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Cao L, Zhang D, Zhao Y, Zhou N, Zhang P. Efficacy and safety of different insulin infusion methods in the treatment of total parenteral nutrition-associated hyperglycemia: a systematic review and network meta-analysis. Front Nutr 2023; 10:1181359. [PMID: 37674887 PMCID: PMC10479116 DOI: 10.3389/fnut.2023.1181359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/24/2023] [Indexed: 09/08/2023] Open
Abstract
Aims To systematically evaluate the efficacy and safety of different insulin infusion methods in the treatment of total parenteral nutrition (TPN)-associated hyperglycemia based on published literature and the data of completed clinical trials using a network meta-analysis. Methods A comprehensive search of PubMed, Elsevier, Web of Science, EMBASE, Medline, clinicaltrials.gov, Cochrane Library, and three Chinese databases (Wanfang Data, China National Knowledge Infrastructure, and SINOMED) up to December 15, 2022, was performed to collect information on different insulin infusion methods used for the treatment of TPN-associated hyperglycemia, and the Cochrane systematic review method was used to screen the literature, evaluate the quality of the included literature, and extract clinical characteristics for a network meta-analysis. Clinical outcomes included mean blood glucose (MBG), hypoglycemia, hospital length of stay, hyperglycemia, surgical site infection (SSI) and mean total daily insulin. Results A total of 21 articles, including 1,459 patients, were included to analyze 6 different routes of insulin infusion, including continuous intravenous insulin infusion (CVII), continuous subcutaneous insulin infusion (CSII), subcutaneous glargine insulin (s.c. GI), the addition of regular insulin to the PN mixture (RI-in-PN), multiple subcutaneous insulin injections (MSII) and 50% of insulin administered as RI-in-PN + 50% of insulin administered as s.c. GI (50% RI-in-PN + 50% s.c. GI). The results of the network meta-analysis showed that MSII was the least effective in terms of MBG, followed by CVII. The 6 interventions were basically equivalent in terms of the hypoglycemia incidence. In terms of the length of hospital stay, patients in the CVII group had the shortest hospital stay, while the MSII group had the longest. CVII was the best intervention in reducing the incidence of hyperglycemia. The incidence of SSI was the lowest in the CSII and CVII groups, and the mean daily insulin dosage was the lowest in the CVII group. Conclusion Current literature shows that for the treatment of TPN-associated hyperglycemia, CVII is the most effective, reducing the incidence of hyperglycemia and shortening the length of hospital stay without increasing the incidence of hypoglycemia. MSII has the worst efficacy, leading to a higher MBG and longer hospital stay, and RI-in-PN, CSII, s.c. GI and 50% RI-in-PN + 50% s.c. GI are better in terms of efficacy and safety and can be substituted for each other. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023439290.
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Affiliation(s)
| | | | | | - Nan Zhou
- Department of Pharmacy, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Peng Zhang
- Department of Pharmacy, Shaanxi Provincial People’s Hospital, Xi’an, China
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2
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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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3
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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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4
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Schönenberger KA, Reber E, Dürig C, Baumgartner A, Efthymiou A, Huwiler VV, Laimer M, Bally L, Stanga Z. Management of Hyperglycemia in Hospitalized Patients Receiving Parenteral Nutrition. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:829412. [PMID: 36992742 PMCID: PMC10012056 DOI: 10.3389/fcdhc.2022.829412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 01/03/2022] [Indexed: 12/14/2022]
Abstract
Almost half of inpatients on parenteral nutrition experience hyperglycemia, which increases the risk of complications and mortality. The blood glucose target for hospitalized patients on parenteral nutrition is 7.8 to 10.0 mmol/L (140 to 180 mg/dL). For patients with diabetes, the same parenteral nutrition formulae as for patients without diabetes can be used, as long as blood glucose levels can be adequately controlled using insulin. Insulin can be delivered via the subcutaneous or intravenous route or, alternatively, added to parenteral nutrition admixtures. Combining parenteral with enteral and oral nutrition can improve glycemic control in patients with sufficient endogenous insulin stores. Intravenous insulin infusion is the preferred route of insulin delivery in critical care as doses can be rapidly adjusted to altered requirements. For stable patients, insulin can be added directly to the parenteral nutrition bag. If parenteral nutrition is infused continuously over 24 hours, the subcutaneous injection of a long-acting insulin combined with correctional bolus insulin may be adequate. The aim of this review is to give an overview of the management of parenteral nutrition-associated hyperglycemia in inpatients with diabetes.
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Affiliation(s)
- Katja A. Schönenberger
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
- *Correspondence: Katja A. Schönenberger,
| | - Emilie Reber
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christa Dürig
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Annic Baumgartner
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andriana Efthymiou
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Valentina V. Huwiler
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Markus Laimer
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lia Bally
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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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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6
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Sigala M, Canada T. Insulin considerations for total parenteral nutrition. Clin Nutr 2021; 40:1436-1437. [PMID: 33583663 DOI: 10.1016/j.clnu.2021.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Mariah Sigala
- University of Texas at Austin College of Pharmacy, Austin, TX, USA.
| | - Todd Canada
- Division of Pharmacy, University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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Sangrador Pelluz C, Pardo Pastor J, Navas Moya E, Nicolás Picó J, Quintana S. Factores predictores de hiperglucemia en pacientes con nutrición parenteral. Med Clin (Barc) 2020; 154:157-162. [DOI: 10.1016/j.medcli.2019.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/26/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
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8
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Nader ND, Hamishehkar H, Naghizadeh A, Shadvar K, Iranpour A, Sanaie S, Chang F, Mahmoodpoor A. Effect of Adding Insulin Glargine on Glycemic Control in Critically Ill Patients Admitted to Intensive Care Units: A Prospective Randomized Controlled Study. Diabetes Metab Syndr Obes 2020; 13:671-678. [PMID: 32210600 PMCID: PMC7073596 DOI: 10.2147/dmso.s240645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 02/20/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE We aimed to examine the effects of adding a longer-acting insulin glargine to existing glucose control on reducing blood-glucose fluctuations in an intensive care unit (ICU). METHODS A total of 110 patients randomly received adjuvant insulin glargine 15 IU/day (glargine) or placebo (control), in addition to daily infusion of insulin to maintain glucose levels at a target of 140-180 mg/dL. End points were mean and variance of blood glucose and frequency of hypoglycemia, hyperglycemia, ICU stay, and mortality. Data were analyzed with repeated-measures ANOVA and Mann-Whitney U test. RESULTS Average daily glucose level was significantly less in the glargine group than controls (P<0.0001), while there was no difference in daily variance in blood glucose between the two groups. The duration of glucose concentrations being within the target range was identical between the glargine and control groups (16.6±4.9 vs 16.4±4.6 hours/day, P=0.844) during the 7 days of admission. The frequency of hypoglycemia was greater in the glargine group and total duration of hyperglycemia (>180 mg/dL) much longer among controls (P<0.001). Similar mortality rates were observed in both groups, while ICU length of stay was 2 days shorter in the glargine group. CONCLUSION Addition of insulin glargine to routine protocols more effectively reduces glucose levels and decreases incidence of hyperglycemic episodes and regular insulin usage. This adjustment may be associated with decreases in duration of ICU stay or increases in hypoglycemic events.
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Affiliation(s)
- Nader D Nader
- State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Hadi Hamishehkar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Abdolreza Naghizadeh
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kamran Shadvar
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Sarvin Sanaie
- Neurosiences Research Center, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Francis Chang
- State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Ata Mahmoodpoor
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Correspondence: Ata Mahmoodpoor Anesthesiology, Tabriz University of Medical Sciences, School of Medicine, Tabriz, Iran Email
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Laesser CI, Cumming P, Reber E, Stanga Z, Muka T, Bally L. Management of Glucose Control in Noncritically Ill, Hospitalized Patients Receiving Parenteral and/or Enteral Nutrition: A Systematic Review. J Clin Med 2019; 8:jcm8070935. [PMID: 31261760 PMCID: PMC6678336 DOI: 10.3390/jcm8070935] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 12/25/2022] Open
Abstract
Hyperglycemia is a common occurrence in hospitalized patients receiving parenteral and/or enteral nutrition. Although there are several approaches to manage hyperglycemia, there is no consensus on the best practice. We systematically searched PubMed, Embase, Cochrane Central, and ClinicalTrials.gov to identify records (published or registered between April 1999 and April 2019) investigating strategies to manage glucose control in adults receiving parenteral and/or enteral nutrition whilst hospitalized in noncritical care units. A total of 15 completed studies comprising 1170 patients were identified, of which 11 were clinical trials and four observational studies. Diabetes management strategies entailed adaptations of nutritional regimens in four studies, while the remainder assessed different insulin regimens and administration routes. Diabetes-specific nutritional regimens that reduced glycemic excursions, as well as algorithm-driven insulin delivery approaches that allowed for flexible glucose-responsive insulin dosing, were both effective in improving glycemic control. However, the assessed studies were, in general, of limited quality, and we see a clear need for future rigorous studies to establish standards of care for patients with hyperglycemia receiving nutrition support.
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Affiliation(s)
- Céline Isabelle Laesser
- Department of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Paul Cumming
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- School of Psychology and Counselling and IHBI, Queensland University of Technology, Brisbane, QLD 4059, Australia
| | - Emilie Reber
- Department of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Zeno Stanga
- Department of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Taulant Muka
- Institute of Social and Preventive Medicine, University of Bern, 3012 Bern, Switzerland
| | - Lia Bally
- Department of Diabetes, Endocrinology, Clinical Nutrition, and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
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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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11
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Truong S, Park A, Kamalay S, Hung N, Meyer JG, Nguyen N, Momenzadeh A. Glycemic Control in Adult Surgical Patients Receiving Regular Insulin Added to Parenteral Nutrition vs Insulin Glargine: A Retrospective Chart Review. Nutr Clin Pract 2019; 34:775-782. [PMID: 30693980 DOI: 10.1002/ncp.10252] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Hyperglycemia is a frequent complication in patients receiving parenteral nutrition (PN) and has been associated with an increased risk of mortality. Treatment of hyperglycemia requires insulin therapy; however, the optimal dose and route have not been established. This study aimed to compare regular insulin added to PN (RI-in-PN) with subcutaneous insulin glargine for the management of hyperglycemia in patients receiving PN. METHODS This retrospective study was conducted at a tertiary medical center and reviewed 113 adult, non-critically ill surgical patient admissions receiving PN over a 5-year period. The primary outcome was achievement of glycemic control. Secondary outcomes were time to glycemic control, hypoglycemic events, hospital length of stay, and 1-year mortality. RESULTS The RI-in-PN group had a significantly higher percentage of patient admissions who achieved glycemic control compared with the insulin glargine group (71.8% vs 48.6%, P = 0.017). There was no difference in time to glycemic control, hypoglycemic events, hospital length of stay, or 1-year mortality between groups. Among patients with diabetes mellitus (DM), however, the insulin glargine group had a significantly higher percentage of admissions with at least 1 hypoglycemic event (45.5% vs 20%, P = 0.035). CONCLUSIONS RI-in-PN is recommended over insulin glargine because of the higher likelihood of achieving glycemic control and, in patients with DM, lower risk of hypoglycemic events. Large, randomized controlled trials are needed to further guide prescribing practice.
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Affiliation(s)
- Stephanie Truong
- Department of Clinical Pharmacy, San Francisco Medical Center, University of California, San Francisco, California, USA
| | - Annie Park
- Department of Clinical Pharmacy, San Francisco Medical Center, University of California, San Francisco, California, USA
| | - Salem Kamalay
- Department of Clinical Pharmacy, San Francisco Medical Center, University of California, San Francisco, California, USA
| | - Nancy Hung
- Department of Clinical Pharmacy, San Francisco Medical Center, University of California, San Francisco, California, USA
| | - Jesse G Meyer
- Department of Chemistry, University of Wisconsin, Madison, Wisconsin, USA
| | - Nicole Nguyen
- Department of Clinical Pharmacy, San Francisco Medical Center, University of California, San Francisco, California, USA
| | - Amanda Momenzadeh
- Department of Clinical Pharmacy, San Francisco Medical Center, University of California, San Francisco, California, USA
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12
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Colunga‐Lozano LE, Gonzalez Torres FJ, Delgado‐Figueroa N, Gonzalez‐Padilla DA, Hernandez AV, Roman Y, Cuello‐García CA. Sliding scale insulin for non-critically ill hospitalised adults with diabetes mellitus. Cochrane Database Syst Rev 2018; 11:CD011296. [PMID: 30488948 PMCID: PMC6517001 DOI: 10.1002/14651858.cd011296.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Luis Enrique Colunga‐Lozano
- McMaster UniversityDepartments of Health Research Methods, Evidence, and Impact1280 Main Street WestHamiltonOntarioCanadaL8S 4L8
| | | | - Netzahualpilli Delgado‐Figueroa
- Hospital Civil de Guadalajara Dr. Juan I. MenchacaDepartment of PediatricsSalvador Quevedo y Zubieta No. 750GuadalajaraJaliscoMexico44340
| | - Daniel A Gonzalez‐Padilla
- Hospital Universitario 12 de OctubreDepartment of UrologyAvenida de Córdoba, s/nMadridMadridSpain28041
| | | | - Yuani Roman
- Institute of Biomedical Research Sant Pau (IIB Sant Pau), BarcelonaIberoamerican Cochrane CentreSant Antoni Ma Claret, 171BarcelonaBarcelonaSpain08041
| | - Carlos A Cuello‐García
- McMaster UniversityDepartment of Health Research Methods, Evidence, and Impact1280 Main Street West. HSC‐2CHamiltonOntarioCanadaL8S 4K1
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13
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Ramos A, Rabasa F, Mendoza L, Cardenete J, Gill P, Morilla A, Cardona D, Pérez A. Differences in Glycemic Control in Diabetic and Non-diabetic Patients with Parenteral Nutrition Using a Basal plus Correction Insulin Regimen: An Observational, Retrospective Study. Diabetes Ther 2018; 9:1359-1367. [PMID: 29725969 PMCID: PMC5984936 DOI: 10.1007/s13300-018-0433-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Hyperglycemia is a frequent complication of parenteral nutrition (PN) in patients both with and without diabetes mellitis (DM). The aim of this study was to evaluate the quality of glucose control achieved with basal plus-correction insulin in surgical patients with and without a history of DM receiving PN. METHODS Retrospective evaluation of a protocol applied during the period of January 2013-December 2015. The insulin dose was started at 0.4 and 0.3 IU/kg/day in patients with previous DM and without a history of DM, respectively, and the target blood glucose (BG) was < 180 mg/dl. Mean BG levels, insulin total daily dose (TDD) and hypoglycemic (< 70 mg/dl) events on different days of PN were also evaluated. RESULTS Forty-one patients with previous type 2 DM and 39 without DM were evaluated. Glycemic control in both groups was as follows: during the first 48 h (230.4 ± 67 vs. 189.4 ± 38 mg/dl, p = 0.002); at the midpoint (224.6 ± 58 vs. 181.3 ± 27 mg/dl, p = 0.003); 48 h before ending TPN (196.4 ± 43 vs. 169.8 ± 40 mg/dl, p = 0.004). Insulin TDD was 0.5 ± 0.3 U/kg/day in patients with DM and 0.37 ± 0.3 units/kg/day in those without DM (p < 0.05). A total of 18 patients experienced hypoglycemic events, without differences between the groups. CONCLUSION A basal-correction insulin regimen is an alternative method for managing hyperglycemia in non-critically ill surgical patients on PN.
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Affiliation(s)
- Analía Ramos
- Department of Endocrinology and Nutrition, Hospital Santa Creu i Sant Pau, Barcelona, Barcelona, Spain
| | - Fernanda Rabasa
- Department of Endocrinology and Nutrition, Hospital Santa Creu i Sant Pau, Barcelona, Barcelona, Spain
| | - Lilian Mendoza
- Department of Endocrinology and Nutrition, Hospital Santa Creu i Sant Pau, Barcelona, Barcelona, Spain
| | - Joana Cardenete
- Department of Pharmacy Service, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Pedro Gill
- Department of Endocrinology and Nutrition, Hospital Santa Creu i Sant Pau, Barcelona, Barcelona, Spain
| | - Alba Morilla
- Department of Endocrinology and Nutrition, Hospital Santa Creu i Sant Pau, Barcelona, Barcelona, Spain
| | - Daniel Cardona
- Department of Pharmacy Service, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Antonio Pérez
- Department of Endocrinology and Nutrition, Hospital Santa Creu i Sant Pau, Barcelona, Barcelona, Spain.
- Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain.
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain.
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14
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Verçoza Viana M, Verçoza Viana L, Tavares AL, de Azevedo MJ. Insulin Regimens to Treat Hyperglycemia in Hospitalized Patients on Nutritional Support: Systematic Review and Meta-Analyses. ANNALS OF NUTRITION AND METABOLISM 2017; 71:183-194. [PMID: 29017173 DOI: 10.1159/000481355] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 09/05/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND The best insulin regimen to treat hyperglycemia in hospitalized patients on nutritional support (NS) is unclear. METHODS We searched electronic databases to identify cohort studies or randomized clinical trials in order to evaluate the efficacy of different insulin regimens used to treat hyperglycemia in hospitalized patients on NS on diverse outcomes: mean blood glucose (MBG), hypoglycemia, length of stay in hospital, and mortality. RESULTS Seventeen studies from a total of 5,030 were included. Enteral Group included 8 studies; 1,203 patients using rapid, glargine, NPH, or Premix insulin; MBG 108-225 mg/dL; hypoglycemia 0-13%. In indirect meta-analyses, NPH insulin ranked best for glucose control (MD 95% CI -2.50 mg/dL [2.65 to -2.35]). Parenteral Group included 4 studies; 228 patients using regular and glargine or NPH insulin; MBG 137-202 mg/dL; hypoglycemia 0-40%. In meta-analyses comparing regular insulin added to parenteral nutrition bag with glargine, MBG (MD 95% CI -3.78 mg/dL [-11.93 to 4.37]; I2 = 0%) or hypoglycemia frequency (RR 95% CI 1.37 [0.43-4.32]; I2 = 70.7%) did not differ. The description related to hospital length of stay and mortality was inconsistent between groups. CONCLUSIONS The best insulin regimen to treat hyperglycemia in hospitalized patients on NS has not been established; best results using insulin regimens with NPH in enteral nutrition do not seem to be clinically relevant.
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Affiliation(s)
- Marina Verçoza Viana
- Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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15
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Drincic AT, Knezevich JT, Akkireddy P. Nutrition and Hyperglycemia Management in the Inpatient Setting (Meals on Demand, Parenteral, or Enteral Nutrition). Curr Diab Rep 2017; 17:59. [PMID: 28664252 DOI: 10.1007/s11892-017-0882-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW The goal of this paper is to provide the latest evidence and expert recommendations for management of hospitalized patients with diabetes or hyperglycemia receiving enteral (EN), parenteral (PN) nutrition support or, those with unrestricted oral diet, consuming meals on demand. RECENT FINDINGS Patients with and without diabetes mellitus commonly develop hyperglycemia while receiving EN or PN support, placing them at increased risk of adverse outcomes, including in-hospital mortality. Very little new evidence is available in the form of randomized controlled trials (RCT) to guide the glycemic management of these patients. Reduction in the dextrose concentration within parenteral nutrition as well as selection of an enteral formula that diminishes the carbohydrate exposure to a patient receiving enteral nutrition are common strategies utilized in practice. No specific insulin regimen has been shown to be superior in the management of patients receiving EN or PN nutrition support. For those receiving oral nutrition, new challenges have been introduced with the most recent practice allowing patients to eat meals on demand, leading to extreme variability in carbohydrate exposure and risk of hypo and hyperglycemia. Synchronization of nutrition delivery with the astute use of intravenous or subcutaneous insulin therapy to match the physiologic action of insulin in patients receiving nutritional support should be implemented to improve glycemic control in hospitalized patients. Further RCTs are needed to evaluate glycemic and other clinical outcomes of patients receiving nutritional support. For patients eating meals on demand, development of hospital guidelines and policies are needed, ensuring optimization and coordination of meal insulin delivery in order to facilitate patient safety.
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Affiliation(s)
- Andjela T Drincic
- Department of Internal Medicine: Diabetes, Endocrinology and Metabolism, University of Nebraska Medical Center, 984120 Nebraska Medical Center, Omaha, NE, 68198-4120, USA.
| | - Jon T Knezevich
- Department of Pharmaceutical and Nutrition Care, University of Nebraska Medical Center, 984120 Nebraska Medical Center, Omaha, NE, 68198-4120, USA
| | - Padmaja Akkireddy
- Department of Internal Medicine: Diabetes, Endocrinology and Metabolism, University of Nebraska Medical Center, 984120 Nebraska Medical Center, Omaha, NE, 68198-4120, USA
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16
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Marín-Peñalver JJ, Martín-Timón I, del Cañizo-Gómez FJ. Management of hospitalized type 2 diabetes mellitus patients. J Transl Int Med 2016; 4:155-161. [PMID: 28191539 PMCID: PMC5290892 DOI: 10.1515/jtim-2016-0027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Both hyperglycemia and hypoglycemia in hospitalized patients are associated with adverse outcomes including increased rates of infection, longer hospital length of stay, and even death. Clinical trials in patients with type 2 diabetes mellitus proved that by improving glycemic control, we can reduce all of them. Insulin is the preferred treatment for glycemic control in most cases, but alternative treatment options that can normalize blood glucose levels without hypoglycemia are being sought. Moreover, hospitalized patients are particularly vulnerable to severe, prolonged hypoglycemia since they may be unable to sense or respond to the early warning signs and symptoms of low blood glucose. Finally, nutritional support, corticosteroid therapy, and surgery increase the risk of hyperglycemia that leads to an increased risk of morbidity and mortality. We review the management of type 2 diabetes mellitus patients who are admitted to the general medical wards of the hospital for a procedure of intercurrent illness.
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Affiliation(s)
- Juan José Marín-Peñalver
- Section of Endocrinology, University Hospital Infanta Leonor, School of Medicine, Complutense University, Madrid 28031, Spain
| | - Iciar Martín-Timón
- Section of Endocrinology, University Hospital Infanta Leonor, School of Medicine, Complutense University, Madrid 28031, Spain
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