Safety and Efficacy of Insulins in Critically Ill Patients Receiving Continuous Enteral Nutrition.

OBJECTIVE: There is a relative lack of consensus regarding the optimal management of hyperglycemia in patients receiving continuous enteral nutrition (EN), with or without a diagnosis of diabetes. METHODS: This retrospective study examined 475 patients (303 with known diabetes) hospitalized in critical care setting units in 2019 in a single center who received continuous EN. Rates of hypoglycemia, hyperglycemia, and glucose levels within the target range (70-180 mg/dL) were compared between patients with and without diabetes, and among patients treated with intermediate-acting (IA) biphasic neutral protamine Hagedorn 70/30, long-acting (LA) insulin, or rapid-acting insulin only. RESULTS: Among those with type 2 diabetes mellitus, IA and LA insulin regimens were associated with a significantly higher proportion of patient-days in the target glucose range and fewer hyperglycemic days. Level 1 (<70 mg/dL) and level 2 (<54 mg/dL) hypoglycemia occurred rarely, and there were no significant differences in level 2 hypoglycemia frequency across the different insulin regimens. CONCLUSION: Administration of IA and LA insulin can be safe and effective for those receiving insulin doses for EN-related hyperglycemia.

Cardiovascular Safety of Antidiabetic Drugs in the Hospital Setting.

PURPOSE OF REVIEW: Patients with diabetes and/or stress hyperglycemia requires good glycemic control in the hospital setting, often requiring the use of glucose-lowering therapy. Standard-of-care dictates that non-insulin therapy be discontinued, with insulin therapy initiated using a basal-bolus approach. However, insulin is associated with a high risk for hypoglycemia and medical errors. Alternatives to insulin are needed in the inpatient setting, but the cardiovascular (CV) safety of non-insulin therapy is a concern. RECENT FINDINGS: Most studies of antidiabetic drugs have been performed in the outpatient setting, and except for insulin therapy, trials in the inpatient setting have been insufficient to establish CV safety. Randomized controlled trials support the safety of insulin with more moderate glycemic control in the hospital, when hypoglycemia is minimized. Two recent multicenter randomized controlled clinical trials support the safety of sitagliptin, a dipeptidylpeptidase-4 inhibitor (DPP4i), in hospitalized patients, although the sample sizes were likely too small to detect CV events. Small trials suggest a possible CV benefit of glucagon-like peptide-1 receptor agonist therapy. A paucity of evidence and presence of side effects and cautions with insulin secretagogues, sodium glucose-co-transporter-2 inhibitors, and metformin preclude their routine use in the hospital setting. Available evidence is inadequate to evaluate the CV safety of most antidiabetic drug classes in the hospital setting. However, preliminary data from randomized clinical trials suggest the potential safety of the DPP4i sitagliptin.

Transitional care clinic for uninsured and medicaid-covered patients with diabetes mellitus discharged from the hospital: a pilot quality improvement study.

Transitioning from the inpatient to outpatient setting is often a problematic aspect of diabetes mellitus (DM) care. Different factors during hospitalization may adversely affect glycemic control in patients, who are frequently discharged on regimens that differ markedly from prehospitalization outpatient regimens. Moreover, the discharge recommendations may not have been tested adequately during a relatively short hospital length of stay and pose a significant threat to patient safety upon discharge. Our pilot study evaluated the effect on hospital utilization of the transitional care clinic (TCC), where patients with DM are seen within 2 to 5 days of hospital discharge. One hundred patients with DM, who were either medically indigent (no insurance or Medicaid and no primary care providers) or covered by Medicaid, and who did not have a primary care provider, were randomized into either a control or an intervention group upon discharge from the hospital. Subjects from the intervention group (n = 50) were seen in the TCC. All subjects were contacted 90 days after discharge to collect information about emergency department visits and readmissions. Thirteen subjects from the control group and 13 from the intervention group visited the emergency department within 90 days of discharge. Fourteen control subjects (28%) and 10 intervention patients (20%) were rehospitalized for various medical conditions during the follow-up period (P = not significant). Among patients originally admitted for DM-related issues, 6 of 14 in the control group (42.9%) and 2 out of 16 in the intervention group (12.5%) were readmitted during follow-up (P < 0.05). We conclude that the TCC may be effective for the prevention of rehospitalizations in indigent patients admitted for DM-related problems and who did not have primary care providers. The benefit of the TCC was not seen when patients with DM were admitted for other medical problems. Larger randomized controlled trials are needed to confirm this preliminary finding.

Effect of glargine insulin delivery method (pen device versus vial/syringe) on glycemic control and patient preferences in patients with type 1 and type 2 diabetes.

OBJECTIVE: To evaluate the effects of two different glargine insulin delivery methods (pen device vs. vial/syringe) on glycemic control and patient preferences in a randomized, open-label, crossover, comparative effectiveness study. METHODS: Thirty-one patients discharged from the hospital were recruited for this study. In the hospital, all patients were treated with a basal-bolus insulin regimen. Upon discharge, 21 patients received glargine by pen device for 3 months and were then switched to vial/syringe for the next 3 months (group 1). Group 2 consisted of 10 patients discharged on vial/syringe and converted to pen device after 3 months. Hemoglobin A1c (HbA1c) was measured at enrollment and at 3 and 6 months. A questionnaire assessing patient preference was administered at 3 and 6 months. RESULTS: Groups 1 and 2 had similar baseline HbA1c (10.7 ± 2.2% and 11.2 ± 2.5%, respectively) and similar reduction in HbA1c at 3 months (7.8 ± 1.7% and 7.3 ± 1.4%, respectively; P<.001 vs. baseline). However, after crossover, the changes in HbA1c from 3 to 6 months were significantly different between groups. HbA1c increased to 8.5 ± 2.0% at 6 months in group 1 after switching to the vial/syringe but remained unchanged (7.1 ± 1.6%) in group 2 after switching to a pen device (P<.01, group 1 vs. group 2). Patient questionnaires after each phase of the trial revealed that patients found the pen device more convenient and were more likely to recommend this insulin delivery method to someone else. CONCLUSION: Patients switching to a glargine pen device achieved lower HbA1c at the 6-month follow-up. Patients in both groups overwhelmingly preferred glargine pens over vials/syringes.

Comparison of 70/30 biphasic insulin with glargine/lispro regimen in non-critically ill diabetic patients on continuous enteral nutrition therapy.

Despite significant advances in inpatient diabetes management, it is still a challenge to choose the safest and most efficacious subcutaneous insulin regimen for diabetic patients on continuous enteral nutrition (EN) therapy. The authors conducted a retrospective analysis of glycemic control in 22 non-critically ill diabetic patients, receiving at least 3 days of continuous EN. Patients received different insulin regimens while on continuous EN, including a basal/bolus glargine/lispro regimen (group 1, n = 8), 70/30 biphasic insulin twice daily (group 2, n = 8), and 70/30 biphasic insulin 3 times a day (group 3, n = 6). The glucose data from 72 hours from the initiation of EN were analyzed (12 point-of-contact glucose measurements per patient). Overall, the degree of control was comparable in all groups, with target range maintained more consistently in group 3 (70/30 insulin administered 3 times daily). In this group, 69% of values were in the target range (140-180 mg/dL) as compared with 24% in glargine/lispro group and 22% in the 70/30 insulin bid group. Eight hypoglycemic episodes occurred among the 3 groups: 5 episodes in group 1 (5.4%), 2 episodes in group 2 (2.1%), and 1 episode in group 3 (1.4%) (P = .05, groups 2 and 3 vs group 1). Administration of 70/30 biphasic insulin 3 times daily is a safe therapeutic regimen in diabetic patients on continuous EN as it maintains glycemia in the target range and might produce fewer episodes of hypoglycemia.

Hitting the target for inpatient glycemic management.

Hyperglycemia in the hospital setting can lead to increased morbidity and mortality. Many factors can influence glucose levels including critical illness, supplemental feeding, and glucocorticoid administration. An understanding of glycemic treatment options for hospitalized patients is essential for good patient outcomes.