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Webster RE, Belfer JJ, Schmidt KJ. Evaluation of Basal Plus Versus Sliding Scale Insulin Therapy on Glucose Variability in Critically Ill Patients Without Preexisting Diabetes. Ann Pharmacother 2024; 58:565-571. [PMID: 37700565 DOI: 10.1177/10600280231197255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND There is limited evidence evaluating the impact of insulin treatment strategies on glucose variability in critically ill patients without preexisting diabetes. OBJECTIVE Compare basal plus insulin (BPI) and sliding scale insulin (SSI) impact on glycemic control outcomes in critically ill patients without preexisting diabetes experiencing hyperglycemia. METHODS This multicenter, retrospective review analyzed critically ill patients with hyperglycemia who received either BPI or SSI. Patients with a hemoglobin A1C >6.5% during the admission of interest or in the previous 3 months, or a diagnosis of diabetes at the time of discharge were excluded. The primary outcome was glucose variability during the intensive care unit (ICU) admission. Secondary outcomes included hypoglycemia frequency, frequency of goal glucose levels, mortality, and length of stay. RESULTS The analysis included 228 patients (39 in BPI, 189 in SSI). Average glucose variability was higher in the BPI group compared with the SSI group (85.8 mg/dL ± 33.1 vs 70.2 mg/dL ± 30.7; P = 0.009), which remained when controlling for baseline confounding (-12.1 [5.6], 95% CI -23.2 to -0.99; P = 0.033). Hypoglycemia incidence was similar between groups. BPI patients had a lower incidence of glucose values within goal range than SSI patients (P = 0.046). There was no difference in length of stay or hospital mortality. CONCLUSIONS AND RELEVANCE The use of SSI compared with a BPI regimen may result in reduced glycemic variability in critically ill patients without preexisting diabetes. Future prospective studies, with a larger sample size, are warranted to confirm our exploratory findings and characterize clinically significant benefits.
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Affiliation(s)
- Rachel E Webster
- Department of Pharmacy, Trinity Health Grand Rapids, Grand Rapids, MI, USA
| | - Julie J Belfer
- Department of Pharmacy, Trinity Health Grand Rapids, Grand Rapids, MI, USA
| | - Kyle J Schmidt
- Department of Pharmacy, Trinity Health Grand Rapids, Grand Rapids, MI, USA
- College of Pharmacy, Ferris State University, Big Rapids, MI, USA
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Zhang X, Zhang T, Xiang G, Wang W, Li Y, Du T, Zhao Y, Mosha SS, Li W. Comparison of weight-based insulin titration (WIT) and glucose-based insulin titration using basal-bolus algorithm in hospitalized patients with type 2 diabetes: a multicenter, randomized, clinical study. BMJ Open Diabetes Res Care 2020; 8:8/1/e001261. [PMID: 32933950 PMCID: PMC7493103 DOI: 10.1136/bmjdrc-2020-001261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/26/2020] [Accepted: 07/30/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Subcutaneous administration of insulin is the preferred method for achieving glucose control in non-critically ill patients with diabetes. Glucose-based titration protocols were widely applied in clinical practice. However, most of these algorithms are experience-based and there is considerable variability and complexity. This study aimed to compare the effectiveness and safety of a weight-based insulin titration algorithm versus glucose-based algorithm in hospitalized patients with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS This randomized clinical trial was carried out at four centers in the South, Central and North China. Inpatients with T2DM were randomly assigned (1:1) to receive weight-based and glucose-based insulin titration algorithms. The primary outcome was the length of time for reaching blood glucose (BG) targets (fasting BG (FBG) and 2-hour postprandial BG (2hBG) after three meals). The secondary outcome included insulin dose for achieving glycemic control and the incidence of hypoglycemia during hospitalization. RESULTS Between January 2016 and June 2019, 780 patients were screened, and 575 completed the trial (283 in the weight-based group and 292 in the glucose-based group). The lengths of time for reaching BG targets at four time points were comparable between two groups. FBG reached targets within 3 days and 2hBG after three meals within 4 days. There is no significant difference in insulin doses between two groups at the end of the study. The total daily dosage was about 1 unit/kg/day, and the ratio of basal-to-bolus was about 2:3 in both groups. The incidence of hypoglycemia was similar in both groups, and severe hypoglycemia was not detected in either of the groups. CONCLUSIONS Weight-based insulin titration algorithm is equally effective and safe in hospitalized patients with T2DM compared with glucose-based algorithm. TRIAL REGISTRATION NUMBER NCT03220919.
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Affiliation(s)
- Xiaodan Zhang
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Tong Zhang
- Department of Endocrinology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Guangda Xiang
- Department of Endocrinology, Wuhan General Hospital of Chinese People's Liberation Army, Wuhan, China
| | - Wenbo Wang
- Department of Endocrinology, Peking University Shougang Hospital, Beijing, China
| | - Yanli Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Tao Du
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yunjuan Zhao
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Singla Sethiel Mosha
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Wangen Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Shabani M, Rashedi M, Razzazzadeh S, Saffaei A, Sahraei Z. Blood Glucose Control and Opportunities for Clinical Pharmacists in Infectious Diseases Ward. J Res Pharm Pract 2019; 8:202-207. [PMID: 31956633 PMCID: PMC6952754 DOI: 10.4103/jrpp.jrpp_18_109] [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] [Received: 12/27/2018] [Accepted: 08/02/2019] [Indexed: 11/04/2022] Open
Abstract
Objective Increased risk of infection following hyperglycemia has been reported in hospitalized patients. Sliding-scale insulin protocol is an out-of-date method; therefore, it is necessary to examine new approaches in this regard. This study aimed to evaluate the efficacy of sliding-scale protocol versus basal-bolus insulin protocol, which supervised by clinical pharmacists in an infectious disease ward. Methods In this prospective randomized clinical trial, 90 hyperglycemic patients who hospitalized in Loghman Hakim Hospital Infectious Disease Ward (Tehran, Iran) were randomized into two groups: sliding-scale insulin protocol (the control group) and the basal-bolus protocol groups that were under supervision clinical pharmacists. Some demographic, laboratory, and clinical variables, as well as patient's blood glucose were measured four times daily. Findings The results indicated significant improvement among the patients in the intervention group. General indicators including fever, blood glucose level, the duration of hospitalization, incidence of hypoglycemia, days to achieve normal blood glucose, and leukocyte count improved in intervention group. Conclusion According to this study, basal-bolus insulin protocol, which supervised by clinical pharmacy service, showed better blood glucose control and infection remission compared to the sliding-scale protocol.
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Affiliation(s)
- Minoosh Shabani
- Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Rashedi
- Students' Research Committee, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sareh Razzazzadeh
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Saffaei
- Students' Research Committee, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Sahraei
- Department of Clinical Pharmacy, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Masse J, Giuliano CA, Brown S, Paxton RA. Association Between the Use of Long-Acting Insulin and Hypoglycemia in Nondiabetic Patients in the Surgical Intensive Care Unit. J Intensive Care Med 2016; 33:317-321. [PMID: 27821581 DOI: 10.1177/0885066616677030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE The purpose of this study was to examine the association between long-acting insulin and hypoglycemia in nondiabetic surgical intensive care patients. METHODS This single-center, retrospective cohort study evaluated glycemic control in nondiabetic critically ill surgical patients receiving long-acting insulin plus sliding scale versus those receiving sliding scale alone. Patients were matched based on sliding scale order and type of surgery. The primary outcome was the proportion of patients who experienced hypoglycemia (glucose values <70 mg/dL). Secondary outcomes included comparing the distribution of glycemic events in the 2 groups and describing the proportion of patients transferred out of the intensive care unit on long-acting insulin who experienced hypoglycemia. RESULTS One hundred twenty patients met the study criteria. Hypoglycemia was significantly higher in the long-acting insulin plus sliding scale group compared to those receiving sliding scale alone (17 [28.3%] patients vs 8 [13.3%] patients; P = .047). After adjusting for body mass index, renal failure, age, and Acute Physiology and Chronic Health Evaluation II, the odds of hypoglycemia were 4.1 times higher for patients receiving long-acting insulin and sliding scale compared to those receiving sliding scale alone ( P = .02). There were more hypoglycemic events (42 vs 20; P = .05) and hyperglycemic events (313 vs 135; P = .02) in the long-acting insulin group. CONCLUSION This study demonstrated higher rates of hypoglycemia associated with the utilization of long-acting insulin in nondiabetic surgical intensive care patients. Risk of hypoglycemia should be weighed against possible benefits in this population.
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Affiliation(s)
- Jordan Masse
- 1 Department of Pharmacy, St. John Hospital and Medical Center, Detroit, MI, USA
| | - Christopher Alan Giuliano
- 1 Department of Pharmacy, St. John Hospital and Medical Center, Detroit, MI, USA.,2 Department of Pharmacy Practice, Wayne State University, Detroit, MI, USA
| | - Sara Brown
- 1 Department of Pharmacy, St. John Hospital and Medical Center, Detroit, MI, USA
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Gómez Cuervo C, Sánchez Morla A, Pérez-Jacoiste Asín MA, Bisbal Pardo O, Pérez Ordoño L, Vila Santos J. Effective adverse event reduction with bolus-basal versus sliding scale insulin therapy in patients with diabetes during conventional hospitalization: Systematic review and meta-analysis. ACTA ACUST UNITED AC 2016; 63:145-56. [PMID: 26826772 DOI: 10.1016/j.endonu.2015.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 11/22/2015] [Accepted: 11/28/2015] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
| | - Ana Sánchez Morla
- Servicio de Urgencias, Hospital Universitario 12 de Octubre, Madrid, España
| | | | - Otilia Bisbal Pardo
- Servicio de Medicina Interna, Hospital Universitario 12 de Octubre, Madrid, España
| | - Luis Pérez Ordoño
- Servicio de Urgencias, Hospital Universitario 12 de Octubre, Madrid, España
| | - Juan Vila Santos
- Servicio de Urgencias, Hospital Universitario 12 de Octubre, Madrid, España
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Efficacy and Safety of Weight-based Insulin Glargine Dose Titration Regimen Compared With Glucose Level- and Current Dose-based Regimens in Hospitalized Patients With Type 2 Diabetes: A Randomized, Controlled Study. Clin Ther 2014; 36:1269-75. [DOI: 10.1016/j.clinthera.2014.06.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/03/2014] [Accepted: 06/27/2014] [Indexed: 11/23/2022]
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Crawford K. Guidelines for care of the hospitalized patient with hyperglycemia and diabetes. Crit Care Nurs Clin North Am 2012; 25:1-6. [PMID: 23410640 DOI: 10.1016/j.ccell.2012.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hyperglycemia and diabetes place hospitalized patients at greater risk for serious complications such as infections, diabetic ketoacidosis, hyperosmolar hyperglycemic state, dehydration, electrolyte imbalances, greater antibiotic use, and lengthened hospitalization. Identification and proper treatment of hyperglycemia and diabetes are therefore essential for prevention of significant morbidity and mortality to the patient and to conserve ever-shrinking health care resources. The author discusses standards for the identification of diabetes and hyperglycemia, provides recommendations for target blood glucose values, and discusses current consensus guidelines on inpatient glycemic management in non-critically ill hospitalized patients.
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Affiliation(s)
- Kate Crawford
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1461, Houston, TX 77030, USA.
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Beltramello G, Manicardi V, Trevisan R. Trialogue. La gestione dell’iperglicemia in area medica. Istruzioni per l’uso. ITALIAN JOURNAL OF MEDICINE 2012. [DOI: 10.1016/j.itjm.2012.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Roberts GW, Aguilar‐Loza N, Esterman A, Burt MG, Stranks SN. Basal–bolus insulin versus sliding‐scale insulin for inpatient glycaemic control: a clinical practice comparison. Med J Aust 2012; 196:266-9. [DOI: 10.5694/mja11.10853] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Greg W Roberts
- Pharmacy Department, Repatriation General Hospital, Adelaide, SA
- School of Medicine, Flinders University, Adelaide, SA
| | - Norma Aguilar‐Loza
- Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, SA
| | - Adrian Esterman
- Sansom Institute of Health Service Research and School of Nursing and Midwifery, University of South Australia, Adelaide, SA
| | - Morton G Burt
- School of Medicine, Flinders University, Adelaide, SA
- Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, SA
| | - Stephen N Stranks
- School of Medicine, Flinders University, Adelaide, SA
- Southern Adelaide Diabetes and Endocrine Services, Repatriation General Hospital, Adelaide, SA
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