Mortality risk in admitted patients with diabetes mellitus according to treatment

Evaluation of Insulin Use and Hypoglycemia in Hospitalized Elderly Patients

Background: Routine administration of correctional insulin is no longer recommended as a primary strategy to treat hyperglycemia in hospitalized patients. Studies have demonstrated significant improvement in glycemic control in patients treated with basal and correctional insulin (B+C) versus correctional insulin alone (C). However, the effect of C or B+C on hypoglycemic events is not well understood. Objective: The objective of this study was to investigate the effect of B+C versus C on hypoglycemic events in hospitalized elderly patients. Methods: A single-center retrospective review of patients at least 65 years old that were admitted between April and July 2016, who were prescribed any type of insulin. Exclusion criteria included admission to the intensive care unit (ICU) on hospital admission, history of hypersensitivity to insulin, or insulin use for the management of hyperkalemia. Patients were divided based on the insulin regimen prescribed, B+C or C. The primary outcome of the study was the incidence of hypoglycemic episodes between groups. Secondary outcomes included severity of hypoglycemia, hospital length of stay (LOS), hospital mortality, and ICU transfer. Hypoglycemia was defined as a blood glucose level less than 70 mg/dL. Results: A total of 709 patients were included, with 144 (20.3%) prescribed B+C and 565 (79.7%) prescribed C. Incidence of hypoglycemia was greater in the B+C group than C (29.1% vs 12.6%, p=0.012). The average blood glucose readings during hypoglycemic episodes between B+C and C were 50 mg/dL and 52.5 mg/dL, respectively (p<0.01). There was no difference observed in hospital LOS. No patients required ICU admission within 24 hours of a hypoglycemic event or died during the index hospitalization. Conclusion: There is a higher incidence of hypoglycemia in elderly patients prescribed basal plus correctional insulin than correctional insulin alone.

A Systematic Approach for the Prevention and Reduction of Hypoglycemia in Hospitalized Patients

PURPOSE OF REVIEW

Hypoglycemia and severe hypoglycemia (SH) in the inpatient setting are associated with poor outcomes. This review is designed to highlight approaches to predict and prevent inpatient hypoglycemia that has been successfully implemented focusing on developing overlapping policies and procedures that allow safe glycemic management to occur at all levels of the institution.

RECENT FINDINGS

Standardizing point-of-care (POC) testing, nursing protocols, meal delivery, and formulary restriction are useful tools to prevent hypoglycemia. Informatics and real-time alert processes are highly effective tools to reduce hypoglycemia but require a significant investment in time and infrastructure as well as clear policies on how alerts are acted upon. Computerized dosing support technology and continuous glucose monitoring (CGM) technology are an emerging area of investigation showing promising results. Inpatient hypoglycemia is often predictable and preventable and requires institutional support to deliver targeted and safe diabetes care. This requires each institution to do periodic reassessment of policies and technologies. Future research needs to focus on the cost/benefits of interventions including studies of automated dosing algorithms as well as CGM in higher-risk patient populations.

Mortality Among Hospitalized Patients With Hypoglycemia: Insulin Related and Noninsulin Related

CONTEXT

Hypoglycemia is common among hospitalized patients with and without diabetes mellitus.

OBJECTIVE

Investigate the association between spontaneous or insulin-related hypoglycemia and mortality in hospitalized patients.

DESIGN

Hypoglycemia was defined as blood glucose <70 mg/dl (3.9 mmol/l), including moderate (40 to 70 mg/dl, 2.2 to 3.9 mmol/l) and severe hypoglycemia (<40 mg/dl, 2.2 mmol/l). Use of insulin during hospitalization defined insulin-related hypoglycemia, thus patients were classified into 6 groups: non-insulin treated (NITC) and insulin-treated controls (ITC), insulin-related hypoglycemia (IH) or severe hypoglycemia (ISH), and non insulin-related hypoglycemia (NIH) and severe hypoglycemia (NISH).

SETTING AND PATIENTS

Historical prospectively data of patients ≥ 18 years of age, hospitalized in medical wards for any cause between January 2011 and December 2013.

MAIN OUTCOME MEASURE

All-cause mortality at the end of follow-up.

RESULTS

The cohort included 33,675 patients, including 2605 with moderate hypoglycemia (IH, 1011; NIH, 1594) and 342 with severe hypoglycemia (ISH, 201; NISH,141). Overall end-of-follow-up mortality was 31.9% (NITC, 28.0%; ITC, 42.9%; NIH, 50.7%; IH, 55.3%; NISH, 70.9%; ISH, 69.1%). Compared with NITC, unadjusted hazard ratios (95% confidence intervals) for mortality were as follows: ITC, 1.7 (1.6 to 1.8), NIH, 2.2 (2.0 to 2.4), IH, 2.5 (2.2 to 2.7), NISH, 4.2 (3.5 to 5.2), and ISH, 3.8 (3.2 to 4.5); with P < 0.001. Following multivariate analysis, respective hazard ratios were 1.8, 2.1, 2.4, 3.2, and 3.6 (P < 0.001). Cause of admission did not affect the association.

CONCLUSIONS

In hospitalized patients, hypoglycemia, either with insulin use or spontaneous, is associated with increased short- and long-term mortality.