Effectiveness of regular versus glargine insulin in stable critical care patients receiving parenteral nutrition: a randomized controlled trial

Evaluation of Basal Plus Versus Sliding Scale Insulin Therapy on Glucose Variability in Critically Ill Patients Without Preexisting Diabetes

BACKGROUND

There is limited evidence evaluating the impact of insulin treatment strategies on glucose variability in critically ill patients without preexisting diabetes.

OBJECTIVE

Compare basal plus insulin (BPI) and sliding scale insulin (SSI) impact on glycemic control outcomes in critically ill patients without preexisting diabetes experiencing hyperglycemia.

METHODS

This multicenter, retrospective review analyzed critically ill patients with hyperglycemia who received either BPI or SSI. Patients with a hemoglobin A1C >6.5% during the admission of interest or in the previous 3 months, or a diagnosis of diabetes at the time of discharge were excluded. The primary outcome was glucose variability during the intensive care unit (ICU) admission. Secondary outcomes included hypoglycemia frequency, frequency of goal glucose levels, mortality, and length of stay.

RESULTS

The analysis included 228 patients (39 in BPI, 189 in SSI). Average glucose variability was higher in the BPI group compared with the SSI group (85.8 mg/dL ± 33.1 vs 70.2 mg/dL ± 30.7; P = 0.009), which remained when controlling for baseline confounding (-12.1 [5.6], 95% CI -23.2 to -0.99; P = 0.033). Hypoglycemia incidence was similar between groups. BPI patients had a lower incidence of glucose values within goal range than SSI patients (P = 0.046). There was no difference in length of stay or hospital mortality.

CONCLUSIONS AND RELEVANCE

The use of SSI compared with a BPI regimen may result in reduced glycemic variability in critically ill patients without preexisting diabetes. Future prospective studies, with a larger sample size, are warranted to confirm our exploratory findings and characterize clinically significant benefits.

Finding the sweet spot: Managing parenteral nutrition-related glycemic complications in hospitalized adults

Parenteral nutrition (PN) remains an important aspect of treating hospitalized adult patients who are otherwise unable to achieve adequate nutrition intake. PN is highly individualized and requires careful adjustment of macronutrients and micronutrients to minimize complications. One frequent complication associated with PN involves blood glucose (BG) derangements including both hypoglycemia and hyperglycemia. PN-related glycemic complications are complex and multifactorial. Close BG monitoring is required for selecting and evaluating therapeutic interventions. BG goals for patients treated with PN may vary depending on patient-specific characteristics. Since dextrose provides the carbohydrate source in PN prescriptions, hyperglycemia may be expected, but nondextrose causes must also be considered. Insulin is a mainstay of therapy for managing glycemic complications related to PN, and the regimen chosen depends on patient-specific factors. However, insulin therapy also places the patient at an increased risk of hypoglycemia. Similarly, insulin is not the sole cause of hypoglycemia in these patients. The aim of this review is to describe the factors associated with dysglycemia during PN therapy and provide recommendations for minimizing and managing these complications, which is paramount to providing high-quality patient care and improving clinical outcomes.

Efficacy and safety of different insulin infusion methods in the treatment of total parenteral nutrition-associated hyperglycemia: a systematic review and network meta-analysis

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.

Insulin therapy and blood glucose management in critically ill patients: a 1-day cross-sectional observational study in 69 French intensive care units

BACKGROUND

Hyperglycaemia is common in critically ill patients, but blood glucose and insulin management may differ widely among intensive care units (ICUs). We aimed to describe insulin use practices and the resulting glycaemic control in French ICUs. We conducted a multicentre 1-day observational study on November 23, 2021, in 69 French ICUs. Adult patients hospitalized for an acute organ failure, severe infection or post-operative care were included. Data were recorded from midnight to 11:59 p.m. the day of the study by 4-h periods.

RESULTS

Two ICUs declared to have no insulin protocol. There was a wide disparity in blood glucose targets between ICUs with 35 different target ranges recorded. In 893 included patients we collected 4823 blood glucose values whose distribution varied significantly across ICUs (P < 0.0001). We observed 1135 hyperglycaemias (> 1.8 g/L) in 402 (45.0%) patients, 35 hypoglycaemias (≤ 0.7 g/L) in 26 (2.9%) patients, and one instance of severe hypoglycaemia (≤ 0.4 g/L). Four hundred eight (45.7%) patients received either IV insulin (255 [62.5%]), subcutaneous (SC) insulin (126 [30.9%]), or both (27 [6.6%]). Among patients under protocolized intravenous (IV) insulin, 767/1681 (45.6%) of glycaemias were above the target range. Among patients receiving insulin, short- and long-acting SC insulin use were associated with higher counts of hyperglycaemias as assessed by multivariable negative binomial regression adjusted for the propensity to receive SC insulin: incidence rate ratio of 3.45 (95% confidence interval [CI] 2.97-4.00) (P < 0.0001) and 3.58 (95% CI 2.84-4.52) (P < 0.0001), respectively.

CONCLUSIONS

Practices regarding blood glucose management varied widely among French ICUs. Administration of short or long-acting SC insulin was not unusual and associated with more frequent hyperglycaemia. The protocolized insulin algorithms used failed to prevent hyperglycaemic events.

Behavior of Regular Insulin in a Parenteral Nutrition Admixture: Validation of an LC/MS-MS Assay and the In Vitro Evaluation of Insulin Glycation

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.

A randomized trial to investigate the efficacy and safety of insulin glargine in hyperglycemic acute stroke patients receiving intensive care

This pilot, randomized, open-label controlled study compared the basal–bolus regimens of insulin glargine (IG) and neutral protamine Hagedorn (NPH) insulin in stroke patients with hyperglycemia receiving intensive care. The study recruited acute stroke patients requiring intensive care within 72 h (h) of onset and had blood glucose > 200 mg/dL. 50 patients received IG (n = 26) or NPH (n = 24) with added short-acting prandial regular insulin over a 72-h period. The primary end point was the percentage of glucose within 80–180 mg/dL assessed through continuous glucose monitoring. The baseline characteristics were comparable, except the IG had higher glucose pre-randomization than the NPH (290.69 ± 82.31 vs. 246.04 ± 41.76 mg/dL, P = 0.021). The percentage of time with glucose between 80 and 180 mg/dL was 45.88 ± 27.04% in the IG and 53.56 ± 22.89% in the NPH (P = 0.341) and the percentage of glucose reduction was 31.47 ± 17.52% in the IG and 27.28 ± 14.56% in the NPH (P = 0.374). The percentage of time with glucose < 60 mg/dL was 0.14 ± 0.49% in the IG and 0.47 ± 1.74% in the NPH. Poststroke outcomes were not significantly different. In conclusion, IG is safe and equally effective as an NPH-based basal-bolus regimen for acute stroke patients with hyperglycemia receiving intensive care.

Trial registration ClinicalTrials.gov, NCT02607943. Registered 18/11/2015, https://clinicaltrials.gov/ct2/show/NCT02607943.

Addition of Regular Insulin to Ternary Parenteral Nutrition: A Stability Study

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.

[Measurement of insulin in multilayer bags for parenteral nutrition]

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.

Effect of Adding Insulin Glargine on Glycemic Control in Critically Ill Patients Admitted to Intensive Care Units: A Prospective Randomized Controlled Study

OBJECTIVE

We aimed to examine the effects of adding a longer-acting insulin glargine to existing glucose control on reducing blood-glucose fluctuations in an intensive care unit (ICU).

METHODS

A total of 110 patients randomly received adjuvant insulin glargine 15 IU/day (glargine) or placebo (control), in addition to daily infusion of insulin to maintain glucose levels at a target of 140-180 mg/dL. End points were mean and variance of blood glucose and frequency of hypoglycemia, hyperglycemia, ICU stay, and mortality. Data were analyzed with repeated-measures ANOVA and Mann-Whitney U test.

RESULTS

Average daily glucose level was significantly less in the glargine group than controls (P<0.0001), while there was no difference in daily variance in blood glucose between the two groups. The duration of glucose concentrations being within the target range was identical between the glargine and control groups (16.6±4.9 vs 16.4±4.6 hours/day, P=0.844) during the 7 days of admission. The frequency of hypoglycemia was greater in the glargine group and total duration of hyperglycemia (>180 mg/dL) much longer among controls (P<0.001). Similar mortality rates were observed in both groups, while ICU length of stay was 2 days shorter in the glargine group.

CONCLUSION

Addition of insulin glargine to routine protocols more effectively reduces glucose levels and decreases incidence of hyperglycemic episodes and regular insulin usage. This adjustment may be associated with decreases in duration of ICU stay or increases in hypoglycemic events.

Regular insulin added to total parenteral nutrition vs subcutaneous glargine in non-critically ill diabetic inpatients, a multicenter randomized clinical trial: INSUPAR trial

BACKGROUND

There is no established insulin regimen in T2DM patients receiving parenteral nutrition.

AIMS

To compare the effectiveness (metabolic control) and safety of two insulin regimens in patients with diabetes receiving TPN.

DESIGN

Prospective, open-label, multicenter, clinical trial on adult inpatients with type 2 diabetes on a non-critical setting with indication for TPN. Patients were randomized on one of these two regimens: 100% of RI on TPN or 50% of Regular insulin added to TPN bag and 50% subcutaneous GI. Data were analyzed according to intention-to-treat principle.

RESULTS

81 patients were on RI and 80 on GI. No differences were observed in neither average total daily dose of insulin, programmed or correction, nor in capillary mean blood glucose during TPN infusion (165.3 ± 35.4 in RI vs 172.5 ± 43.6 mg/dL in GI; p = 0.25). Mean capillary glucose was significantly lower in the GI group within two days after TPN interruption (160.3 ± 45.1 in RI vs 141.7 ± 43.8 mg/dL in GI; p = 0.024). The percentage of capillary glucose above 180 mg/dL was similar in both groups. The rate of capillary glucose ≤70 mg/dL, the number of hypoglycemic episodes per 100 days of TPN, and the percentage of patients with non-severe hypoglycemia were significantly higher on GI group. No severe hypoglycemia was detected. No differences were observed in length of stay, infectious complications, or hospital mortality.

CONCLUSION

Effectiveness of both regimens was similar. GI group achieved better metabolic control after TPN interruption but non-severe hypoglycemia rate was higher in the GI group.

CLINICAL TRIAL REGISTRY

This trial is registered at clinicaltrials.gov as NCT02706119.

Glycemic Control in Adult Surgical Patients Receiving Regular Insulin Added to Parenteral Nutrition vs Insulin Glargine: A Retrospective Chart Review

BACKGROUND

Hyperglycemia is a frequent complication in patients receiving parenteral nutrition (PN) and has been associated with an increased risk of mortality. Treatment of hyperglycemia requires insulin therapy; however, the optimal dose and route have not been established. This study aimed to compare regular insulin added to PN (RI-in-PN) with subcutaneous insulin glargine for the management of hyperglycemia in patients receiving PN.

METHODS

This retrospective study was conducted at a tertiary medical center and reviewed 113 adult, non-critically ill surgical patient admissions receiving PN over a 5-year period. The primary outcome was achievement of glycemic control. Secondary outcomes were time to glycemic control, hypoglycemic events, hospital length of stay, and 1-year mortality.

RESULTS

The RI-in-PN group had a significantly higher percentage of patient admissions who achieved glycemic control compared with the insulin glargine group (71.8% vs 48.6%, P = 0.017). There was no difference in time to glycemic control, hypoglycemic events, hospital length of stay, or 1-year mortality between groups. Among patients with diabetes mellitus (DM), however, the insulin glargine group had a significantly higher percentage of admissions with at least 1 hypoglycemic event (45.5% vs 20%, P = 0.035).

CONCLUSIONS

RI-in-PN is recommended over insulin glargine because of the higher likelihood of achieving glycemic control and, in patients with DM, lower risk of hypoglycemic events. Large, randomized controlled trials are needed to further guide prescribing practice.

THE MANAGEMENT OF HYPERGLYCEMIA IN NONCRITICALLY ILL HOSPITALIZED PATIENTS TREATED WITH CONTINUOUS ENTERAL OR PARENTERAL NUTRITION

OBJECTIVE

Hyperglycemia is a common problem in hospitalized patients receiving artificial nutrition, and this development of hyperglycemia during parenteral nutrition therapy (PNT) and enteral nutrition therapy (ENT) increases the risks of hospital-related complications and mortality. This review aims to discuss the pathogenesis of hyperglycemia from artificial nutrition in the hospital, summarize current evidence on the treatment of hyperglycemia with insulin in these patients, and review current guidelines.

METHODS

A systematic literature review using PubMed and the Medical Subject Headings (MeSH) terms "hyperglycemia," "enteral nutrition," and "parenteral nutrition" were used to evaluate the current evidence available for treating noncritically ill patients with hyperglycemia who were receiving artificial nutrition.

RESULTS

The literature review showed that few randomized control trials exist regarding treatment of hyperglycemia in this cohort of patients, and the multiple retrospective evaluations that have addressed this topic provided varied results. In general, intravenous (IV) continuous insulin infusion offers the best glycemic control; however, this route of insulin administration is often burdensome for floor patients and their care teams. Administration of scheduled subcutaneous (SQ) insulin in patients on ENT or PNT is a safe and effective way to manage hyperglycemia, however limited data exist on an appropriate insulin regimen.

CONCLUSION

Further prospective, randomized control trials are necessary to determine the optimal treatment of hyperglycemia for patients receiving ENT or PNT.

ABBREVIATIONS

BG = blood glucose; CG = conventional glycemic control; ENT = enteral nutrition therapy; GIP = glucose-dependent insulinotropic polypeptide; GLP-1 = glucagon-like peptide 1; IG = intensive glycemic control; IV = intravenous; NPH = neutral protamine Hagedorn; PNT = parenteral nutrition therapy; SQ = subcutaneous; T2DM = type 2 diabetes mellitus; TDD = total daily dose; TPN = total parenteral nutrition.

Differences in Glycemic Control in Diabetic and Non-diabetic Patients with Parenteral Nutrition Using a Basal plus Correction Insulin Regimen: An Observational, Retrospective Study

INTRODUCTION

Hyperglycemia is a frequent complication of parenteral nutrition (PN) in patients both with and without diabetes mellitis (DM). The aim of this study was to evaluate the quality of glucose control achieved with basal plus-correction insulin in surgical patients with and without a history of DM receiving PN.

METHODS

Retrospective evaluation of a protocol applied during the period of January 2013-December 2015. The insulin dose was started at 0.4 and 0.3 IU/kg/day in patients with previous DM and without a history of DM, respectively, and the target blood glucose (BG) was < 180 mg/dl. Mean BG levels, insulin total daily dose (TDD) and hypoglycemic (< 70 mg/dl) events on different days of PN were also evaluated.

RESULTS

Forty-one patients with previous type 2 DM and 39 without DM were evaluated. Glycemic control in both groups was as follows: during the first 48 h (230.4 ± 67 vs. 189.4 ± 38 mg/dl, p = 0.002); at the midpoint (224.6 ± 58 vs. 181.3 ± 27 mg/dl, p = 0.003); 48 h before ending TPN (196.4 ± 43 vs. 169.8 ± 40 mg/dl, p = 0.004). Insulin TDD was 0.5 ± 0.3 U/kg/day in patients with DM and 0.37 ± 0.3 units/kg/day in those without DM (p < 0.05). A total of 18 patients experienced hypoglycemic events, without differences between the groups.

CONCLUSION

A basal-correction insulin regimen is an alternative method for managing hyperglycemia in non-critically ill surgical patients on PN.

Addition of Insulin to Parenteral Nutrition for Control of Hyperglycemia

Administration of parenteral nutrition (PN) may result in hyperglycemia in patients with preexisting diabetes or disease-related insulin resistance, and it can be associated with increased rates of complications. Treatment requires insulin therapy. Insulin can be administered subcutaneously, intravenously via a variable rate sliding scale, or by adding it directly to the PN. The last method is a potentially attractive technique for a number of reasons-it could deliver the insulin intravenously at a steady rate alongside carbohydrates, and in malnourished patients with little subcutaneous tissue, it may prevent the need for frequent insulin injections. Despite such potential advantages, the addition of insulin to PN remains controversial, largely with respect to the bioavailability of insulin in PN and resultant concerns of the risk of hypoglycemia. There is a paucity of long-term quality controlled studies to address this question. The available literature suggests that, at least in the short term, insulin addition to PN can achieve reasonable glycemic control with low rates of hypoglycemia, and the technique compares favorably with the use of long-acting insulin preparations. This literature review finds a wide range of values reported for insulin availability via PN, ranging from 44% to 95% depending on the type of PN container material used and the presence of added vitamins and trace elements. Few studies looking at glycemic control among patients receiving home PN were found, and larger prospective trials are needed to assess the efficacy and safety of this technique in this patient group.

Insulin Regimens to Treat Hyperglycemia in Hospitalized Patients on Nutritional Support: Systematic Review and Meta-Analyses

BACKGROUND

The best insulin regimen to treat hyperglycemia in hospitalized patients on nutritional support (NS) is unclear.

METHODS

We searched electronic databases to identify cohort studies or randomized clinical trials in order to evaluate the efficacy of different insulin regimens used to treat hyperglycemia in hospitalized patients on NS on diverse outcomes: mean blood glucose (MBG), hypoglycemia, length of stay in hospital, and mortality.

RESULTS

Seventeen studies from a total of 5,030 were included. Enteral Group included 8 studies; 1,203 patients using rapid, glargine, NPH, or Premix insulin; MBG 108-225 mg/dL; hypoglycemia 0-13%. In indirect meta-analyses, NPH insulin ranked best for glucose control (MD 95% CI -2.50 mg/dL [2.65 to -2.35]). Parenteral Group included 4 studies; 228 patients using regular and glargine or NPH insulin; MBG 137-202 mg/dL; hypoglycemia 0-40%. In meta-analyses comparing regular insulin added to parenteral nutrition bag with glargine, MBG (MD 95% CI -3.78 mg/dL [-11.93 to 4.37]; I2 = 0%) or hypoglycemia frequency (RR 95% CI 1.37 [0.43-4.32]; I2 = 70.7%) did not differ. The description related to hospital length of stay and mortality was inconsistent between groups.

CONCLUSIONS

The best insulin regimen to treat hyperglycemia in hospitalized patients on NS has not been established; best results using insulin regimens with NPH in enteral nutrition do not seem to be clinically relevant.

Management of hospitalized type 2 diabetes mellitus patients

Both hyperglycemia and hypoglycemia in hospitalized patients are associated with adverse outcomes including increased rates of infection, longer hospital length of stay, and even death. Clinical trials in patients with type 2 diabetes mellitus proved that by improving glycemic control, we can reduce all of them. Insulin is the preferred treatment for glycemic control in most cases, but alternative treatment options that can normalize blood glucose levels without hypoglycemia are being sought. Moreover, hospitalized patients are particularly vulnerable to severe, prolonged hypoglycemia since they may be unable to sense or respond to the early warning signs and symptoms of low blood glucose. Finally, nutritional support, corticosteroid therapy, and surgery increase the risk of hyperglycemia that leads to an increased risk of morbidity and mortality. We review the management of type 2 diabetes mellitus patients who are admitted to the general medical wards of the hospital for a procedure of intercurrent illness.

Association Between the Use of Long-Acting Insulin and Hypoglycemia in Nondiabetic Patients in the Surgical Intensive Care Unit

PURPOSE

The purpose of this study was to examine the association between long-acting insulin and hypoglycemia in nondiabetic surgical intensive care patients.

METHODS

This single-center, retrospective cohort study evaluated glycemic control in nondiabetic critically ill surgical patients receiving long-acting insulin plus sliding scale versus those receiving sliding scale alone. Patients were matched based on sliding scale order and type of surgery. The primary outcome was the proportion of patients who experienced hypoglycemia (glucose values <70 mg/dL). Secondary outcomes included comparing the distribution of glycemic events in the 2 groups and describing the proportion of patients transferred out of the intensive care unit on long-acting insulin who experienced hypoglycemia.

RESULTS

One hundred twenty patients met the study criteria. Hypoglycemia was significantly higher in the long-acting insulin plus sliding scale group compared to those receiving sliding scale alone (17 [28.3%] patients vs 8 [13.3%] patients; P = .047). After adjusting for body mass index, renal failure, age, and Acute Physiology and Chronic Health Evaluation II, the odds of hypoglycemia were 4.1 times higher for patients receiving long-acting insulin and sliding scale compared to those receiving sliding scale alone ( P = .02). There were more hypoglycemic events (42 vs 20; P = .05) and hyperglycemic events (313 vs 135; P = .02) in the long-acting insulin group.

CONCLUSION

This study demonstrated higher rates of hypoglycemia associated with the utilization of long-acting insulin in nondiabetic surgical intensive care patients. Risk of hypoglycemia should be weighed against possible benefits in this population.

Significant Published Articles for Pharmacy Nutrition Support Practice in 2014 and 2015

PURPOSE

To assist the pharmacy clinician engaged in nutrition support in staying current with the most pertinent literature.

METHODS

Several experienced board-certified clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2014 and 2015 that they considered to be important to their practice. Only those articles available in print format were considered for potential inclusion. Articles available only in preprint electronic format were not evaluated. The citation list was compiled into a single spreadsheet where the author participants were asked to ascertain whether they considered the paper important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority of author participants (at least 5 out of 8) considered the paper to be important.

RESULTS

A total of 108 articles were identified; 36 of which were considered to be of high importance. An important guideline article published in early 2016, but not ranked, was also included. The top-ranked articles from the primary literature were reviewed.

CONCLUSION

It is recommended that the informed pharmacist, who is engaged in nutrition support therapy, be familiar with the majority of these articles.