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Kurnikowski A, Werzowa J, Hödlmoser S, Krenn S, Paschen C, Mussnig S, Tura A, Harreiter J, Krebs M, Song PX, Eller K, Pascual J, Budde K, Hecking M, Schwaiger E. Continuous Insulin Therapy to Prevent Post-Transplant Diabetes Mellitus: A Randomized Controlled Trial. Kidney Med 2024; 6:100860. [PMID: 39157193 PMCID: PMC11326904 DOI: 10.1016/j.xkme.2024.100860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2024] Open
Abstract
Rationale & Objectives Hyperglycemia is frequently observed early after transplantation and associated with development of post-transplant diabetes mellitus (PTDM). Here, we assessed continuous subcutaneous insulin infusion (CSII) targeting afternoon hyperglycemia. Study Design Open-label randomized parallel 3-arm design. Settings & Participants In total, 85 kidney transplant recipients without previous diabetes diagnosis were randomized to postoperative CSII therapy, basal insulin, or control. Interventions Insulin was to be initiated at afternoon capillary blood glucose level of ≥140 mg/dL (7.8 mmol/L; CSII and basal insulin) or fasting plasma glucose level of ≥200 mg/dL (11.1 mmol/L; control). Outcomes Hemoglobin A1c (HbA1c) levels at 3 months post-transplant (primary endpoint). PTDM assessed using oral glucose tolerance test at 12 and 24 months. Results CSII therapy lasted until median day 18 and maximum day 88. The median HbA1c value at month 3 was 5.6% (38 mmol/mol) in the CSII group versus 5.7% (39 mmol/mol) in the control group (P = 0.70) and 5.4% (36 mmol/mol) in the basal insulin group (P = 0.02). At months 12 and 24, the odds for PTDM were similar compared with the control group (odds ratios [95% confidence intervals], 0.80 [0.18-3.49] and 0.71 [0.15-3.16], respectively) and the basal insulin group (0.96 [0.18-5.68] and 1.51 [0.24-12.84], respectively). Mild hypoglycemia events occurred in the CSII and the basal insulin groups. Limitations This study is limited by outdated insulin pump technology, frequent discontinuations of CSII, a complex protocol, and concerns regarding reliability of HbA1c measurements. Conclusions CSII therapy was not superior at reducing HbA1c levels at month 3 or PTDM prevalence at months 12 and 24 compared with the control or basal insulin group.
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Affiliation(s)
- Amelie Kurnikowski
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Johannes Werzowa
- Ludwig Boltzmann Institute of Osteology, Hanusch Hospital of WGKK and AUVA Trauma Centre Meidling, Vienna, Austria
- First Medical Department, Hanusch Hospital, Vienna, Austria
| | - Sebastian Hödlmoser
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Simon Krenn
- Center for Health & Bioresources, Medical Signal Analysis, Austrian Institute of Technology GmbH, Vienna, Austria
| | - Christopher Paschen
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Sebastian Mussnig
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Andrea Tura
- CNR Institute of Neuroscience, Padova, Italy
| | - Jürgen Harreiter
- Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
- Department of Medicine, Landesklinikum Scheibbs, Scheibbs, Austria
| | - Michael Krebs
- Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Peter X.K. Song
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Kathrin Eller
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Julio Pascual
- Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Klemens Budde
- Medizinische Klinik m. S. Nephrologie, Charité Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Manfred Hecking
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
- Kuratorium for Dialysis and Kidney Transplantation (KfH) e.V., Germany
| | - Elisabeth Schwaiger
- Division of Nephrology and Dialysis, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Department of Internal Medicine I: Cardiology and Nephrology, Hospital of the Brothers of St. John of God, Eisenstadt, Austria
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Hayashishita A, Watanabe T, Suzuki N, Nakaya T, Sugimoto A, Yokota I, Ohira H, Nishimura M, Tsujino I. Insulin resistance assessed by short insulin tolerance test and its association with obesity and insulin resistance-related parameters in humans: A pilot randomized trial. PLoS One 2024; 19:e0297718. [PMID: 38905235 PMCID: PMC11192359 DOI: 10.1371/journal.pone.0297718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 06/05/2024] [Indexed: 06/23/2024] Open
Abstract
The aim of this study was to examine the association of insulin resistance (evaluated by the short insulin tolerance test [SITT]) with parameters related to obesity and insulin resistance. We prospectively recruited controls and patients with type 2 diabetes mellitus (T2DM), subjected them to the SITT, and calculated the K indices of the intravenous insulin tolerance test (KITT(iv)) and the subcutaneous insulin tolerance test (KITT(sc)). We compared KITT(iv) results between the volunteers and patients and examined its correlation with KITT(sc). We also examined the association of KITT(iv) with obesity, insulin resistance-related parameters, and the insulin dose required for glycemic control. A total of 24 participants (seven controls and 17 patients with T2DM) were studied. The mean KITT(iv) was significantly lower in patients with T2DM than in the controls (2.5%±2.1% vs. 4.5%±1.8%). In all participants, KITT(iv) was significantly correlated with the homeostasis model assessment for insulin resistance (HOMA-IR) values (r = -0.601, p<0.05) but not with KITT(sc) (p = 0.62). KITT(iv) was correlated positively with the serum adiponectin concentration, but negatively with the visceral fat area and serum concentrations of tumor necrosis factor-α and branched-chain amino acids. In patients with T2DM, KITT(iv) and HOMA-IR values were significantly correlated with the total insulin dose required for glycemic control. Insulin resistance evaluated using KITT(iv) was correlated with the HOMA-IR values, but not with the resistance evaluated using KITT(sc). The degree of insulin resistance was associated with biomarkers, such as adiponectin, tumor necrosis factor-α, branched-chain amino acids, the visceral fat area, and the dose of insulin required for glycemic control.
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Affiliation(s)
- Akiko Hayashishita
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Taku Watanabe
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Naoko Suzuki
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Toshitaka Nakaya
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Ayako Sugimoto
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate school of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Hiroshi Ohira
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Masaharu Nishimura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Ichizo Tsujino
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
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Clements JN, Castelli G, Meade LT, Odom JM. A guide for the pharmacist's role in insulin pump management during transitions of care. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Jennifer N. Clements
- Department of Nursing Administration Spartanburg Regional Healthcare System Spartanburg South Carolina USA
| | - Gregory Castelli
- Department of Medical Education UPMC St. Margaret Pittsburgh Pennsylvania USA
| | - Lisa T. Meade
- Wingate University and Clinical Pharmacist Piedmont HealthCare Endocrinology Statesville North Carolina USA
| | - Jessica M. Odom
- Department of Pharmacy Prisma Health Greenville South Carolina USA
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Thompson B, Korytkowski M, Klonoff DC, Cook CB. Consensus Statement on Use of Continuous Subcutaneous Insulin Infusion Therapy in the Hospital. J Diabetes Sci Technol 2018; 12:880-889. [PMID: 29681173 PMCID: PMC6134295 DOI: 10.1177/1932296818769933] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In May 2017, the Diabetes Technology Society convened a panel of US experts on inpatient diabetes management to discuss the current and potential role of continuous subcutaneous insulin infusion (CSII) therapy in the hospital. The panel (1) discussed evidence for current use of CSII in the hospital, (2) recommended contraindications for use in the hospital, and (3) recommended guidelines to maximize chances for safe use of CSII in the hospital. Panel members agreed that larger, prospective, randomized studies are needed to evaluate safety and efficacy of CSII use in the hospital. As CSII technology becomes more complex and its use increases, it is imperative that institutional protocols be in place to ensure safe use of this technology and safe transitions across care areas. Providers need to be cognizant that not all patients currently using CSII as an outpatient are appropriate candidates for continued use in the hospital. This consensus statement provides guidelines for practitioners who may encounter patients using this technology in the inpatient setting.
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Affiliation(s)
- Bithika Thompson
- Division of Endocrinology, Mayo Clinic
Arizona, Scottsdale, AZ, USA
- Bithika Thompson, MD, Division of
Endocrinology, Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ 85259,
USA.
| | - Mary Korytkowski
- Division of Endocrinology and
Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David C. Klonoff
- Diabetes Research Institute,
Mills-Peninsula Medical Center, San Mateo, CA, USA
| | - Curtiss B. Cook
- Division of Endocrinology, Mayo Clinic
Arizona, Scottsdale, AZ, USA
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Levitt DL, Spanakis EK, Ryan KA, Silver KD. Insulin Pump and Continuous Glucose Monitor Initiation in Hospitalized Patients with Type 2 Diabetes Mellitus. Diabetes Technol Ther 2018; 20:32-38. [PMID: 29293367 PMCID: PMC5770096 DOI: 10.1089/dia.2017.0250] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Insulin pumps and continuous glucose monitoring (CGM) are commonly used by patients with diabetes mellitus in the outpatient setting. The efficacy and safety of initiating inpatient insulin pumps and CGM in the nonintensive care unit setting is unknown. MATERIALS AND METHODS In a prospective pilot study, inpatients with type 2 diabetes were randomized to receive standard subcutaneous basal-bolus insulin and blinded CGM (group 1, n = 5), insulin pump and blinded CGM (group 2, n = 6), or insulin pump and nonblinded CGM (group 3, n = 5). Feasibility, glycemic control, and patient satisfaction were evaluated among groups. RESULTS Group 1 had lower mean capillary glucose levels, 144.5 ± 19.5 mg/dL, compared with groups 2 and 3, 191.5 ± 52.3 and 182.7 ± 59.9 mg/dL (P1 vs. 2+3 = 0.05). CGM detected 19 hypoglycemic episodes (glucose <70 mg/dL) among all treatment groups, compared with 12 episodes detected by capillary testing, although not statistically significant. No significant differences were found for the total daily dose of insulin or percentage of time spent below target glucose range (<90 mg/dL), in target glucose range (90-180 mg/dL), or above target glucose range (>180 mg/dL). On the Diabetes Treatment Satisfaction Questionnaire-Change, group 3 reported increased hyperglycemia and decreased hypoglycemia frequency compared with the other two groups, although the differences did not reach statistical significance. CONCLUSIONS Insulin pump and CGM initiation are feasible during hospitalization, although they are labor intensive. Although insulin pump initiation may not lead to improved glycemic control, there is a trend toward CGM detecting a greater number of hypoglycemic episodes. Larger studies are needed to determine whether use of this technology can lower inpatient morbidity and mortality.
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Affiliation(s)
- David L. Levitt
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Elias K. Spanakis
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
- Division of Endocrinology and Diabetes, Baltimore Veterans Administration Medical Center, Baltimore, Maryland
| | - Kathleen A. Ryan
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kristi D. Silver
- Division of Endocrinology, Diabetes, and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Jin JF, Zhu LL, Chen M, Xu HM, Wang HF, Feng XQ, Zhu XP, Zhou Q. The optimal choice of medication administration route regarding intravenous, intramuscular, and subcutaneous injection. Patient Prefer Adherence 2015; 9:923-42. [PMID: 26170642 PMCID: PMC4494621 DOI: 10.2147/ppa.s87271] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Intravenous (IV), intramuscular (IM), and subcutaneous (SC) are the three most frequently used injection routes in medication administration. Comparative studies of SC versus IV, IM versus IV, or IM versus SC have been sporadically conducted, and some new findings are completely different from the dosage recommendation as described in prescribing information. However, clinicians may still be ignorant of such new evidence-based findings when choosing treatment methods. METHODS A literature search was performed using PubMed, MEDLINE, and Web of Sciences™ Core Collection to analyze the advantages and disadvantages of SC, IV, and IM administration in head-to-head comparative studies. RESULTS "SC better than IV" involves trastuzumab, rituximab, antitumor necrosis factor medications, bortezomib, amifostine, recombinant human granulocyte-macrophage colony-stimulating factor, granulocyte colony-stimulating factor, recombinant interleukin-2, immunoglobulin, epoetin alfa, heparin, and opioids. "IV better than SC" involves ketamine, vitamin K1, and abatacept. With respect to insulin and ketamine, whether IV has advantages over SC is determined by specific clinical circumstances. "IM better than IV" involves epinephrine, hepatitis B immu-noglobulin, pegaspargase, and some antibiotics. "IV better than IM" involves ketamine, morphine, and antivenom. "IM better than SC" involves epinephrine. "SC better than IM" involves interferon-beta-1a, methotrexate, human chorionic gonadotropin, hepatitis B immunoglobulin, hydrocortisone, and morphine. Safety, efficacy, patient preference, and pharmacoeconomics are four principles governing the choice of injection route. Safety and efficacy must be the preferred principles to be considered (eg, epinephrine should be given intramuscularly during an episode of systemic anaphylaxis). If the safety and efficacy of two injection routes are equivalent, clinicians should consider more about patient preference and pharmacoeconomics because patient preference will ensure optimal treatment adherence and ultimately improve patient experience or satisfaction, while pharmacoeconomic concern will help alleviate nurse shortages and reduce overall health care costs. Besides the principles, the following detailed factors might affect the decision: patient characteristics-related factors (body mass index, age, sex, medical status [eg, renal impairment, comorbidities], personal attitudes toward safety and convenience, past experience, perception of current disease status, health literacy, and socioeconomic status), medication administration-related factors (anatomical site of injection, dose, frequency, formulation characteristics, administration time, indication, flexibility in the route of administration), and health care staff/institution-related factors (knowledge, human resources). CONCLUSION This updated review of findings of comparative studies of different injection routes will enrich the knowledge of safe, efficacious, economic, and patient preference-oriented medication administration as well as catching research opportunities in clinical nursing practice.
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Affiliation(s)
- Jing-fen Jin
- Division of Nursing, Division of Nursing, Zhejiang University, Hangzhou, People’s Republic of China
| | - Ling-ling Zhu
- VIP Care Ward, Division of Nursing, Zhejiang University, Hangzhou, People’s Republic of China
| | - Meng Chen
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Hui-min Xu
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Hua-fen Wang
- Division of Nursing, Division of Nursing, Zhejiang University, Hangzhou, People’s Republic of China
| | - Xiu-qin Feng
- Division of Nursing, Division of Nursing, Zhejiang University, Hangzhou, People’s Republic of China
| | - Xiu-ping Zhu
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
| | - Quan Zhou
- Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China
- Correspondence: Quan Zhou, Department of Pharmacy, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Jiefang Road No 88, Shangcheng District, Hangzhou 310009, Zhejiang Province, People’s Republic of China, Tel +86 571 8778 4615, Fax +86 571 8702 2776, Email
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Cook CB, Beer KA, Seifert KM, Boyle ME, Mackey PA, Castro JC. Transitioning insulin pump therapy from the outpatient to the inpatient setting: a review of 6 years' experience with 253 cases. J Diabetes Sci Technol 2012; 6:995-1002. [PMID: 23063024 PMCID: PMC3570832 DOI: 10.1177/193229681200600502] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND We reviewed the care of a large cohort of patients with diabetes mellitus on insulin pump therapy who required an inpatient stay. METHODS Records were reviewed of patients hospitalized between January 1, 2006, and December 31, 2011. RESULTS A total of 136 patients using insulin pumps had 253 hospitalizations. Mean (standard deviation) patient age was 55 (16) years, diabetes duration was 29 (15) years, and pump duration was 6 (5) years. Insulin pump therapy was continued in 164 (65%) hospitalizations. Adherence to core process measures improved over time: by 2011, 100% of cases had an endocrinology consultation, 100% had the required insulin pump order set completed, and 94% had documentation of the signed agreement specifying patient responsibilities for continued use of the technology while hospitalized. Documentation of the insulin pump flow sheet also increased but could still be located in only 64% of cases by the end of 2011. Mean glucose was not significantly different among patients who remained on insulin pump therapy compared to those for whom it was discontinued (p > .1), but episodes of severe hyperglycemia (>300 mg/dl) and hypoglycemia (<40 mg/dl) were significantly less common among pump users. No pump site infections, mechanical pump failures, or episodes of diabetic ketoacidosis were observed among patients remaining on therapy. CONCLUSIONS With appropriate patient selection and usage guidelines, most patients using insulin pumps can safely have their therapy transitioned to the inpatient setting. Further study is needed to determine whether this approach can be translated to other hospital settings.
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Affiliation(s)
- Curtiss B Cook
- Division of Endocrinology, Mayo Clinic, Scottsdale, Arizona 85259, USA.
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