institute of Social and Preventive Medicine, University of Bern, 3012 Bern, Switzerland
| | - Lia Bally
- Department of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
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ÇELEBİ D, YILMAZ E. Cerrahi Hastalarda Enteral ve Parenteral Beslenmede Kanıta Dayalı Uygulamalar ve Hemşirelik Bakımı. İSTANBUL GELIŞIM ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2019. [DOI: 10.38079/igusabder.546979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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