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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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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:pharmaceutics14051081. [PMID: 35631667 PMCID: PMC9148014 DOI: 10.3390/pharmaceutics14051081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [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.)
- Correspondence: ; Tel.: +33-(0)3-20-96-49-59
| | - 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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Umpierrez G, Rushakoff R, Seley JJ, Zhang JY, Shang T, Han J, Spanakis EK, Alexanian S, Drincic A, Kulasa K, Mendez CE, Tanton D, Wallia A, Zilbermint M, Klonoff DC. Hospital Diabetes Meeting 2020. J Diabetes Sci Technol 2020; 14:928-944. [PMID: 32783456 PMCID: PMC7477766 DOI: 10.1177/1932296820939626] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Patients with diabetes may experience adverse outcomes related to their glycemic control when hospitalized. Continuous glucose monitoring systems, insulin-dosing software, enhancements to the electronic health record, and other medical technologies are now available to improve hospital care. Because of these developments, new approaches are needed to incorporate evolving treatments into routine care. With the goal of educating healthcare professionals on the most recent practices and research for managing diabetes in the hospital, Diabetes Technology Society hosted the Virtual Hospital Diabetes Meeting on April 24-25, 2020. Because of the coronavirus disease 2019 (COVID-19) pandemic, the meeting was restructured to be held virtually during the national lockdown to ensure the safety of the participants and allow them to remain at their posts treating COVID-19 patients. The meeting focused on (1) inpatient management and perioperative care, (2) diabetic ketoacidosis and hyperglycemic hyperosmolar state, (3) computer-guided insulin dosing, (4) Coronavirus Disease 2019 and diabetes, (5) technology, (6) hypoglycemia, (7) data and cybersecurity, (8) special situations, (9) glucometrics and insulinometrics, and (10) quality and safety. This meeting report contains summaries of each of the ten sessions. A virtual poster session will be presented within two months of the meeting.
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Affiliation(s)
| | | | | | | | - Trisha Shang
- Diabetes Technology Society, Burlingame, CA, USA
| | - Julia Han
- Diabetes Technology Society, Burlingame, CA, USA
| | - Elias K. Spanakis
- University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
| | | | | | | | | | - Damon Tanton
- AdventHealth Diabetes Institute, Orlando, FL, USA
| | | | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University, Baltimore, MD, USA
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
- Johns Hopkins Carey Business School, Baltimore, MD, USA
| | - David C. Klonoff
- Mills-Peninsula Medical Center, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin), Fellow AIMBE, Mills-Peninsula Medical Center, 100 South San Mateo Drive, Room 5147, San Mateo, CA 94401, USA.
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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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