Factors associated with glycemic control after an inpatient program

Comparison of Inpatient Glycemic Control with Insulin Vials Versus Insulin Pens in General Medicine Patients

BACKGROUND

The Institute for Safe Medication Practices has recommended against routine use of insulin pen devices for inpatients, but the quality of inpatient glycemic control that is achieved with insulin pens versus insulin vials and syringes has not been compared.

OBJECTIVE

To evaluate the quality of glycemic control achieved with insulin vials versus insulin pens in type 2 diabetic general medicine patients.

METHODS

This retrospective cohort study compared glycemic control between 2 groups of patients on rapid-acting insulin protocols: those receiving insulin via patient-specific pen devices and those receiving insulin from patient-specific vials. Patients on a prespecified subacute care floor with a diagnosis of type 2 diabetes and at least 24 hours of glucose monitoring while on an insulin protocol with insulin lispro were included. Glycemic control was compared by area under the curve (AUC) estimations of average overall glucose and average glucose above, below, and within goal range (70-180 mg/dL). Percentages of time above, below, and within goal range were also compared.

RESULTS

The mean ± SD AUC-estimated average glucose for pens was 160 ± 39 mg/dL compared to 158 ± 45 mg/dL for vials (P = .752). The mean ± SD percentage time within goal range was 68.2% ± 28.1% in the pen group versus 69.4% ± 31.8% percent in the vial group (P = .825). No statistically significant differences were detected between those receiving pens or vials for any outcome before and after adjusting for baseline differences and significant covariates.

CONCLUSION

Glycemic control did not differ based on insulin delivery system.

Sliding-scale insulin used for blood glucose control: a meta-analysis of randomized controlled trials

BACKGROUND

Sliding-scale insulin has been widely used in treating inpatient hyperglycemia. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate the efficacy and possible adverse effects of sliding-scale insulin in hospitalized patients.

METHODS

PubMed, EMBASE, Cochrane Library, Scopus, and ClinicalTrials.gov registry were searched for studies published up to May 2015. Individual effect sizes were standardized, and a meta-analysis was performed to calculate a pooled effect size using random effects models.

RESULTS

Eleven RCTs containing a total of 1322 patients were identified. Among eight studies in which the RISS was compared with other regimens, no significant difference was observed in the percentage of patients who achieved the mean blood glucose level between the two groups, which was determined according to the numbers of blood samples (RR: 2.84; 95% CI: 0.94 to 8.59) and patients (RR: 1.75; 95% CI: 0.86 to 3.55). The mean blood glucose level (weighted mean difference=27.33, 95% CI: 14.74 to 39.92) and incidence of hyperglycemic events were significantly higher in the RISS group than in the non-sliding-scale group. No significant difference in the incidence of severe hypoglycemia and length of hospitalization between the groups was identified.

CONCLUSIONS

The overall results of the meta-analysis indicated that applying the RISS alone or in combination with other antidiabetic medications did not provide any benefits in blood glucose control, but was accompanied by an increased incidence of hyperglycemic events. Therefore, we suggest that the use of sliding-scale insulin be discontinued in hospitals.

Determinants of successful glycemic control among participants in the BARI 2D trial: a post-hoc analysis

OBJECTIVE

The BARI 2D trial compared insulin provision (IP) versus insulin sensitization (IS) for the primary outcome of total mortality in participants with T2DM and cardiovascular disease (CVD). In this analysis we examine baseline characteristics that are associated with successful long-term glycemic control.

RESEARCH DESIGN AND METHODS

In a 2×2 factorial design, 2368 participants were randomized to either IP or IS therapy, and to either prompt revascularization with medical therapy or medical therapy alone. Successful long-term glycemic control (success) was defined by simultaneously meeting 1) a mean HbA1c level of <7.0% after each participant's third year of follow-up period, and 2) adherence with medications only from the assigned glycemic treatment arm during >80% of the BARI 2D follow-up. The association between baseline variables and success was determined using unadjusted and adjusted logistic regression models.

RESULTS

1917 participants (962 IP and 955 IS participants) had sufficiently long follow-up and data for this analysis. Among these IP and IS participants, 235 and 335 participants met both criteria of success, respectively (p<0.001). Those not on insulin at entry had higher odds of success (OR 2.25; CI 1.79-2.82) when treated with IS versus IP medications, irrespective of baseline HbA1c levels. Younger age, shorter duration of T2DM, and lower HbA1c at baseline were also each independently associated with higher success when treated with IS versus IP medications.

CONCLUSION

Patients similar to those in the BARI 2D trial may have a higher chance of achieving success with IS versus IP medications if they are younger, have shorter duration of T2DM, have lower HbA1c levels, have moderate or strenuous physically activity, and are not on insulin. In contrast, increasing age, longer duration of T2DM, higher HbA1c, and insulin therapy are associated with increased chance of success if treated with IP medications.