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.

IMPACT OF GLUCOSE MANAGEMENT TEAM ON OUTCOMES OF HOSPITALIZARON IN PATIENTS WITH TYPE 2 DIABETES ADMITTED TO THE MEDICAL SERVICE.

OBJECTIVE: To improve glycemic control of hospitalized patients with diabetes and hyperglycemia, many medical centers have established dedicated glucose management teams (GMTs). However, the impact of these specialized teams on clinical outcomes has not been evaluated. METHODS: We conducted a retrospective study of 440 patients with type 2 diabetes admitted to the medical service for cardiac or infection-related diagnosis. The primary endpoint was a composite outcome of several well-recognized markers of morbidity, consisting of: death during hospitalization, transfer to intensive care unit, initiation of enteral or parenteral nutrition, line infection, new in-hospital infection or infection lasting more than 20 days of hospitalization, deep venous thrombosis or pulmonary embolism, rise in plasma creatinine, and hospital re-admissions. RESULTS: Medical housestaff managed the glycemia in 79% of patients (usual care group), while the GMT managed the glycemia in 21% of patients (GMT group). The primary outcome was similar between cohorts (0.95 events per patient versus 0.99 events per patient in the GMT and usual care cohorts, respectively). For subanalysis, the subjects in both groups were stratified into those with average glycemia of <180 mg/dL versus those with glycemia >180 mg/dL. We found a significant beneficial impact of glycemic management by the GMT on the composite outcome in patients with average glycemia >180 mg/dL during their hospital stay. The number of patients who met primary outcome was significantly higher in the usual care group (40 of 83 patients, 48%) than in the GMT-treated cohort (8 of 33 patients, 25.7%) (P<.02). CONCLUSION: Our data suggest that GMTs may have an important role in managing difficult-to-control hyperglycemia in the inpatient setting. ABBREVIATIONS: BG = blood glucose GMT = glucose management team HbA1c = hemoglobin A1c ICU = intensive care unit POC = point of care T2D = type 2 diabetes.

Glycemic control and outcomes of hospitalization in noncritically ill patients with type 2 diabetes admitted with cardiac problems or infections.

OBJECTIVE: Although the importance of glycemic control is well established for patients with diabetes hospitalized for surgical problems, it has not been supported by clinical studies for patients with diabetes hospitalized on the medical floors. METHODS: We conducted a retrospective study of 378 patients with type 2 diabetes admitted for cardiac or infectious disease (ID) diagnosis between September 1, 2011, and August 1, 2012. Exclusion criteria included type 1 diabetes, admission to the intensive care unit (ICU), hospital stay shorter than 3 days, and daily glucocorticoid dose >20 mg of methylprednisolone. The primary composite outcome included death during hospitalization, ICU transfer, initiation of enteral or parenteral nutrition, line infection, deep vein thrombosis, pulmonary embolism, rise in plasma creatinine by 1 or >2 mg/dL, new infection, an infection lasting for more than 20 days, and readmission within 30 days and between 1 and 10 months after discharge. RESULTS: Patients were stratified by mean blood glucose (BG) level: group 1 had mean BG of <180 mg/dL (n = 286; mean BG, 142 ± 23 mg/dL), whereas group 2 had mean BG levels >181 mg/dL (n = 92; mean BG, 218 ± 34 mg/dL; P<.0001). Group 2 had a 46% higher occurrence of the primary outcome (P<.0004). The rate of unfavorable events was greater in cardiac and ID patients with worse glycemic control (group 2). CONCLUSION: Our data strongly support a positive influence of better glycemic control (average glycemia <180 mg/dL or 10 mmol/L) on outcomes of hospitalization in patients with type 2 diabetes.

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.

Cystic fibrosis-related diabetes in adults: inpatient management of 121 patients during 410 admissions.

BACKGROUND: With improved longevity, cystic fibrosis (CF)-related diabetes (CFRD) has emerged as the most common nonpulmonary complication of CF. Patients with CFRD are frequently admitted to the hospital with infections and deterioration of pulmonary function, during which time glycemic control might have an impact on pulmonary function, recovery from infection, and survival. METHODS AND RESULTS: In an attempt to share our insight into inpatient management of CFRD, this article summarizes the experience of our inpatient glucose management team with hospital management of 121 adult CFRD patients who were hospitalized on 410 occasions at the University of Colorado Hospital between January 2009 and September 2011. This is a retrospective chart review descriptive study of inpatient management of CFRD in our center. Our cohort includes CFRD patients treated with basal and mealtime insulin through multiple daily injections or continuous subcutaneous insulin infusion (CSII), as well as patients receiving steroids or enteral nutrition, which adds complexity to the management of CFRD during hospitalization. CONCLUSIONS: Multiple hospitalizations and intensive inpatient management of CF are integral elements of treatment. Inpatient therapy for CFRD requires a customized approach that is uniquely different from that of type 1 or type 2 diabetes. Our experience highlights clinical circumstances such as irregular food intake, high dose steroid therapy, and supplemental tube feeding. For many patients, it is possible to continue CSII therapy during hospitalization through a combination of mutual trust between the patient and hospital staff and oversight provided by the glucose management team.

Subcutaneous administration of glargine to diabetic patients receiving insulin infusion prevents rebound hyperglycemia.

CONTEXT: Transition of diabetic patients from iv insulin infusion to s.c. insulin frequently results in rebound hyperglycemia. OBJECTIVES: We hypothesized that initiation of a long-acting insulin therapy concurrently with i.v. insulin infusion would decrease the rate of rebound hyperglycemia after discontinuation of the insulin infusion. DESIGN AND INTERVENTION: Sixty-one diabetic patients receiving i.v. insulin therapy participated in this prospective randomized study. Subjects in the intervention group received daily injections of glargine s.c. (0.25 U/kg body weight) starting within 12 h of initiation of i.v. insulin infusion. Capillary blood glucose measurements were obtained up to 12 h after discontinuation of insulin infusion. Rebound hyperglycemia was defined as a blood glucose level greater than 180 mg/dl. SETTING: The study was conducted at the University of Colorado Hospital. PATIENTS: Sixty-one hospitalized patients with known type 1 or type 2 diabetes receiving i.v. insulin infusion participated in the study. MAIN OUTCOME: The primary outcome of this study was to compare the rates of rebound hyperglycemia between the control and the intervention groups after i.v. insulin infusion is discontinued. RESULTS: Overall, 29 subjects in the control group (93.5%) had at least one glucose value above 180 mg/dl during the 12-h follow-up period. This was significantly greater than the rate of rebound hyperglycemia in the intervention group (10 subjects or 33.3%, P < 0.001). The effect of the intervention was apparent in subjects who presented with diabetic ketoacidosis, after solid organ transplantation, and in patients with other surgical and medical diagnoses. There were three hypoglycemic measurements in two control subjects (68, 62, and 58 mg/dl) and none in the intervention group. CONCLUSIONS: Once-daily s.c. insulin glargine administered during i.v. insulin infusion is a safe method for preventing future rebound hyperglycemia, without increased risk of hypoglycemia.