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Pantanetti P, Cangelosi G, Sguanci M, Morales Palomares S, Nguyen CTT, Morresi G, Mancin S, Petrelli F. Glycemic Control in Diabetic Patients Receiving a Diabetes-Specific Nutritional Enteral Formula: A Case Series in Home Care Settings. Nutrients 2024; 16:2602. [PMID: 39203739 PMCID: PMC11357306 DOI: 10.3390/nu16162602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 07/26/2024] [Accepted: 08/05/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND AND AIM In patients with Diabetes Mellitus (DM), Enteral Nutrition (EN) is associated with less hyperglycemia and lower insulin requirements compared to Parenteral Nutrition (PN). The primary aim of this study was to assess changes in glycemic control (GC) in DM patients on EN therapy. The secondary objectives included evaluating the impact of the specialized formula on various clinical parameters and the tolerability of the nutritional formula by monitoring potential gastrointestinal side effects. METHODS We report a case series on the effects of a Diabetes-Specific Formula (DSF) on GC, lipid profile (LP), and renal and hepatic function in a DM cohort receiving EN support. RESULTS Twenty-two DM subjects with total dysphagia (thirteen men, nine women) on continuous EN were observed. The use of a DSF in EN was associated with an improvement in glycemic indices across all patients studied, leading to a reduction in average insulin demand. No hospitalizations were reported during the study period. CONCLUSION The study demonstrated that the use of DSFs in a multi-dimensional home care management setting can improve glycemic control, reduce glycemic variability and insulin need, and positively impact the lipid profile of the DM cohort. The metabolic improvements were supported by the clinical outcomes observed.
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Affiliation(s)
- Paola Pantanetti
- Unit of Diabetology, Asur Marche–Area Vasta 4, 63900 Fermo, Italy; (P.P.); (G.C.)
| | - Giovanni Cangelosi
- Unit of Diabetology, Asur Marche–Area Vasta 4, 63900 Fermo, Italy; (P.P.); (G.C.)
| | - Marco Sguanci
- A.O. Polyclinic San Martino Hospital, Largo R. Benzi 10, 16132 Genova, Italy;
| | - Sara Morales Palomares
- Department of Pharmacy, Health and Nutritional Sciences (DFSSN), University of Calabria, 87036 Rende, Italy;
| | - Cuc Thi Thu Nguyen
- Department of Pharmaceutical Administration and Economics, Hanoi University of Pharmacy, Hanoi 100000, Vietnam;
| | | | - Stefano Mancin
- IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy;
| | - Fabio Petrelli
- School of Pharmacy, Polo Medicina Sperimentale e Sanità Pubblica “Stefania Scuri”, Via Madonna delle Carceri 9, 62032 Camerino, Italy
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Rebollo-Pérez MI, Florencio Ojeda L, García-Luna PP, Irles Rocamora JA, Olveira G, Lacalle Remigio JR, Arraiza Irigoyen C, Calañas Continente A, Campos Martín C, Fernández Soto ML, García Almeida JM, López ML, Losada Morell C, Luengo Pérez LM, Muñoz de Escalona Martínez T, Pereira-Cunill JL, Vílchez-López FJ, Rabat-Restrepo JM. Standards for the Use of Enteral Nutrition in Patients with Diabetes or Stress Hyperglycaemia: Expert Consensus. Nutrients 2023; 15:4976. [PMID: 38068834 PMCID: PMC10707756 DOI: 10.3390/nu15234976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
(1) Background: Hyperglycaemia that occurs during enteral nutrition (EN) should be prevented and treated appropriately since it can have important consequences for morbidity and mortality. However, there are few quality studies in the literature regarding the management of EN in this situation. The objective of this project was to attempt to respond, through a panel of experts, to those clinical problems regarding EN in patients with diabetes or stress hyperglycaemia (hereinafter referred to only as hyperglycaemia) for which we do not have conclusive scientific evidence; (2) Methods: The RAND/UCLA Appropriateness Method, a modified Delphi panel method, was applied. A panel of experts made up of 10 clinical nutrition specialists was formed, and they scored on the appropriateness of EN in hyperglycaemia, doing so in two rounds. A total of 2992 clinical scenarios were examined, which were stratified into five chapters: type of formula used, method of administration, infusion site, treatment of diabetes, and gastrointestinal complications. (3) Results: consensus was detected in 36.4% of the clinical scenarios presented, of which 23.7% were deemed appropriate scenarios, while 12.7% were deemed inappropriate. The remaining 63.6% of the scenarios were classified as uncertain; (4) Conclusions: The recommendations extracted will be useful for improving the clinical management of these patients. However, there are still many uncertain scenarios reflecting that the criteria for the management of EN in hyperglycaemia are not completely standardised. More studies are required to provide quality recommendations in this area.
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Affiliation(s)
- María I. Rebollo-Pérez
- Endocrinology and Nutrition Clinical Management Unit, University Hospital Juan Ramón Jiménez, 21005 Huelva, Spain; (M.I.R.-P.); (L.F.O.); (M.L.L.)
| | - Luna Florencio Ojeda
- Endocrinology and Nutrition Clinical Management Unit, University Hospital Juan Ramón Jiménez, 21005 Huelva, Spain; (M.I.R.-P.); (L.F.O.); (M.L.L.)
| | - Pedro P. García-Luna
- Regional Andalusian Health Service, Service of Endocrinology and Nutrition, University Hospitals Virgen del Rocío, 41013 Seville, Spain; (P.P.G.-L.); (J.L.P.-C.)
- Faculty of Medicine, University of Seville, 41009 Seville, Spain; (J.A.I.R.); (J.M.R.-R.)
| | - José A. Irles Rocamora
- Faculty of Medicine, University of Seville, 41009 Seville, Spain; (J.A.I.R.); (J.M.R.-R.)
- Endocrinology and Nutrition Clinical Management Unit, University Hospital Valme, 41014 Seville, Spain
| | - Gabriel Olveira
- Biomedical Research Institute of Málaga (IBIMA), 29010 Málaga, Spain;
- Endocrinology and Nutrition Clinical Management Unit, Regional University Hospital of Málaga/University of Málaga, 29010 Málaga, Spain
- Biomedical Network Research Centre for Diabetes and Associated Metabolic Diseases (CIBERDEM) (CB07/08/0019), Health institute Carlos III, 28029 Madrid, Spain
- Medicine and Dermatology Department, Faculty of Medicine, University of Málaga, 29010 Málaga, Spain
| | | | | | - Alfonso Calañas Continente
- Endocrinology and Nutrition Clinical Management Unit, University Hospital Reina Sofia, 14004 Córdoba, Spain;
| | - Cristina Campos Martín
- Endocrinology and Nutrition Clinical Management Unit, University Hospital Virgen Macarena, 41009 Seville, Spain
| | - María Luisa Fernández Soto
- Endocrinology and Nutrition Clinical Management Unit, University Hospital San Cecilio, 18012 Granada, Spain;
- Biosanitary Institute of Granada, Medicine Department, Faculty of Medicine of Granada, University of Granada, 18010 Granada, Spain
| | - José Manuel García Almeida
- Biomedical Research Institute of Málaga (IBIMA), 29010 Málaga, Spain;
- Endocrinology and Nutrition Clinical Management Unit, University Hospital Virgen de la Victoria, 29010 Málaga, Spain
| | - María Laínez López
- Endocrinology and Nutrition Clinical Management Unit, University Hospital Juan Ramón Jiménez, 21005 Huelva, Spain; (M.I.R.-P.); (L.F.O.); (M.L.L.)
| | - Concepción Losada Morell
- Endocrinology and Nutrition Clinical Management Unit, Internal Medicine Clinical Management Unit, Hospital Infanta Margarita, 14940 Cabra, Córdoba, Spain;
| | | | | | - José L. Pereira-Cunill
- Regional Andalusian Health Service, Service of Endocrinology and Nutrition, University Hospitals Virgen del Rocío, 41013 Seville, Spain; (P.P.G.-L.); (J.L.P.-C.)
- Faculty of Medicine, University of Seville, 41009 Seville, Spain; (J.A.I.R.); (J.M.R.-R.)
| | - Francisco J. Vílchez-López
- Endocrinology and Nutrition Clinical Management Unit, Biomedical Research and Innovation Institute of Cádiz, University Hospital Puerta del Mar, 11009 Cádiz, Spain;
| | - Juana M. Rabat-Restrepo
- Faculty of Medicine, University of Seville, 41009 Seville, Spain; (J.A.I.R.); (J.M.R.-R.)
- Endocrinology and Nutrition Clinical Management Unit, University Hospital Virgen Macarena, 41009 Seville, Spain
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3
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Polavarapu P, Pachigolla S, Drincic A. Glycemic Management of Hospitalized Patients Receiving Nutrition Support. Diabetes Spectr 2022; 35:427-439. [PMID: 36561651 PMCID: PMC9668719 DOI: 10.2337/dsi22-0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Enteral nutrition (EN) and parenteral nutrition (PN) increase the risk of hyperglycemia and adverse outcomes, including mortality, in patients with and without diabetes. A blood glucose target range of 140-180 mg/dL is recommended for hospitalized patients receiving artificial nutrition. Using a diabetes-specific EN formula, lowering the dextrose content, and using a hypocaloric PN formula have all been shown to prevent hyperglycemia and associated adverse outcomes. Insulin, given either subcutaneously or as a continuous infusion, is the mainstay of treatment for hyperglycemia. However, no subcutaneous insulin regimen has been shown to be superior to others. This review summarizes the evidence on and provides recommendations for the treatment of EN- and PN-associated hyperglycemia and offers strategies for hypoglycemia prevention. The authors also highlight their institution's protocol for the safe use of insulin in the PN bag. Randomized controlled trials evaluating safety and efficacy of targeted insulin therapy synchronized with different types of EN or PN delivery are needed.
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Affiliation(s)
- Preethi Polavarapu
- Department of Diabetes, Endocrinology and Metabolism, Division of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
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Galindo RJ, Pasquel FJ, Vellanki P, Alicic R, Lam DW, Fayfman M, Migdal AL, Davis GM, Cardona S, Urrutia MA, Perez-Guzman C, Zamudio-Coronado KW, Peng L, Tuttle KR, Umpierrez GE. Degludec hospital trial: A randomized controlled trial comparing insulin degludec U100 and glargine U100 for the inpatient management of patients with type 2 diabetes. Diabetes Obes Metab 2022; 24:42-49. [PMID: 34490700 PMCID: PMC8665002 DOI: 10.1111/dom.14544] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 01/03/2023]
Abstract
AIMS Limited data exist about the use of insulin degludec in the hospital. This multicentre, non-inferiority, open-label, prospective randomized trial compared the safety and efficacy of insulin degludec-U100 and glargine-U100 for the management of hospitalized patients with type 2 diabetes. METHODS In total, 180 general medical and surgical patients with an admission blood glucose (BG) between 7.8 and 22.2 mmol/L, treated with oral agents or insulin before hospitalization were randomly allocated (1:1) to a basal-bolus regimen using degludec (n = 92) or glargine (n = 88), as basal and aspart before meals. Insulin dose was adjusted daily to a target BG between 3.9 and 10.0 mmol/L. The primary endpoint was the difference in mean hospital daily BG between groups. RESULTS Overall, the randomization BG was 12.2 ± 2.9 mmol/L and glycated haemoglobin 84 mmol/mol (9.8% ± 2.0%). There were no differences in mean daily BG (10.0 ± 2.1 vs. 10.0 ± 2.5 mmol/L, p = .9), proportion of BG in target range (54·5% ± 29% vs. 55·3% ± 28%, p = .85), basal insulin (29.6 ± 13 vs. 30.4 ± 18 units/day, p = .85), length of stay [median (IQR): 6.7 (4.7-10.5) vs. 7.5 (4.7-11.6) days, p = .61], hospital complications (23% vs. 23%, p = .95) between treatment groups. There were no differences in the proportion of patients with BG <3.9 mmol/L (17% vs. 19%, p = .75) or <3.0 mmol/L (3.7% vs. 1.3%, p = .62) between degludec and glargine. CONCLUSION Hospital treatment with degludec-U100 or glargine-U100 is equally safe and effective for the management of hyperglycaemia in general medical and surgical patients with type 2 diabetes.
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Affiliation(s)
- Rodolfo J Galindo
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Francisco J Pasquel
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Priyathama Vellanki
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Radica Alicic
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Providence Health Care, Spokane, Washington, USA
| | - David W Lam
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Maya Fayfman
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alexandra L Migdal
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Georgia M Davis
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Saumeth Cardona
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maria A Urrutia
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Citlalli Perez-Guzman
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Limin Peng
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Katherine R Tuttle
- Providence Health Care, Spokane, Washington, USA
- Division of Nephrology and Kidney Research Institute, Department of Medicine, University of Washington, Seattle, Washington, USA
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Gracia-Ramos AE, Carretero-Gómez J, Mendez CE, Carrasco-Sánchez FJ. Evidence-based therapeutics for hyperglycemia in hospitalized noncritically ill patients. Curr Med Res Opin 2022; 38:43-53. [PMID: 34694181 DOI: 10.1080/03007995.2021.1997288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Hyperglycemia in hospitalized patients, either with or without diabetes, is a common, serious, and costly healthcare problem. Evidence accumulated over 20 years has associated hyperglycemia with a significant increase in morbidity and mortality, both in surgical and medical patients. Based on this documented link between hyperglycemia and poor outcomes, clinical guidelines from professional organizations recommend the treatment of hospital hyperglycemia with a therapeutic goal of maintaining blood glucose (BG) levels less than 180 mg/dL. Insulin therapy remains a mainstay of glycemic management in the inpatient setting. The use of non-insulin antidiabetic drugs in the hospital setting is limited because little data are available regarding their safety and efficacy. However, information about the use of incretin-based therapy in inpatients has increased in the past 15 years. This review aims to summarize the different treatment strategies for hyperglycemia in hospitalized noncritical patients that are supported by observational studies or clinical trials with insulin and non-insulin drugs. In addition, we propose a protocol to help with the management of this important clinical problem.
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Affiliation(s)
- Abraham Edgar Gracia-Ramos
- Department of Internal Medicine, General Hospital, National Medicinal Center "La Raza," Instituto Mexicano del Seguro Social, Mexico City, Mexico
- Sección de Estudios de Posgrado e Investigación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City, Mexico
| | | | - Carlos E Mendez
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Diabetes and Endocrinology, Milwaukee VA Medical Center, Milwaukee, WI, USA
| | - Francisco Javier Carrasco-Sánchez
- Department of Internal Medicine, Diabetes and Cardiovascular Risk Factor Unit, University Hospital Juan Ramón Jimenez, Huelva, Spain
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Perspectives of glycemic variability in diabetic neuropathy: a comprehensive review. Commun Biol 2021; 4:1366. [PMID: 34876671 PMCID: PMC8651799 DOI: 10.1038/s42003-021-02896-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/16/2021] [Indexed: 12/14/2022] Open
Abstract
Diabetic neuropathy is one of the most prevalent chronic complications of diabetes, and up to half of diabetic patients will develop diabetic neuropathy during their disease course. Notably, emerging evidence suggests that glycemic variability is associated with the pathogenesis of diabetic complications and has emerged as a possible independent risk factor for diabetic neuropathy. In this review, we describe the commonly used metrics for evaluating glycemic variability in clinical practice and summarize the role and related mechanisms of glycemic variability in diabetic neuropathy, including cardiovascular autonomic neuropathy, diabetic peripheral neuropathy and cognitive impairment. In addition, we also address the potential pharmacological and non-pharmacological treatment methods for diabetic neuropathy, aiming to provide ideas for the treatment of diabetic neuropathy. Zhang et al. describe metrics for evaluating glycaemic variability (GV) in clinical practice and summarize the role and related mechanisms of GV in diabetic neuropathy, including cardiovascular autonomic neuropathy, diabetic peripheral neuropathy and cognitive impairment. They aim to stimulate ideas for the treatment of diabetic neuropathy.
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D'Souza SC, Kruger DF. Considerations for Insulin-Treated Type 2 Diabetes Patients During Hospitalization: A Narrative Review of What We Need to Know in the Age of Second-Generation Basal Insulin Analogs. Diabetes Ther 2020; 11:2775-2790. [PMID: 33000382 PMCID: PMC7526709 DOI: 10.1007/s13300-020-00920-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Indexed: 12/11/2022] Open
Abstract
With the availability of second-generation basal insulin analogs, insulin degludec (100 and 200 units/ml [degludec]) and insulin glargine 300 units/ml (glargine U300), clinicians now have long-acting, efficacious treatment options with stable pharmacokinetic profiles and associated low risks of hypoglycemia that may be desirable for many patients with type 2 diabetes. In this narrative review, we summarize the current evidence on glycemic control in hospitalized patients and review the pharmacokinetic properties of degludec and glargine U300 in relation to the challenges these may pose during the hospitalization of patients with type 2 diabetes who are receiving outpatient regimens involving these newer insulins. Their increased use in clinical practice requires that hospital healthcare professionals (HCPs) have appropriate protocols to transfer patients from these second-generation insulins to formulary insulin on admission, and ensure the safe discharge of patients and transition back to degludec or glargine U300. However, there is no guidance available on this. Based on the authors' clinical experience, we identify key issues to consider when arranging hospital care of such patients. We also summarize the limited available evidence on the potential utility of these second-generation basal insulin analogs in the non-critical inpatient setting and identify avenues for future research. To address current knowledge gaps, it is important that HCPs are educated about the differences between standard formulary insulins and second-generation insulins, and the importance of clear communication during patient transitions.
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Olveira G, Abuín J, López R, Herranz S, García-Almeida JM, García-Malpartida K, Ferrer M, Cancer E, Luengo-Pérez LM, Álvarez J, Aragón C, Ocón MJ, García-Manzanares Á, Bretón I, Serrano-Aguayo P, Pérez-Ferre N, López-Gómez JJ, Olivares J, Arraiza C, Tejera C, Martín JD, García S, Abad ÁL, Alhambra MR, Zugasti A, Parra J, Torrejón S, Tapia MJ. Regular insulin added to total parenteral nutrition vs subcutaneous glargine in non-critically ill diabetic inpatients, a multicenter randomized clinical trial: INSUPAR trial. Clin Nutr 2019; 39:388-394. [PMID: 30930133 DOI: 10.1016/j.clnu.2019.02.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Gabriel Olveira
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Spain; Universidad de Málaga, Spain; CIBERDEM (CB07/08/0019), Instituto de Salud Carlos III, Madrid, Spain.
| | - Jose Abuín
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Spain; Universidad de Málaga, Spain
| | - Rafael López
- Servicio de Endocrinología y Nutrición, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat (Barcelona), Spain
| | - Sandra Herranz
- Servicio de Endocrinología y Nutrición, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Jose M García-Almeida
- Servicio de Endocrinología y Nutrición, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | | | - Mercedes Ferrer
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Emilia Cancer
- Sección de Endocrinología y Nutrición, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Luis M Luengo-Pérez
- Servicio de Endocrinología y Nutrición, Hospital Universitario de Badajoz, Badajoz, Spain
| | - Julia Álvarez
- Servicio de Endocrinología y Nutrición, Hospital Universitario Príncipe de Asturias, Madrid, Spain
| | - Carmen Aragón
- Servicio de Endocrinología y Nutrición, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - María J Ocón
- Servicio de Endocrinología y Nutrición, Hospital Universitario Lozano Blesa, Zaragoza, Spain
| | - Álvaro García-Manzanares
- Servicio de Endocrinología y Nutrición, Hospital General La Mancha Centro, Alcázar de San Juan, Spain
| | - Irene Bretón
- Servicio de Endocrinología y Nutrición, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Pilar Serrano-Aguayo
- Unidad de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Natalia Pérez-Ferre
- Servicio de Endocrinología y Nutrición, Hospital Clínico San Carlos, Madrid, Spain
| | - Juan J López-Gómez
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Josefina Olivares
- Servicio de Endocrinología y Nutrición, Hospital Universitario Son Llatzer, Illes Balears, Spain
| | - Carmen Arraiza
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario de Jaén, Jaén, Spain
| | - Cristina Tejera
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Ferrol, A Coruña, Spain
| | - Jorge D Martín
- Servicio de Endocrinología y Nutrición, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Sara García
- Servicio de Endocrinología y Nutrición, Complejo Asistencial Universitario de León, León, Spain
| | - Ángel L Abad
- Unidad de Nutrición - Sección de Endocrinología, Hospital General Universitario de Alicante, Alicante, Spain
| | - María R Alhambra
- Servicio de Endocrinología y Nutrición, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Ana Zugasti
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario de Navarra, Navarra, Spain
| | - Juan Parra
- Servicio de Endocrinología y Nutrición, Hospital de Mérida, Badajoz, Spain
| | - Sara Torrejón
- Servicio de Endocrinología y Nutrición, Hospital de Sant Joan Despí Moisès Broggi, Barcelona, Spain
| | - María J Tapia
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Spain
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