Optimizing inpatient glycemic control with basal-bolus insulin therapy

Sliding Scale Insulin vs Basal-Bolus Insulin Therapy in Long-Term Care: A 21-Day Randomized Controlled Trial Comparing Efficacy, Safety and Feasibility

INTRODUCTION

Sliding scale insulin (SSI) therapy remains a common means of insulin therapy in long-term care (LTC) for the management of type 2 diabetes mellitus, despite current recommendations not supportive of the form of therapy today. Lack of randomized trial data on the efficacy and safety of basal-bolus insulin (B-BI) therapy in nursing home residents may have precluded this form of insulin administration in the LTC setting. Our study is a comparison of the efficacy of SSI (control) and B-BI (intervention) therapies during a 21-day intervention trial in older nursing home residents.

METHODS

Fourteen LTC facilities in the US participated; 110 residents with type 2 diabetes volunteered to participate; 35 failed inclusion criteria, 75 signed informed written consent, and 11 were discharged to home/hospital or withdrew consent; data from 64 participants are reported. Recent fasting blood glucose (FBG), hemoglobin A1c, and chemistries were obtained. Four glucose readings (prior to breakfast, lunch, dinner, and bedtime), oral antiglycemic drug, and insulin doses and changes, and all adverse events/serious adverse events, both those related to glucose control [hypoglycemic (<70 mg/dL) and hyperglycemic (>200 mg/dL) episodes] and those unrelated, were recorded daily. Patients were randomized to either remain on SSI or be shifted to the B-BI group.

RESULTS

Nursing home residents 80 ± 8 (standard deviation) years, 66% female participated; Control and Intervention participants had similar age, gender, race distributions, comorbidity, and 3-day average pretrial FBG levels (all P > .05). At study end, B-BI volunteers had significantly lower 3-day average FBG levels vs pretrial (P = .0231) while SSI participants had no change in 3-day average FBG (P > .05). During the trial, participants from both groups had similar rates of hypoglycemia, hyperglycemia, other adverse events, and hospitalizations (serious adverse events) unrelated to glucose control (all P > .05).

CONCLUSIONS

B-BI therapy produced significantly lower average FBG levels after 21 days compared with SSI therapy; both groups had similar rates of hypo- and hyperglycemia. Switching to B-BI therapy is feasible, safe, and effective in the LTC setting.

Basal-bolus insulin therapy and glycemic control in adult patients with type 2 diabetes mellitus: a review of the literature

PURPOSE

To present an integrative review related to basal-bolus insulin therapy and glycemic control in adult patients with type 2 diabetes mellitus.

DATA SOURCES

A search of the Cochrane, Medline (first search and PubMed), and CINAHL electronic databases was conducted from 2004 through 2011 using the search terms "basal-bolus insulin therapy, sliding scale insulin, glycemic control, and adult."

CONCLUSIONS

Comparisons were made of glycemic control, safety, adverse events, body weight, and insulin dose showing basal-bolus insulin therapy to be at least equal, if not superior to sliding scale insulin for the patient with type 2 diabetes mellitus. Overall patients using basal-bolus insulin therapy experienced better glycemic control, fewer hypoglycemic events, and had less weight gain.

IMPLICATIONS FOR PRACTICE

Basal-bolus insulin therapy is recommended over sliding scale insulin for achieving glycemic control in both the inpatient and outpatient setting because of a reduced number of occurrences of hyper- or hypoglycemic events. This could translate to decreased hospitalizations, decreased length of stay, decreased healthcare costs, and improved patient outcomes.

Management of the hyperglycemic inpatient: tips, tools, and protocols for the clinician

Inpatient hyperglycemia is increasingly recognized as a contributor to in-hospital complications and prolonged hospital stays. Protocols to assist in management of hyperglycemia are becoming more widely used and have been shown to improve outcomes for hyperglycemic patients. In this article, several evidence-based protocols are reviewed for use by hospital-based clinicians, both for subcutaneous and intravenous insulin. Clinicians should consider implementing protocols for hyperglycemia management in the inpatient setting.