Effective adverse event reduction with bolus-basal versus sliding scale insulin therapy in patients with diabetes during conventional hospitalization: Systematic review and meta-analysis

Inpatient Glycemic Control With Sliding Scale Insulin in Noncritical Patients With Type 2 Diabetes: Who Can Slide?

OBJECTIVE

Despite clinical guideline recommendations, sliding scale insulin (SSI) is widely used for the hospital management of patients with type 2 diabetes (T2D). We aimed to determine which patients with T2D can be appropriately managed with SSI in non-critical care settings.

METHODS

We used electronic health records to assess inpatient glycemic control in medicine and surgical patients treated with SSI according to admission blood glucose (BG) concentration between June 2010 and June 2018. Primary outcome was the percentage of patients with T2D achieving target glycemic control, defined as mean hospital BG 70 to 180 mg/dL without hypoglycemia <70 mg/dL during SSI therapy.

RESULTS

Among 25,813 adult patients with T2D, 8,095 patients (31.4%) were treated with SSI. Among patients with admission BG <140 mg/dL and BG 140 to 180 mg/dL, 86% and 83%, respectively, achieved target control without hypoglycemia, as compared with only 18% of those with admission BG ≥250 mg/dL (P < .001). After adjusting for age, gender, body mass index (BMI), race, Charlson Comorbidity Index score, and setting, the odds of poor glycemic control increased with higher admission BG (BG 140-180 mg/dL: odds ratio [OR], 1.8; 95% CI, 1.5-2.2; BG 181-250 mg/dL: OR, 3.7; 95% CI, 3.1-4.4; BG >250 mg/dL: OR, 7.2; 95% CI, 5.8-9.0), as compared with patients with BG <140 mg/dL. A total of 1,192 patients (15%) treated with SSI required additional basal insulin during hospitalization.

CONCLUSION

Most non-intensive care unit patients with admission BG <180 mg/dL treated with SSI alone achieve target glycemic control during hospitalization, suggesting that cautious use of SSI may be a viable option for certain patients with mild hyperglycemia.

Association Between Intra-Hospital Uncontrolled Glycemia and Health Outcomes in Patients with Diabetes: A Systematic Review of Observational Studies

BACKGROUND

Many people are still getting affected by uncontrolled glycemic events during hospital admission, which encompasses hypoglycemia, hyperglycemia, and high glycemic variability.

INTRODUCTION

Primary studies have shown an association of glycemic dysregulation with increased length of hospital stay and mortality among overall patients, however, there is no systematic review of current evidence on the association between uncontrolled in-hospital glycemia in patients with diabetes and health outcomes. This study aimed to systematically review the current evidence on the association between uncontrolled in-hospital glycemia in patients with diabetes and health outcomes.

METHODS

The association between glycemic dysregulation and health outcomes for inpatients with diabetes was systematically reviewed. PubMed, Embase, and LILACS databases were searched. Two independent reviewers were involved in each of the following steps: screening titles, abstracts, and fulltexts; assessing the methodological quality; and extracting data from included reviews. Descriptive analysis method was used.

RESULTS

Seven cohort studies were included, and only two had a prospective design, consisting of 7,174 hospitalized patients with diabetes. In-hospital occurrence of hypoglycemia, hyperglycemia, and glycemic variability were assessed, and outcomes were mortality, infections, renal complications, and adverse events. Among the exposure and outcomes, an association was observed between severe hypoglycemia and mortality, hyperglycemia and infection, and hyperglycemia and adverse events.

CONCLUSION

In-hospital uncontrolled glycemia in patients with diabetes is associated with poor health outcomes. More studies should be conducted for proper investigation because diabetes is a complex condition. Effects of glycemic dysregulation should be investigated on the basis of overall health of a patient instead from only organ-target perspective, which makes the investigation difficult.

Sliding scale insulin for non-critically ill hospitalised adults with diabetes mellitus

BACKGROUND

Diabetes mellitus is a metabolic disorder resulting from a defect in insulin secretion, function, or both. Hyperglycaemia in non-critically ill hospitalised people is associated with poor clinical outcomes (infections, prolonged hospital stay, poor wound healing, higher morbidity and mortality). In the hospital setting people diagnosed with diabetes receive insulin therapy as part of their treatment in order to achieve metabolic control. However, insulin therapy can be provided by different strategies (sliding scale insulin (SSI), basal-bolus insulin, and other modalities). Sliding scale insulin is currently the most commonly used method, however there is uncertainty about which strategy provides the best patient outcomes.

OBJECTIVES

To assess the effects of SSI for non-critically ill hospitalised adults with diabetes mellitus.

SEARCH METHODS

We identified eligible trials by searching MEDLINE, Embase, LILACS, and the Cochrane Library. We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov trial registers. The date of the last search for all databases was December 2017. We also examined reference lists of identified randomised controlled trials (RCTs) and systematic reviews, and contacted trial authors.

SELECTION CRITERIA

We included RCTs comparing SSI with other strategies for glycaemic control in non-critically ill hospitalised adult participants of any sex with diabetes mellitus.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed trials for risk of bias, and evaluated the overall certainty of evidence utilising the GRADE instrument. We synthesised data using a random-effects model meta-analysis with 95% prediction intervals, if possible, or descriptive analysis, as appropriate.

MAIN RESULTS

Of 720 records screened, we included eight trials that randomised 1048 participants with type 2 diabetes (387 SSI participants and 615 participants in comparator groups were available for final analysis). We included non-critically ill medical and surgical adults with the diagnosis of diabetes mellitus. The mean follow-up time was measured by the mean length of hospital stay and ranged between five and 24 days. The mean age of participants was 44.5 years to 71 years.Overall, we judged the risk of bias on the trial level as unclear for selection bias, high for outcome-related performance and detection bias with regard to hypoglycaemic episodes, other adverse events, and mean glucose levels, and low for all-cause mortality and length of hospital stay. Attrition bias was low for all outcome measures.Six trials compared SSI with a basal-bolus insulin scheme, three of which investigating 64% of all participants in this category also applying an SSI approach in the bolus comparator part. One trial had a basal insulin-only comparator arm, and the remaining trial used continuous insulin infusion as the comparator. For our main comparison of SSI versus basal-bolus insulin, the results were as follows. Four trials reported mortality data. One out of 268 participants in the SSI group (0.3%) compared with two out of 334 participants in the basal-bolus group (0.6%) died (low-certainty evidence). Severe hypoglycaemic episodes, defined as blood glucose levels below 40 mg/dL (2.2 mmol/L), showed a risk ratio (RR) of 0.22, 95% confidence interval (CI) 0.05 to 1.00; P = 0.05; 5 trials; 667 participants; very low-certainty evidence. The 95% prediction interval ranged between 0.02 and 2.57. All nine severe hypoglycaemic episodes were observed among the 369 participants on basal-bolus insulin (2.4%). The mean length of hospital stay was 0.5 days longer for the SSI group, 95% CI -0.5 to 1.4; P = 0.32; 6 trials; 717 participants; very low-certainty evidence. The 95% prediction interval ranged between -1.7 days and 2.7 days. Adverse events other than hypoglycaemic episodes, such as postoperative infections, showed a RR of 1.16, 95% CI 0.25 to 5.37; P = 0.85; 3 trials; 481 participants; very low-certainty evidence. The mean blood glucose levels ranged across basal-bolus groups from 156 mg/dL (8.7 mmol/L) to 221 mg/dL (12.3 mmol/L). The mean blood glucose level in the SSI groups was 14.8 mg/dL (0.8 mmol/L) higher (95% CI 7.8 (0.4) to 21.8 (1.2); P < 0.001; 6 trials; 717 participants; low-certainty evidence). The 95% prediction interval ranged between -3.6 mg/dL (-0.2 mmol/L) and 33.2 mg/dL (1.8 mmol/L). No trial reported on diabetes-related mortality or socioeconomic effects.

AUTHORS' CONCLUSIONS

We are uncertain which insulin strategy (SSI or basal-bolus insulin) is best for non-critically hospitalised adults with diabetes mellitus. A basal-bolus insulin strategy in these patients might result in better short-term glycaemic control but could increase the risk for severe hypoglycaemic episodes. The certainty of the body of evidence comparing SSI with basal-bolus insulin was low to very low and needs to be improved by adequately performed, well-powered RCTs in different hospital environments with well-educated medical staff using identical short-acting insulins in both intervention and comparator arms to compare the rigid SSI approach with flexible insulin application strategies.

Safely Converting an Entire Academic Medical Center From Sliding Scale to Basal Bolus Insulin via Implementation of the eGlycemic Management System

OBJECTIVE

Hyperglycemia is common in the inpatient setting and providers frequently rely on sliding scale insulin. This case study reviews the experience of one hospital moving from high utilization of sliding scale to basal bolus insulin therapy.

METHOD

This Retrospective Quality Improvement Study describes the journey of clinicians at a 580-bed hospital to convert from high usage of SSI to BBI. Hyperglycemic adult patients prescribed insulin, with/without a diagnosis of diabetes, were included.

RESULTS

Data over the first year showed that patients treated with Glucommander (GM) spent more time in the target range of 70-180 mg/dL than patients treated with non-Glucommander (non-GM), with 2,434 fewer hypoglycemic events and 40,589 fewer hyperglycemic events. Prior to implementation of GM, SSI was close to 95%, BBI at 5%. Within the first month of use, 96% usage of BBI was achieved. Reduction of hypoglycemic events (% of BG < 70 mg/dL) by 21% with 2.16% non-GM compared to GM at 1.74% and severe Hypoglycemia (% of BG < 50 mg/dL) by 50% in the ICU 3% non-GM compared to GM at 1.5%. In addition, patients treated with GM had a shorter LOS than patients treated with non-GM by 3.18 days and used 47.4% less point of care tests per patient.

CONCLUSION

Glycemic management improved with use of eGMS. The conversion from SSI to BBI enhanced overall patient safety, eliminated the time and effort otherwise required when manually titrating insulin and reduced overall cost of care for patients on insulin therapy.