Management of Diabetes Mellitus in Hospitalized Patients: Efficiency and Effectiveness of Sliding-Scale Insulin Therapy

Sliding Scale Insulin Use in Nursing Homes Before and After Onset of the COVID-19 Pandemic

OBJECTIVE

To characterize sliding-scale insulin (SSI) use in US nursing homes (NHs) before and after the COVID-19 pandemic.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

A total of 129,829 US NH residents on SSI (01/2018-06/2022) across 12 NH chains with a common electronic health record system.

METHODS

Among all residents with at least 1 administration of SSI documented in the electronic medication administration record, we described resident demographics, frequency of SSI monotherapy vs combination therapy with another diabetes medication, number of daily capillary blood glucose readings ("fingersticks"), and hypoglycemia (capillary blood glucose <70 mg/dL) and hyperglycemia after first SSI use. We used interrupted time series analysis (ITS) with segmented linear regression models to examine whether the monthly prevalence of SSI use changed at and after the onset of the COVID-19 pandemic (March 2020).

RESULTS

There were 129,829 unique NH residents with SSI use [51% women, average age 71.3 (SD 11.7) years]. Of these, 36% of residents received SSI monotherapy and 64% received SSI combination therapy. Residents on SSI received an average of 3.96 (SD 1.41) fingersticks per day. Overall, 26% of SSI users experienced a hypoglycemic event within 30 days of the first SSI dose. The ITS analysis identified a step decrease in the rate of SSI use following the onset of the COVID-19 pandemic (43 fewer SSI users per 1000 insulin users) but no change in overall trend over time from before the onset of the pandemic.

CONCLUSIONS AND IMPLICATIONS

SSI use and fingerstick burden are high in NH residents. Hypoglycemia occurred commonly among residents on SSI. Future research should compare the safety and effectiveness of SSI monotherapy vs other diabetes medication regimens to guide person-centered prescribing decisions in NHs.

Glycemic Management in Insulin-Naive Patients in the Inpatient Setting

Objective

The ideal inpatient insulin regimen efficiently attains the target blood glucose range, effectively treats hyperglycemia, and minimizes the risk of hypoglycemia. The objective of this study was to compare glycemic targets achieved by using correctional monotherapy (CM) and basal-bolus therapy (BBT) in insulin-naive patients in the inpatient setting to determine optimal blood glucose management for these patients.

Design

This was a retrospective observational cohort study of 792 patients with diabetes not on home insulin therapy who were admitted to an academic hospital over a 5.5-month period. The percentages of hyperglycemic and hypoglycemic values in each group were compared.

Results

Among the 3,112 measured blood glucose values obtained from 792 patients within the first 24 hours of insulin administration, 28.5% were hyperglycemic in the BBT group compared with 23.5% in the CM group. When adjusted for covariates, there was a 23% decrease in hyperglycemia in the BBT group (incidence rate ratio = 0.77, 95% CI 0.64-0.95, P = 0.006). Increases in A1C and admission blood glucose, as well as decreases in admission creatinine and inpatient steroid use, were independently associated with higher rates of hyperglycemia, adjusted for all other covariates. There was no significant difference between the groups in the rate of hypoglycemia in the first 24 hours, which was 1.9% in the BBT group and 1.4% in the CM group (P = 0.301).

Conclusion

Utilizing BBT in insulin-naive patients admitted to the hospital within the first 24 hours of insulin administration results in lower rates of hyperglycemia without higher rates of hypoglycemia when compared with CM.

Sliding scale insulin use in a national cohort study of nursing home residents with type 2 diabetes

BACKGROUND

Guidelines discourage sliding scale insulin (SSI) use after the first week of a nursing home (NH) admission. We sought to determine the prevalence of SSI and identify factors associated with stopping SSI or transitioning to another short-acting insulin regimen.

METHODS

In an observational study from October 1, 2013, to June 30, 2017 of non-hospice Veterans Affairs NH residents with type 2 diabetes and an NH admission over 1 week, we compared the weekly prevalence of SSI versus two other short-acting insulin regimens - fixed dose insulin (FDI) or correction dose insulin (CDI, defined as variable SSI given alongside fixed doses of insulin) - from week 2 to week 12 of admission. Among those on SSI in week 2, we examined factors associated with stopping SSI or transitioning to other regimens by week 5. Factors included demographics (e.g., age, sex, race/ethnicity), frailty-related factors (e.g., comorbidities, cognitive impairment, functional impairment), and diabetes-related factors (e.g., HbA1c, long-acting insulin use, hyperglycemia, and hypoglycemia).

RESULTS

In week 2, 21% of our cohort was on SSI, 8% was on FDI, and 7% was on CDI. SSI was the most common regimen in frail subgroups (e.g., 18% of our cohort with moderate-severe cognitive impairment was on SSI vs 5% on FDI and 4% on CDI). SSI prevalence decreased steadily from 21% to 16% at week 12 (p for linear trend <0.001), mostly through stopping SSI. Diabetes-related factors (e.g., hyperglycemia) were more strongly associated with continuing SSI or transitioning to a non-SSI short-acting insulin regimen than frailty-related factors.

CONCLUSIONS

SSI is the most common method of administering short-acting insulin in NH residents. More research needs to be done to explore why sliding scale use persists weeks after NH admission and explore how we can replace this practice with safer, more effective, and less burdensome regimens.

Comparison of Prevailing Insulin Regimens at Different Time Periods in Hospitalized Patients: A Real-World Experience from a Tertiary Hospital

BACKGROUND

Prevailing insulin regimens for glycemic control in hospitalized patients have changed over time. We aimed to determine whether the current basal-bolus insulin (BBI) regimen is superior to the previous insulin regimen, mainly comprising split-mixed insulin therapy.

METHODS

This was a single tertiary center, retrospective observational study that included non-critically ill patients with type 2 diabetes mellitus who were treated with split-mixed insulin regimens from 2004 to 2007 (period 1) and with BBI from 2008 to 2018 (period 2). Patients from each period were analyzed after propensity score matching. The mean difference in glucose levels and the achievement of fasting and preprandial glycemic targets by day 6 of admission were assessed. The total daily insulin dose, incidence of hypoglycemia, and length of hospital stay were also evaluated.

RESULTS

Among 244 patients from each period, both fasting glucose (estimated mean±standard error, 147.4±3.1 mg/dL vs. 129.4±3.2 mg/dL, P<0.001, day 6) and preprandial glucose (177.7±2.8 mg/dL vs. 152.8±2.8 mg/dL, P<0.001, day 6) were lower in period 2 than in period 1. By day 6 of hospital admission, 42.6% and 67.2% of patients achieved a preprandial glycemic target of <140 mg/dL in periods 1 and 2, respectively (relative risk, 2.00; 95% confidence interval, 1.54 to 2.59), without an increased incidence of hypoglycemia. Length of stay was shorter in period 2 (10.23±0.26 days vs. 8.70±0.26 days, P<0.001).

CONCLUSION

BBI improved glycemic control in a more efficacious manner than a split-mixed insulin regimen without increasing the risk of hypoglycemia in a hospital setting.

Nurse-managed basal-bolus versus sliding-scale insulin regimen in subjects with hyperglycemia at admission for orthopedic surgery: a propensity score approach

AIMS

A sliding-scale (SS) regimen is discouraged to correct hyperglycemia in hospital patients, but there is resistance to adoption of basal-bolus (BB) treatment in surgical units. We tested the feasibility and the effects of a nurse-based BB regimen in orthopedic surgery.

METHODS

Following an intense training to implement a protocol amenable by nurses, a group of patients admitted with hyperglycemia in an orthopedic institute were prospectively followed according to a basal-bolus insulin regimen (BB, n = 80). They were compared with a hyperglycemic group eventually treated by sliding-scale insulin on demand (SS, n = 122). Diabetes was present in 196 cases. Metabolic control was assessed during the first 3 days of surgery; outcome data were tested by logistic regression, after adjusting for propensity score.

RESULT

Average blood glucose and glucose variability were lower in BB versus SS (P < 0.001), in the presence of similar 3-day insulin doses. Complications were recorded in 68 cases (16.2% vs. 45.1% in BB and SS, respectively). BB regimen was associated with propensity-adjusted reduction in all adverse events [odds ratio (OR) 0.36; 95% confidence interval (CI) 0.17-0.76] and of systemic infections (OR 0.18; 95% CI 0.07-0.50) and with shorter hospital stay (8.8 ± SD 5.2 days vs. 12.5 ± 7.4; P < 0.01). The superiority of BB regimen was confirmed in the pair-matched analysis.

CONCLUSIONS

The study proves the feasibility and the superiority of nurse-based BB versus SS treatment in metabolic control and on the risk of adverse events in orthopedic surgery patients with hyperglycemia.

Collaboration of Hospital Pharmacists and Hospitalists to Address Glycemic Control of General Medicine Patients: Implementation of a Pilot Inpatient Diabetes Management Program

This study examined the clinical benefits of a collaborative pharmacist-physician inpatient diabetes management program that included daily blood glucose assessment and the recommendation and implementation of American Diabetes Association-recommended insulin regimens.

Trauma in the Diabetic Limb

Poorly controlled diabetes with comorbid manifestations negatively affects outcomes in lower extremity trauma, increasing the risk of short-term and long-term complications. Management strategies of patients with diabetes that experience lower extremity trauma should also include perioperative management of hyperglycemia to reduce adverse and serious adverse events.

Impact of type 2 diabetes mellitus on short-term and long-term outcomes of patients with esophageal squamous cell cancer undergoing resection: a propensity score analysis

Background

The association between type 2 diabetes mellitus (T2DM) and the risk of esophageal cancer remains unclear. The present study aimed to evaluate the impact of T2DM on short-term outcomes and long-term survival in patients with esophageal squamous cell cancer (ESCC).

Methods

The present retrospective study included 862 patients diagnosed with ESCC between January 2001 and December 2010. Among them, 280 patients had T2DM. A 1:1 propensity score-matched cohort consisting of 280 patients with and 280 without T2DM was selected from the 862 patients. The associations between T2DM and clinicopathologic characteristics were assessed using the χ² or Fisher’s exact test. Survival of ESCC patients with and without T2DM was calculated by using the Kaplan–Meier method and compared by using the Cox regression model between the two groups.

Results

The occurrence rate of anastomotic leakage was significantly higher in patients with T2DM than in those without T2DM (P < 0.001). In the subgroup with weight loss rate ≤ 5.05%, ESCC patients with T2DM had a significant longer overall survival than did those without T2DM (P = 0.003), whereas in the subgroup with weight loss rate > 5.05%, the patients without T2DM showed a longer survival (P = 0.001). Univariate and multivariate analysis results showed that T2DM was not an independent prognostic factor for patient survival.

Conclusions

Type 2 diabetes mellitus is not an independent prognostic factor in patients with ESCC. However, the combination of T2DM with severe weight loss would be a predictor of poor prognosis.

A practical and evidence-based approach to management of inpatient diabetes in non-critically ill patients and special clinical populations

Inpatient diabetes is a common medical problem encountered in up to 25-30% of hospitalized patients. Several prospective trials showed benefits of structured insulin therapy in managing inpatient hyperglycemia albeit in the expense of high hypoglycemia risk. These approaches, however, remain underutilized in hospital practice. In this review, we discuss clinical applications and limitations of current therapeutic strategies. Considerations for glycemic strategies in special clinical populations are also discussed. We suggest that given the complexity of inpatient glycemic control factors, the "one size fits all" approach should be modified to safe and less complex patient-centered evidence-based treatment strategies without compromising the treatment efficacy.

Comparison of Pulse Rate Variability and Heart Rate Variability for Hypoglycemia Syndrome

BACKGROUND

Heart rate variability (HRV) is a signal obtained from RR intervals of electrocardiography (ECG) signals to evaluate the balance between the sympathetic nervous system and the parasympathetic nervous system; not only HRV but also pulse rate variability (PRV) extracted from finger pulse plethysmography (PPG) can reflect irregularities that may occur in heart rate and control procedures.

OBJECTIVES

The purpose of this study is to compare the HRV and PRV during hypoglycemia in order to evaluate the features that computed from PRV that can be used in detection of hypoglycemia.

METHODS

To this end, PRV and HRV of 10 patients who required testing with insulin-induced hypoglycemia (IIHT) in Clinics of Endocrinology and Metabolism Diseases of Bezm-i Alem University (Istanbul, Turkey), were obtained. The recordings were done at three stages: prior to IIHT, during the IIHT, and after the IIHT. We used Bland-Altman analysis for comparing the parameters and to evaluate the correlation between HRV and PRV if exists.

RESULTS

Significant correlation (r > 0.90, p < 0.05) and close agreement were found between HRV and PRV for mean intervals, the root-mean square of the difference of successive intervals, standard deviation of successive intervals and the ratio of the low-to-high frequency power.

CONCLUSIONS

In conclusion, all the features computed from PRV and HRV have close agreement and correlation according to Bland-Altman analyses' results and features computed from PRV can be used in detection of hypoglycemia.

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

INTRODUCTION

The aim of this review was to assess the effectiveness to reduce clinical adverse events and safety of insulin administered in basal-bolus-corrector or basal-corrector regimens (BB) versus a sliding scale scheme (SS) in patients with diabetes or newly diagnosed hyperglycemia admitted to a conventional (not critical) medical or surgical hospital ward.

METHOD

A Medline search was conducted. The Odds ratio was the main summary measure. A random effects model with the Mantel-Haenszel procedure was used.

RESULTS

A total of 957 citations were collected, of which nine were finally included in the systematic review. Patients in the BB group had better blood glucose control than those with SS. Overall, there was a nonsignificant trend to a lower risk of adverse events in the BB as compared to the SS group (OR 0.67 [95% CI 0.22 to 2.04], [I(2)=71%]). There was a nonsignificant trend to an increased risk of hypoglycemia in the BB group (OR 2.29 [95% CI 0.50 to 10.49] [I(2)=70%]).

CONCLUSION

Despite its benefit for glycemic control during hospitalization, this review did not show that use of the BB scheme decreases clinical events in patients hospitalized in a conventional ward. Because of heterogeneity of the results, we think that clinical trials are needed addressing its effect in patient subgroups in which the BB scheme may be used safely and with longer follow-up periods.

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.

Adverse Drug Events in Critically Ill Patients With Cancer

Objective:

To determine the incidence, characteristics, and outcomes of adverse drug events (ADEs) in critically ill patients with cancer.

Methods:

This was a 5-month prospective observational study. Patients who were admitted to the adult medical/surgical oncology intensive care unit (ICU) were evaluated for any drug-related adverse events during their ICU stay. An ADE was defined as injury or patient harm resulting from medical intervention related to a drug.

Results:

The incidence rate of ADEs was 96.5 per 1000 patient days and 35.3 per 100 ICU admissions. Of the reported ADEs, 57 (64.8%) were serious/life threatening, 30 (34.1%) were significant, 1 (1.1%) was fatal, and 14 (15.9%) of all ADEs were considered preventable. The most common drug classes associated with ADEs were antidiabetics, antibiotics, and analgesics/sedatives. The length of stay and presence of renal or respiratory failure were significantly associated with an increased number of ADEs. The length of stay and female sex were significantly associated with the likelihood of developing an ADE.

Conclusion:

Critically ill patients with cancer are at high risk of developing ADEs. Strategies that reduce the incidence and severity of ADEs are essential to improve the outcomes of this patient population.

Converting continuous insulin infusion to subcutaneous insulin glargine after cardiac surgery using percentage-based versus weight-based dosing: a pilot trial

BACKGROUND

Most studies report using percentage of total daily insulin (TDI) for converting therapy from continuous insulin infusion to subcutaneous insulin in cardiac surgery patients. Few studies have evaluated the efficacy of using body weight to calculate the basal insulin dose.

OBJECTIVE

To compare the efficacy and safety of dosing insulin glargine by weight versus percentage of TDI in cardiac surgery patients transitioning from continuous insulin infusion to subcutaneous insulin.

METHODS

We conducted a prospective, randomized, open-label, pilot study. Study patients who had a preoperative weight less than 100 kg and were receiving at least 6 hours of a continuous insulin infusion were randomized to receive either 50% of their TDI requirement or 0.5 units/kg of glargine as a one-time dose 2 hours before stopping the continuous insulin infusion. All patients were administered subcutaneous corrective insulin. Blood glucose monitoring occurred before each meal, at bedtime, and with morning laboratory tests for 24 hours after administration of the glargine dose.

RESULTS

A total of 200 blood glucose measurements were performed in each group. The percentage of blood glucose measurements in target range (80-140 mg/dL) was similar between the weight-based group and the percentage-based group (66% vs 64%, p = 0.75). Median blood glucose after transition was 120 mg/dL (interquartile range [IQR] 99-147) in the weight-based group compared to 127 mg/dL (IQR 107-149; p = 0.03) in the percentage-based group. The median glargine dose was higher in the weight-based group (41 units; IQR 36-44) than in the weight-based group (24 units; IQR 14-30, p < 0.001). The rate of hypoglycemia (blood glucose <60 mg/dL) was 2.5% in each group.

CONCLUSIONS

In this small cohort, dosing insulin glargine by weight proved to be safe, but larger scale studies are needed before adopting weight-based dosing in this patient population.

Hospital Strategies for Insulin Therapy with Rapid-Acting Insulin Analogs

This article presents strategies on how to meet the challenges presented by the use of insulin in the hospital setting and describes trends seen in current hospital practice. Insulin provides the greatest flexibility in the hospital setting to achieve optimal blood glycemic control in patients with known type 2 diabetes, thereby reducing complications and death. Important challenges include implementing protocols for use of subcutaneous insulin injection (including optimal use of insulin pens), conversion from continuous subcutaneous insulin infusion or intravenous infusion to subcutaneous administration by multiple injections, and dosing of insulin in patients receiving corticosteroids. One important trend is a move away from the use of sliding-scale insulin to the use of correction-dose insulin as an adjunct to basal/bolus insulin. In this approach, insulin treatment is closely tailored to changing levels of glycemia, and a protocol is put in place for administration of a correction dose of rapid-acting insulin in response to a glycemic excursion. Insulin analogs can more closely mimic physiological insulin profiles than regular insulin, and rapid-acting analogs are invaluable agents as correction insulin administered by pump or in transition to multiple daily injections and as part of basal/bolus therapy. Good glycemic control can improve outcomes of hospital patients in several ways, including facilitating more rapid recovery from infections, shortening intensive care stays, and minimizing costs. Strategies employed to meet the challenges of insulin use in the hospital setting include the increasing use of continuous glucose monitoring systems and the development of insulin dosing algorithms.

[Management of hyperglycemia in the non-critical hospitalized patients with oral feeding]

A 67-year-old woman with a history of hypertension, hyperlipidemia and 6 years of evolution of type 2 diabetes mellitus presented with fever, purulent sputum and right chest pain. She was on treatment with metformin 850 mg/bid, glimepiride 4 mg/day, candesartan 16 mg/day, atorvastatin 10mg/day and acetylsalicylic acid 100mg/day. Standing out in the physical examination was blood pressure 90/50 mmHg, temperature 38.6 °C, pulse 112/min, respirations 24/min, weight 8 5 kg, height 1.68 m. She had crackling rales in the right lung-base and edema in lower limbs. The blood analysis showed leukocytosis, glucose 348 mg/dl, urea 70 mg/dl, creatinine 1.5mg/dl and HbA1c 8.4%. A chest x-ray revealed condensation in the lower lobe of the right lung. Antibiotic treatment was begun, maintaining an oral diet from admission. What is the best strategy regarding the treatment of this patient's hyperglycemia, its management and what evidence is there on this subject?

Optimizing inpatient glycemic control with basal-bolus insulin therapy

Hyperglycemia is highly prevalent in the acute-care setting and is associated with an increased risk of morbidity and mortality. Evidence suggests that glycemic control in this population is suboptimal, due in part to continued use of nonphysiologic sliding-scale insulin strategies without scheduled basal insulin doses or prandial insulin with concomitant correction doses. Although the ineffectiveness and risks of sliding-scale insulin regimens have been criticized for decades, sliding-scale insulin is still the most commonly prescribed subcutaneous insulin regimen among inpatients. Improving inpatient management requires the use of scheduled basal-bolus insulin therapy that includes basal insulin, nutritional insulin, and supplemental, or correctional, insulin. Insulin analogs are the preferred insulins, as they provide a more physiologic action than human insulin regimens, are associated with a lower risk of hypoglycemia, and are more convenient to administer than human insulins. Standardized insulin protocols and subcutaneous insulin order sets are critical components of effective inpatient glycemic control. Although preliminary data have demonstrated that inpatient diabetes management programs involving basal-bolus insulin therapy are effective and well tolerated, more research is needed.

Hyperglycemia management using insulin in the acute care setting: therapies and strategies for care in the non-critically ill patient

BACKGROUND

Hyperglycemia is prevalent in hospitalized non-critically ill patients and is associated with higher morbidity and mortality. Poor glycemic control is related to elevated costs due to longer hospital stays and higher rates of complications.

OBJECTIVE

To review current literature evaluating treatment strategies for management of hyperglycemia in the non-critically ill hospitalized patient and to discuss the role of pharmacists in glycemia management.

DATA SOURCES

A literature review (January 2000-January 2010) was conducted via PubMed, Web of Science, Cumulative Index to Nursing and Allied Health, the Cochrane Library, Combined Health Information Database, and Education Resources Information Center. MeSH terms for diabetes were used along with stress hyperglycemia, insulin therapy, and insulin analogs in combination with non-critically ill, hospitalized, acute care, or inpatient.

STUDY SELECTION AND DATA EXTRACTION

All articles identified from the data sources were reviewed for inclusion. Clinical trial reports, practice guidelines, and reviews involving insulin therapies and/or quality improvement initiatives for hyperglycemia in the acute care setting were evaluated. A total of 133 citations were reviewed and an additional 11 citations were identified from reference lists.

DATA SYNTHESIS

The association between hyperglycemia and increased mortality is recognized in the acute care setting among critically ill patients; however, data to support glycemia management in non-critically ill patients continue to be established. National consensus guidelines support strategies for glycemia control that focus on insulin therapy and treatment-driven protocols. These initiatives can result in quality improvement when led by multidisciplinary teams, including pharmacists. Literature supports a pharmacist role in glucose monitoring and insulin dosing.

CONCLUSIONS

Management of hyperglycemia is a critical component of acute care. Insulin treatment regimens and protocols for non-critically ill patients in the acute care setting are evolving with recognition of ideal glucose targets to prevent adverse outcomes. Glycemia management can be complex and presents opportunities for pharmacist involvement.

Addressing hyperglycemia from hospital admission to discharge

BACKGROUND

This review examines glycemia management practices in hospitalized patients. Optimal glycemic control remains a challenge among hospitalized patients. Recent studies have questioned the benefit of tight glycemic control and have raised concerns regarding the safety of this approach. As a result, medical societies have updated glycemic targets and have published new consensus guidelines for management of glycemia in hospitalized patients. This review highlights recent inpatient glycemic trials, the new glycemic targets and recommended strategies for management of glycemia in hospitalized patients.

METHODS

Medline and PubMed searches (diabetes, hyperglycemia, hypoglycemia, intensive therapy insulin, tight glycemic control, and hospital patients) were performed for English-language articles on treatment of diabetes, insulin therapy, hyperglycemia or hypoglycemia in hospitalized patients published from 2004 to present. Earlier works cited in these papers were surveyed. Clinical studies, reviews, consensus/guidelines statements, and meta-analyses relevant to the identification and management of diabetes and hyperglycemia in hospitalized patients were included and selected. This is not an exhaustive review of the published literature.

RESULTS

Insulin remains the most appropriate agent for a majority of hospitalized patients. In critically ill patients insulin is given as a continuous intravenous (IV) infusion and in non-critically ill inpatients hyperglycemia is best managed using scheduled subcutaneous (SC) basal-bolus insulin regimens supplemented with correction doses as needed and adjusted daily with the guidance of frequent blood glucose monitoring. Prevention of hypoglycemia is equally as important to patient outcomes and is an equally necessary part of any effective glucose control program. Modern insulin analogs offer advantages over the older human insulins (e.g., regular and neutral protamine Hagedorn [NPH] insulin) because their time-action profiles more closely correspond to physiological basal and prandial insulin requirements, and have a lower propensity for inducing hypoglycemia than human insulin formulations. Long-acting basal insulin analogs (glargine, detemir) are suitable and preferred for the basal component of therapy; rapid-acting insulin analogs (aspart, lispro, glulisine) are recommended for bolus and correction doses. Sliding-scale insulin (SSI) regimens are not effective and should not be used, especially as this excludes a basal insulin component from the therapy.

CONCLUSIONS

Optimal glycemic management in the hospital setting requires judicious treatment of hyperglycemia while avoiding hypoglycemia. Insulin is the most appropriate agent for management of hyperglycemia for the majority of hospitalized patients. Intravenous insulin infusion is still preferred during and immediately after surgery, but s.c. basal insulin analogs with prandial or correction doses should be used after the immediate post-operative period, and also should be used in non-critically ill patients. Frequent and effective glucose monitoring is critical for avoiding wide deviations from acceptable glucose levels, which under a recently promulgated consensus guideline currently range between 140 mg/dL and 180 mg/dL. Glucose targets near 140 mg/dL are recommended as being the most appropriate for all hospitalized patients.

The nuts and bolts of subcutaneous insulin therapy in non-critical care hospital settings

In non-critical care settings, patients with hyperglycemia experience increased morbidity and mortality. Despite an increased recognition of the importance of treating inpatient hyperglycemia, many patients are still not adequately controlled. Insulin offers flexibility to address varying glucose levels and therefore is the preferred therapy to achieve recommended targets and manage hyperglycemia. Traditional sliding-scale insulin regimens often ineffectively control blood glucose levels as they are unable to mimic physiologic insulin secretion. Basal-bolus insulin regimens are recognized as a more effective way to correct hyperglycemia in non-critical care settings and a systematic glycemic control program is necessary to address hyperglycemia while minimizing hypoglycemia. Critical components of these programs include addressing barriers to glycemic control, understanding varying needs of different types of patients, and developing standardized subcutaneous insulin orders to achieve target glucose levels. This article provides strategies for using insulin in non-critical care settings to facilitate glycemic control.

Glycemic control and surgery-optimizing outcomes for the patient with diabetes

Diabetes mellitus (DM) has reached epidemic proportions globally, and its incidence continues to rise. Considering the increasing number of patients diagnosed with diabetes and the associated complications, such as cardiovascular and renal disease, the complexity of care for this population can be very challenging. In addition, specific postoperative complications, such as delayed wound healing, infections, and cardiac dysrhythmias, are more likely to occur in the presence of perioperative hyperglycemia. Recognition of the presence of diabetes and implementation of a diabetic management protocol will optimize patient outcomes by providing guidelines for avoiding such complications. Although comparative studies of the current published protocols are limited, there is agreement that health care facilities must have a protocol in place that considers the individual's health history, planned surgery, and glycemic control to guide management of diabetes.

Incretin-based therapies: review of the outpatient literature with implications for use in the hospital and after discharge

A large percentage of critically ill adult inpatients have type 2 diabetes, which may be undiagnosed or uncontrolled during hospitalization. Hyperglycemia complicates the therapeutic management of inpatients and leads to adverse outcomes, and intensive glycemic control with insulin reduces morbidity and mortality. Insulin therapy, however, is labor-intensive and time-consuming. More important, long-standing protocols such as the sliding scale do not provide adequate glucose control. Although more research is needed to determine the best methods for treating hyperglycemia in-hospital, the importance of achieving better glycemic control while reducing the risk of hypoglycemia has been demonstrated. Post-discharge diabetes care is equally important, as it is essential in improving long-term outcomes after a hospital stay. Hospital care providers can play an important role in effective antihyperglycemic regimens in patients with diabetes prior to discharge. Post-discharge management is a formidable challenge because of the availability of an array of oral antidiabetes agents, including metformin, sulfonylureas, and thiazolidinediones, each with distinct therapeutic and adverse event profiles. Incretin-based therapies offer a potentially useful option for post-discharge therapy, and possibly for inpatient diabetes treatment. Incretins are effective, safe, and well-tolerated; they are easier for patients to use compared with insulin injections (eg, continual glucose monitoring is not required); and they may provide long-term improvement of cardiovascular parameters and beta-cell function. This review examines the challenges to achieving glycemic control in the hospital setting and summarizes clinical data on the efficacy and safety of incretin-based therapies in their use in the hospital and after discharge.

Evaluation of hospital glycemic control at US academic medical centers

OBJECTIVE

To evaluate contemporary hospital glycemic management in US academic medical centers.

DESIGN

This retrospective cohort study was conducted on patients discharged from 37 academic medical centers between July 1 and September 30, 2004; 1,718 eligible adult patients met at least 1 of the inclusion criteria: 2 consecutive blood glucose readings >180 mg/dL within 24 hours, or insulin treatment at any time during hospitalization. We assessed 3 consecutive measurement days of glucose values, glycemic therapy, and additional clinical and laboratory characteristics.

RESULTS

In this diverse cohort, 79% of patients had a prior diagnosis of diabetes, and 84.6% received insulin on the second measurement day. There was wide variation in hospital performance of recommended hospital diabetes care measures such as glycosylated hemoglobin (A1C) assessment (range, 3%-63%) and timely admission laboratory glucose measurement (range, 39%-97%). Median glucose was significantly lower for patients in the intensive care unit (ICU) compared to ward/intermediate care. ICU patients treated with intravenous insulin had significantly lower median glucose when compared to subcutaneous insulin. Only 25% of ICU patients on day 3 had estimated 6 AM glucose <or=110 mg/dL. Hyperglycemia was common, 50% of all patients had >or=1 glucose measurement >or=180 mg/dL on measurement days 2 and 3. Severe hypoglycemia (<50 mg/dL) occurred in 2.8% of all patient days.

CONCLUSIONS

Despite frequent insulin use, glucose control was suboptimal. Academic medical centers have opportunities to improve care to meet current American Diabetes Association hospital diabetes care standards.

Evaluation of glycemic control following discontinuation of an intensive insulin protocol

BACKGROUND

Intensive insulin protocols (IIPs) have been demonstrated to reduce morbidity and mortality in critically ill patients. Currently, there are no published studies evaluating glycemic control after discontinuation of an IIP.

OBJECTIVE

The purpose of this study was to compare blood glucose (BG) control during an IIP and for 5 days following its discontinuation (follow-up period).

METHODS

The study was a retrospective review of intensive care unit patients who received an IIP for >or=24 hours. Data were collected during the last 12 hours of the IIP and subsequent follow-up period.

RESULTS

For all 65 included patients, the mean +/- standard deviation for BG on the IIP was 123 +/- 26 mg/dL versus 168 +/- 50 mg/dL following discontinuation of the IIP (P < 0.001). The median (interquartile range) insulin that was administered decreased from 40 (22-65) units on the IIP to 8 (0-18) units after the IIP was stopped (P < 0.001). The mean daily BG during the follow-up period was significantly higher than that during the IIP (P < 0.001). Additionally, an insulin requirement of >20 units during the last 12 hours of the IIP was identified as a risk factor for poor glycemic control during the follow-up period (odds ratio: 4.62; 95% confidence interval: 1.17-18.17).

CONCLUSIONS

This study demonstrates a significant increase in BG following discontinuation of an IIP. Higher insulin requirements during the last 12 hours of an IIP were identified as an independent risk factor for poor glycemic control following the IIP. A standardized insulin transition protocol may help better control BG after discontinuation of an IIP.

Managing hyperglycemia in hospitalized patients

Insulin infusion is used in the critical care setting for prevention of hyperglycemia and is administered most safely under a structured, dynamic, dose-defining algorithm. The ordering of basal-prandial-correction SC insulin therapy, appropriate for most hospitalized patients who are eating, is simplified and standardized to excellence by the development of institutional order sets or computerized order entry templates. Basal insulin therapy is prescribed as intermediate-acting insulin or long-acting insulin analogue. Prandial insulin therapy is delivered with meals to prevent excessive glycemic excursions from occurring after ingestion of meals and is prescribed as rapid-acting insulin analogue. Correction-dose insulin therapy is ordered as small doses of rapid-acting insulin analogue delivered to correct hyperglycemia and is prescribed with appropriate timing so as to avoid stacking with previously administered doses of rapid-acting insulin analogue. Patients knowledgeable in diabetes self-management will experience satisfaction under an institutional policy that allows self-management to continue under appropriate conditions during hospitalization. To craft appropriate institutional tools for patient care, the input and consensus of a multidisciplinary group of health care professionals, including primary care providers and hospitalists, as well as specialists in diabetes with backgrounds in endocrinology, nutrition and dietetics, nursing, pharmacy, laboratory sciences, and quality assurance, is required.

Inpatient insulin therapy

PURPOSE OF REVIEW

In a 2001 report from a surgical intensive care unit in Leuven, Belgium, intravenous insulin infusion targeting blood glucose 80-110 mg/dl reduced patient mortality and morbidities. Subsequent research has failed to define glycemic targets necessary or sufficient for attainment of desired health outcomes in other inpatient settings, but a large body of evidence suggests hospital outcomes are related to hyperglycemia.

RECENT FINDINGS

Recent literature describes observational evidence for hypoglycemia as an independent predictor of mortality in a general medical intensive care unit; superiority of performance of computerized intravenous insulin algorithms in comparison to earlier manual algorithms; acceptability of early transition to scheduled basal prandial correction subcutaneous insulin analog therapy for maintenance of glycemic targets after induction of euglycemia by intravenous insulin infusion, among cardiothoracic surgery patients; inferiority of sliding scale insulin compared to basal prandial correction therapy; and feasibility of diabetes patient self-management in the hospital setting.

SUMMARY

With development of improved insulin administration strategies problems of hypoglycemia and variability of glycemic control are reduced. Investigators and care providers need to achieve glycemic targets to optimize patient outcomes.

Treatment intensification and blood glucose control among hospitalized diabetic patients

BACKGROUND

Hyperglycemia is common among diabetic inpatients, and has been linked to adverse outcomes. However, antihyperglycemic treatment is seldom intensified in noncritical care patients, and the relationship between intensification frequency and glucose control is poorly understood. We evaluated the relationship between treatment intensification and changes in blood glucose in hospitalized diabetic patients.

DESIGN

We retrospectively analyzed 3,613 hospitalized diabetic patients who were admitted to the hospital between January 2003 and August 2004, were not hospitalized in an ICU, were not prescribed IV insulin or total parenteral nutrition (TPN), had a length of stay of at least 3 days, and had at least one point-of-care blood glucose measurement. A linear model was used to assess the relationship between intensification of antihyperglycemic medications and the average daily change in point-of-care glucose measurements.

RESULTS

Hyperglycemia (>180 mg/dL) was documented at least once for 82.5% of patient admissions. Antihyperglycemic treatment was intensified for 22.0% of days with hyperglycemia. Intensifications of scheduled and sliding scale insulin, but not oral medications, were associated with a 11.1 mg/dL (p < 0.0001) and 12.2 mg/dL (p < 0.0001) reduction in the average daily glucose, respectively. Hypoglycemia (<50 mg/dL) was documented on 2.2% of days after antihyperglycemic treatment intensification.

CONCLUSION

In this cohort, lack of treatment intensification in response to inpatient hyperglycemia was common. Antihyperglycemic treatment intensification was strongly associated with decrease in average daily glucose, while hypoglycemia was uncommon. This suggests that increasing the frequency of treatment intensifications could lead to improved glycemic control in inpatients with diabetes.

Diabetes: the latest trends in glycemic control

The increasing pervasiveness of diabetes mellitus on a global stage has been well documented. Many groundbreaking studies have detailed the consequences of inadequate glycemic control, but only recently have data supported evidence that demonstrates benefits in the acute setting. Consensus is lacking with regard to how to achieve glycemic control in the hospital setting. This article discusses glycemic control, with special emphasis on the perioperative patient. Emerging therapeutic treatments and less frequently encountered protocols such as insulin pump management and insulin infusion are considered.

The Transition from Insulin Infusions to Long-Term Diabetes Therapy: The Argument for Insulin Analogs

After cardiac surgery, it is medical mismanagement to place an order for sliding scale insulin at the time of transitioning from intravenous insulin. Use of basal-prandial-correction therapy with insulin analogs constitutes a suitable transitioning regimen for inpatient management of hyperglycemia after heart surgery, to be ordered before interruption of intravenous insulin infusion, in conjunction with a program of blood glucose monitoring before meals, at bedtime, and midsleep. In the ambulatory setting, in comparison to neutral protamine Hagedorn, long-acting insulin analogs reduce hypoglycemia. In comparison to regular insulin, rapid-acting insulin analogs reduce hypoglycemia and improve postprandial control. A standardized approach to order entry for basal-prandial-correction therapy enhances safety and staff familiarity while preserving individualization of patient care. Proposed predictors of successful transition are described. Dose requirements during intravenous insulin infusion can be used to guide initial dose assignments of basal insulin therapy. As the patient approaches discharge, the total daily doses of subcutaneous insulin and basal insulin dose are decreased, and the proportion of prandial insulin approaches or exceeds 50% of the total daily dose as the absolute amount of prandial insulin increases. Before discharge, hyperglycemic patients not known to have diabetes should be advised of the need for outpatient reassessment, and those known to have diabetes but requiring intensification of therapy should participate in decision-making concerning their options for intensified treatment.