Comparison of Basal-Bolus and Premixed Insulin Regimens in Hospitalized Patients With Type 2 Diabetes

Perioperative Evaluation and Management of Endocrine Disorders

Evaluation of endocrine issues is a sometimes overlooked yet important component of the preoperative medical evaluation. Patients with diabetes, thyroid disease, and hypothalamic-pituitary-adrenal axis suppression are commonly encountered in the surgical setting and require unique consideration to optimize perioperative risk. For patients with diabetes, perioperative glycemic control has the strongest association with postsurgical outcomes. The preoperative evaluation should include recommendations for adjustment of insulin and noninsulin diabetic medications before surgery. Recommendations differ based on the type of diabetes, the type of insulin, and the patient's predisposition to hyperglycemia or hypoglycemia. Generally, patients with thyroid dysfunction can safely undergo operations unless they have untreated hyperthyroidism or severe hypothyroidism. Patients with known primary or secondary adrenal insufficiency require supplemental glucocorticoids to prevent adrenal crisis in the perioperative setting. Evidence supporting the use of high-dose supplemental corticosteroids for patients undergoing long-term glucocorticoid therapy is sparse. We discuss an approach to these patients based on the dose and duration of ongoing or recent corticosteroid therapy. As with other components of the preoperative medical evaluation, the primary objective is identification and assessment of the severity of endocrine issues before surgery so that the surgeons, anesthesiologists, and internal medicine professionals can optimize management accordingly.

Efficacy and safety of insulin glargine 300 U/mL (Gla-300) during hospitalization and therapy intensification at discharge in patients with insufficiently controlled type 2 diabetes: results of the phase IV COBALTA trial

INTRODUCTION

This study assessed the efficacy and safety of insulin glargine 300 U/mL (Gla-300) during hospitalization and therapy intensification at discharge in insufficiently controlled people with type 2 diabetes.

RESEARCH DESIGN AND METHODS

COBALTA (for its acronym in Spanish, COntrol Basal durante la hospitalizacion y al ALTA) was a multicenter, open-label, single-arm, phase IV trial including 112 evaluable inpatients with type 2 diabetes insufficiently controlled (glycosylated hemoglobin (HbA1c) 8%-10%) with basal insulin and/or non-insulin antidiabetic drugs. Patients were treated with a basal-bolus-correction insulin regimen with Gla-300 during the hospitalization and with Gla-300 and/or non-insulin antidiabetics for 6 months after discharge. The primary endpoint was the HbA1c change from baseline to month 6 postdischarge.

RESULTS

HbA1c levels decreased from 8.8%±0.6% at baseline to 7.2%±1.1% at month 6 postdischarge (p<0.001, mean change 1.6%±1.1%). All 7-point blood glucose levels decreased from baseline to 24 hours predischarge (p≤0.001, mean changes from 25.1±66.6 to 63.0±85.4 mg/dL). Fasting plasma glucose also decreased from baseline to 24 hours predischarge (p<0.001), month 3 (p<0.001) and month 6 (p<0.001) postdischarge (mean changes 51.5±90.9, 68.2±96.0 and 77.6±86.4 mg/dL, respectively). Satisfaction was high and hyperglycemia/hypoglycemia perception was low according to the Diabetes Treatment Satisfaction Questionnaire at month 6 postdischarge. The incidence of confirmed (glucose<70 mg/dL)/severe hypoglycemia was 25.0% during hospitalization and 59.1% 6 months after discharge. No safety concerns were reported.

CONCLUSIONS

Inpatient and intensification therapy at discharge with Gla-300 improved significantly glycemic control of patients with type 2 diabetes insufficiently controlled with other basal insulin and/or non-insulin antidiabetic medication, with high treatment satisfaction. Gla-300 could therefore be a treatment choice for hospital and postdischarge diabetes management.

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

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.

Management of Inpatient Hyperglycemia and Diabetes in Older Adults

Diabetes is one of the world's fastest growing health challenges. Insulin therapy remains a useful regimen for many elderly patients, such as those with moderate to severe hyperglycemia, type 1 diabetes, hyperglycemic emergencies, and those who fail to maintain glucose control on non-insulin agents alone. Recent clinical trials have shown that several non-insulin agents as monotherapy, or in combination with low doses of basal insulin, have comparable efficacy and potential safety advantages to complex insulin therapy regimens. Determining the most appropriate diabetes management plan for older hospitalized patients requires consideration of many factors to prevent poor outcomes related to dysglycemia.

Challenges and Strategies for Inpatient Diabetes Management in Older Adults

Adults older than 65 years of age are the fastest growing segment of the U.S. population. Aging is also one of the most important risk factors for diabetes, and about one-third of all individuals with diabetes are in this age-group. Older people with diabetes are more likely to have comorbidities such as hypertension, ischemic heart disease, chronic kidney disease, and cognitive impairment, which lead to higher rates of hospital admissions compared with individuals without diabetes. Professional organizations have recommended patient-centric individualized glycemic reduction approaches, with an emphasis on potential harms of intensive glycemic control and overtreatment in older adults. Insulin therapy remains a mainstay of diabetes management in the inpatient setting regardless of patients' age; however, there is uncertainty about optimal glycemic targets during the hospital stay. Increasing evidence supports selective use of dipeptidyl peptidase-4 inhibitors, alone or in combination with low-dose basal insulin, in older noncritically ill patients with mild to moderate hyperglycemia. This article reviews the prevalence, diagnosis, and monitoring of, and the available treatment strategies for, diabetes among elderly patients in the inpatient setting.

Insulin Therapy in Hospitalized Patients

BACKGROUND

Hyperglycemia is prevalent and is associated with an increase in morbidity and mortality in hospitalized patients. Insulin therapy is the most appropriate method for controlling glycemia in hospital, but is associated with increased risk of hypoglycemia, which is a barrier to achieving glycemic goals.

AREAS OF UNCERTAINTY

Optimal glycemic targets have not been established in the critical and noncritical hospitalized patients, and there are different modalities of insulin therapy. The primary purpose of this review is to discuss controversy regarding appropriate glycemic targets and summarize the evidence about the safety and efficacy of insulin therapy in critical and noncritical care settings.

DATA SOURCES

A literature search was conducted through PubMed with the following key words (inpatient hyperglycemia, inpatient diabetes, glycemic control AND critically or non-critically ill patient, Insulin therapy in hospital).

RESULTS

In critically ill patient, blood glucose levels >180 mg/dL may increase the risk of hospital complications, and blood glucose levels <110 mg/dL have been associated with an increased risk of hypoglycemia. Continuous intravenous insulin infusion is the best method for achieving glycemic targets in the critically ill patient. The ideal glucose goals for noncritically ill patients remain undefined and must be individualized according to the characteristics of the patients. A basal-bolus insulin strategy resulted in better glycemic control than sliding scale insulin and lower risk of hypoglycemia than premixed insulin regimen.

CONCLUSIONS

Extremes of blood glucose lead to poor outcomes, and target glucose range of 110-180 mg/dL may be appropriate for most critically ill patients and noncritically ill patients. Insulin is the most appropriate pharmacologic agent for effectively controlling glycemia in hospital. A continuous intravenous insulin infusion and scheduled basal-bolus-correction insulin are the preferred modalities for glycemic control in critically and noncritically ill hospitalized patients, respectively.

15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2020

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Efficacy and Safety of Basal Analog Regimens in Type 2 Diabetes Mellitus: Systematic Review and Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

This study compared basal analog (BA: glargine U100/mL and detemir) and premix (PM: human, lispro and aspart biphasic) insulin regimens in terms of their efficacy and safety in type 2 diabetes mellitus patients.

METHODS

Searches of MEDLINE, Embase, and CENTRAL identified primary randomized controlled trials (RCTs) ≥ 12 weeks in duration that compared BA or PM insulin regimens in adults with T2DM, with ≥ 30 patients per arm. A systematic literature review and a pairwise meta-analysis were performed using a random effects model adjusted for between-study variability. Analyses were conducted based on frequency of bolus insulin and PM injections, PM ratio and type, BA type, race, follow-up period, and baseline glycosylated hemoglobin (HbA1c).

RESULTS

Twenty-two primary RCTs with 9691 patients were included. The BA and PM regimens yielded similar changes in HbA1c and postprandial glucose levels, with a statistically significant reduction in fasting glucose [mean difference (MD) - 0.61 mmol/L (95% confidence interval (CI) - 0.90, - 0.32), I² = 89.6%]. The BA regimens showed significantly reduced rates of total hypoglycemia [odds ratio (OR) 0.77 (95% CI 0.64, 0.92), I² = 65.3%] and changes in body weight [MD - 0.48 kg (95% CI - 0.86, - 0.11), I² = 75.7%] compared to PM regimens. Stratification by PM type and dosing ratio demonstrated statistically significant reductions in HbA1c favoring BA compared to human [MD - 0.39% (95% CI - 0.60, - 0.18), I² = 61.8%] or 50/50-ratio [MD - 0.22% (95% CI - 0.40, - 0.04), I² = 0.0%] PM regimens. Other subgroup analyses found no difference in HbA1c change between the BA and PM regimens.

CONCLUSION

When compared to PM regimens, BA regimens yielded similar efficacies and better safety profiles in patients with type 2 diabetes mellitus.

FUNDING

Sanofi (Shanghai, China).

Efficacy and Safety of IDegAsp Versus BIAsp 30, Both Twice Daily, in Elderly Patients with Type 2 Diabetes: Post Hoc Analysis of Two Phase 3 Randomized Controlled BOOST Trials

INTRODUCTION

The majority of elderly patients (≥ 65 years of age) with type 2 diabetes mellitus (T2DM) will eventually require insulin therapy, but they are particularly vulnerable to hypoglycemia and challenging to treat. Insulin degludec/insulin aspart (IDegAsp) is a novel co-formulation of 70% insulin degludec and 30% insulin aspart administered in a single injection, either once or twice daily with main meals.

METHODS

A combined analysis of the phase 3 BOOST INTENSIFY PREMIX I (NCT01009580) and BOOST INTENSIFY ALL (NCT01059812) trials has previously reported lower rates of hypoglycemia during the maintenance period in patients with T2DM treated with IDegAsp twice daily (BID) versus biphasic insulin aspart 30 (BIAsp 30) BID. This post hoc analysis examined the safety and efficacy of IDegAsp versus BIAsp 30 in elderly patients from the global population of these two trials, and also from the Japanese cohort of BOOST INTENSIFY ALL.

RESULTS

Change in HbA1c was similar for IDegAsp versus BIAsp 30 (p > 0.5). Compared with BIAsp 30, IDegAsp resulted in significant reductions in fasting plasma glucose (p  < 0.0001), numerically lower rates of overall and nocturnal hypoglycemia (global estimated rate ratios: 0.92 [0.67; 1.26]95% confidence interval [CI], p  = 0.5980 and 0.67 [0.39; 1.18]95% CI, p  = 0.1676, respectively), and a significantly lower total daily insulin dose at end of trial (global estimated treatment difference 0.79 [0.73; 0.87]95% CI, p  < 0.0001) in elderly patients.

CONCLUSION

The results described here are consistent with those of the overall trial populations, demonstrating that IDegAsp BID is efficacious in elderly patients and suggesting that there is no need for special safety precautions.

FUNDING

Novo Nordisk.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers, NCT01009580 and NCT01059812. Plain language summary available for this article.

Hypoglycemia in blood glucose level in type 2 diabetic Japanese patients by continuous glucose monitoring

BACKGROUND

Hypoglycemia is associated with cardiovascular diseases, increased risk of death. Therefore, it is important to avoid hypoglycemia. The aim of this study was to characterize hypoglycemia according to glycated hemoglobin (HbA1c) level and determine the contributing factors in type 2 diabetes mellitus (T2DM), using continuous glucose monitoring (CGM).

METHODS

T2DM patients (n = 293) receiving inpatient care were divided into five groups according to HbA1c level on admission (Group 1: ≥ 6 to < 7%, Group 2: ≥ 7 to < 8%, Group 3: ≥ 8 to < 9%, Group 4: ≥ 9 to < 10%, and Group 5: ≥ 10%). The frequency of hypoglycemia and factors associated with hypoglycemia were analyzed.

RESULTS

Hypoglycemia occurred in 15 patients (5.1%), including 4 (8%), 4 (6%), and 7 (10%) patients of Groups 1, 2, and 3, respectively, but in none of groups 4 and 5. Patients with hypoglycemia of Groups 1 had low insulin secretion and were high among insulin users, those of Groups 2 had low homeostasis model assessment of insulin resistance (HOMA-IR). Those of Group 2 and 3 had significantly lower mean blood glucose levels, those of Group 3 only had significantly lower maximum blood glucose level and percentage of AUC > 180 mg/dL. In any of the HbA1c groups, variations in blood glucose level were significantly larger in patients with hypoglycemia than without.

CONCLUSIONS

Hypoglycemia occurred in patients with a wide range of HbA1c on admission (range 6-9%), suggesting that prediction of hypoglycemia based on HbA1c alone is inappropriate. Among patients with low HbA1c, strict control sometimes induce hypoglycemia. Among patients with high HbA1c, the possibility of hypoglycemia should be considered if there is a marked discrepancy between HbA1c and randomly measured blood glucose level. Larger variations in blood glucose level induce hypoglycemia in any of the HbA1c groups. The treatment to reduce variations in blood glucose level is important to prevent hypoglycemia.

15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2019

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The basal to total insulin ratio in outpatients with diabetes on basal-bolus regimen

OBJECTIVE

To evaluate the basal/total ratio of daily insulin dose (b/T) in outpatients with diabetes type 1 (DM1) and type 2 (DM2) on basal-bolus regimen, by investigating whether there is a relationship with HbA1c and episodes of hypoglycemia.

METHODS

Multicentric, observational, cross-sectional study in Italy. Adult DM1 (n = 476) and DM2 (n = 541) outpatients, with eGFR >30 mL/min/1.73 m2, on a basal-bolus regimen for at least six months, were recruited from 31 Italian Diabetes services between March and September 2016. Clinicaltrials.govID: NCT03489031.

RESULTS

Total daily insulin dose was significantly higher in DM2 patients (52.3 ± 22.5 vs. 46 ± 20.9 U/day), but this difference disappeared when insulin doses were normalized for body weight. The b/T ratio was lower than 0.50 in both groups: 0.46 ± 0.14 in DM1 and 0.43 ± 0.15 in DM2 patients (p = 0.0011). The b/T was significantly higher in the patients taking metformin in both groups, and significantly different according to the type of basal insulin (Degludec, 0.48 in DM1 and 0.44 in DM2; Glargine, 0.44 in DM1 and 0.43 in DM2; Detemir, 0.45 in DM1 and 0.39 in DM2). The b/T ratio was not correlated in either group to HbA1c or incidence of hypoglycemia (<40 mg/dL, or requiring caregiver intervention, in the last three months). In the multivariate analysis, metformin use and age were independent predictors of the b/T ratio in both DM1 and DM2 patients, while the type of basal insulin was an independent predictor only in DM1.

CONCLUSION

The b/T ratio was independent of glycemic control and incidence of hypoglycemia.

Diabetes management before, during, and after bariatric and metabolic surgery

Metabolic surgery is unrivaled by other therapeutic modalities due to its ability to foster diabetes remission. Metabolic surgery is an integral therapeutic modality in obese and morbidly obese populations because pharmacological and behavioral therapy often fail to effectively manage type II diabetes. However, given the invasiveness of the metabolic surgery relative to behavioral therapy and the need to conform to preparatory and discharge guidelines, patients must adhere to strict nutritional and diabetes management protocols. Also, the pharmacological regimen that is instituted upon discharge is distinct from the preoperative regimen. Oftentimes, the dose for insulin and oral medications are significantly decreased or withdrawn. As time elapses and depending on several factors (e.g., exercise adherence), diabetes control becomes tenuous in a small portion of the patients because there is weight regain and on-going beta cell failure. At this time interval, intensification of diabetes therapy becomes prudent. Indeed, pharmacotherapy from the preoperative to the postoperative phase is labile and may be complex. Therefore, by discussing pharmacology options during the preoperative, perioperative, and postoperative period, the goal is to guide clinician-driven care.

Switching From Pre-mixed Insulin to Regimens with Insulin Glargine in Type 2 Diabetes: A Prospective, Observational Study of Data From Adriatic Countries

INTRODUCTION

Long-acting insulin analogs such as insulin glargine may offer improved glycemic control in patients with type 2 diabetes (T2D) compared to conventional insulin therapies. The objective of this study was to determine whether switching to insulin glargine had beneficial effects on glycemic control, weight gain, and incidence of hypoglycemia in patients with suboptimally managed T2D.

METHODS

This prospective observational study was performed on 1041 patients who were suboptimally controlled on pre-mixed insulin therapy and were switched to an insulin glargine regimen. Clinical markers of glycemic control including glycosylated hemoglobin (HbA1c) < 7% (< 53 mmol/mol) and fasting blood glucose (FBG) levels ranging from 3.9 to 7.2 mmol/L were used for the primary outcome measures. Follow-up assessment of primary outcomes, weight gain, incidence of hypoglycemia, and patient satisfaction with the therapy was performed after three and six months of treatment.

RESULTS

Target therapeutic values of HbA1c were achieved in 9.3% and 30.2% of patients, whereas FBG target values were achieved in 25.9% and 52.3% of patients after the third and sixth month of therapy, respectively. Both the HbA1c and FBG targets were reached in 7% and 25.9% of patients at the third and sixth month of therapy, respectively. Switching to insulin glargine decreased the incidence of hypoglycemia from 49.5% to 5.2% after six months of therapy; this decrease was associated with weight loss and was well perceived by the patients.

CONCLUSION

Insulin glargine-based regimens are beneficial and safe therapeutic alternatives for T2D patients inadequately controlled with pre-mixed insulin.

FUNDING

Sanofi-Aventis Croatia d.o.o., Zagreb, Croatia.

Manejo de pacientes diabéticos hospitalizados

La diabetes es una enfermedad con importante prevalencia en todo el mundo. Se calcula que cerca de 415 millones de personas la padecen en la actualidad y que para el año 2040 esta cifra aumentará poco más del 50%. Debido a esto, se estima que gran parte de los ingresos por urgencias serán de pacientes diabéticos o sujetos a los cuales esta patología se les diagnosticará en dicha hospitalización; esta situación hace necesario conocer los lineamientos y las recomendaciones de las guías para el manejo intrahospitalario de los pacientes con hiperglucemia.El pilar fundamental del manejo hospitalario de diabetes es la monitorización intensiva, junto con la educación al paciente y la administración de insulina. El control glicémico es clave debido a que disminuye complicaciones intrahospitalarias. Cabe resaltar que el control estricto puede llevar a hipoglucemias, por lo que los episodios deben ser debidamente documentados y su causa corregida de inmediato.

Managing Diabetes in Patients Hospitalized in Internal Medicine Units

Diabetes and hyperglycemia are present in over one-third of inpatients in internal medicine units and are associated with worse prognosis in multiple morbidities. Treatment of inpatient hyperglycemia is usually with basal bolus insulin in a dose calculated by the patient's weight, with lower doses recommended in patients who are at a higher risk for hypoglycemia. Other antihyperglycemic medications and insulin regimens can be used in selected patients. There are no adequately powered studies on the effect of improving glycemic control on hospitalization outcomes in non-critically ill patients in internal medicine units, and in most patients a modest glucose target of 140-180 mg/dL is recommended. A structured discharge plan should intensify antihyperglycemic treatment as needed and include an outpatient follow-up appointment shortly after discharge.

EADSG Guidelines: Insulin Therapy in Diabetes

A diagnosis of diabetes or hyperglycemia should be confirmed prior to ordering, dispensing, or administering insulin (A). Insulin is the primary treatment in all patients with type 1 diabetes mellitus (T1DM) (A). Typically, patients with T1DM will require initiation with multiple daily injections at the time of diagnosis. This is usually short-acting insulin or rapid-acting insulin analogue given 0 to 15 min before meals together with one or more daily separate injections of intermediate or long-acting insulin. Two or three premixed insulin injections per day may be used (A). The target glycated hemoglobin A1c (HbA1c) for all children with T1DM, including preschool children, is recommended to be < 7.5% (< 58 mmol/mol). The target is chosen aiming at minimizing hyperglycemia, severe hypoglycemia, hypoglycemic unawareness, and reducing the likelihood of development of long-term complications (B). For patients prone to glycemic variability, glycemic control is best evaluated by a combination of results with self-monitoring of blood glucose (SMBG) (B). Indications for exogenous insulin therapy in patients with type 2 diabetes mellitus (T2DM) include acute illness or surgery, pregnancy, glucose toxicity, contraindications to or failure to achieve goals with oral antidiabetic medications, and a need for flexible therapy (B). In T2DM patients, with regards to achieving glycemic goals, insulin is considered alone or in combination with oral agents when HbA1c is ≥ 7.5% (≥ 58 mmol/mol); and is essential for treatment in those with HbA1c ≥ 10% (≥ 86 mmol/mol), when diet, physical activity, and other antihyperglycemic agents have been optimally used (B). The preferred method of insulin initiation in T2DM is to begin by adding a long-acting (basal) insulin or once-daily premixed/co-formulation insulin or twice-daily premixed insulin, alone or in combination with glucagon-like peptide-1 receptor agonist (GLP-1 RA) or in combination with other oral antidiabetic drugs (OADs) (B). If the desired glucose targets are not met, rapid-acting or short-acting (bolus or prandial) insulin can be added at mealtime to control the expected postprandial raise in glucose. An insulin regimen should be adopted and individualized but should, to the extent possible, closely resemble a natural physiologic state and avoid, to the extent possible, wide fluctuating glucose levels (C). Blood glucose monitoring is an integral part of effective insulin therapy and should not be omitted in the patient's care plan. Fasting plasma glucose (FPG) values should be used to titrate basal insulin, whereas both FPG and postprandial glucose (PPG) values should be used to titrate mealtime insulin (B). Metformin combined with insulin is associated with decreased weight gain, lower insulin dose, and less hypoglycemia when compared with insulin alone (C). Oral medications should not be abruptly discontinued when starting insulin therapy because of the risk of rebound hyperglycemia (D). Analogue insulin is as effective as human insulin but is associated with less postprandial hyperglycemia and delayed hypoglycemia (B). The shortest needles (currently the 4-mm pen and 6-mm syringe needles) are safe, effective, and less painful and should be the first-line choice in all patient categories; intramuscular (IM) injections should be avoided, especially with long-acting insulins, because severe hypoglycemia may result; lipohypertrophy is a frequent complication of therapy that distorts insulin absorption, and therefore, injections and infusions should not be given into these lesions and correct site rotation will help prevent them (A). Many patients in East Africa reuse syringes for various reasons, including financial. This is not recommended by the manufacturer and there is an association between needle reuse and lipohypertrophy. However, patients who reuse needles should not be subjected to alarming claims of excessive morbidity from this practice (A). Health care authorities and planners should be alerted to the risks associated with syringe or pen needles 6 mm or longer in children (A).

Perioperative Management of Hyperglycemia and Diabetes in Cardiac Surgery Patients

Perioperative hyperglycemia is common after cardiac surgery, reported in 60% to 90% of patients with diabetes and in approximately 60% of patients without history of diabetes. Many observational and prospective randomized trials in critically-ill cardiac surgery patients support a strong association between hyperglycemia and poor clinical outcome. Despite ongoing debate about the optimal glucose target, there is strong agreement that improved glycemic control reduces perioperative complications.

14. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2018

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Insulin Pump and Continuous Glucose Monitor Initiation in Hospitalized Patients with Type 2 Diabetes Mellitus

BACKGROUND

Insulin pumps and continuous glucose monitoring (CGM) are commonly used by patients with diabetes mellitus in the outpatient setting. The efficacy and safety of initiating inpatient insulin pumps and CGM in the nonintensive care unit setting is unknown.

MATERIALS AND METHODS

In a prospective pilot study, inpatients with type 2 diabetes were randomized to receive standard subcutaneous basal-bolus insulin and blinded CGM (group 1, n = 5), insulin pump and blinded CGM (group 2, n = 6), or insulin pump and nonblinded CGM (group 3, n = 5). Feasibility, glycemic control, and patient satisfaction were evaluated among groups.

RESULTS

Group 1 had lower mean capillary glucose levels, 144.5 ± 19.5 mg/dL, compared with groups 2 and 3, 191.5 ± 52.3 and 182.7 ± 59.9 mg/dL (P1 vs. 2+3 = 0.05). CGM detected 19 hypoglycemic episodes (glucose <70 mg/dL) among all treatment groups, compared with 12 episodes detected by capillary testing, although not statistically significant. No significant differences were found for the total daily dose of insulin or percentage of time spent below target glucose range (<90 mg/dL), in target glucose range (90-180 mg/dL), or above target glucose range (>180 mg/dL). On the Diabetes Treatment Satisfaction Questionnaire-Change, group 3 reported increased hyperglycemia and decreased hypoglycemia frequency compared with the other two groups, although the differences did not reach statistical significance.

CONCLUSIONS

Insulin pump and CGM initiation are feasible during hospitalization, although they are labor intensive. Although insulin pump initiation may not lead to improved glycemic control, there is a trend toward CGM detecting a greater number of hypoglycemic episodes. Larger studies are needed to determine whether use of this technology can lower inpatient morbidity and mortality.

The Effect of Continuous Glucose Monitoring in Preventing Inpatient Hypoglycemia in General Wards: The Glucose Telemetry System

BACKGROUND

Few studies have examined the use of continuous glucose monitoring (CGM) devices in the general wards. The aim of this pilot study was to examine whether CGM readings can be successfully transmitted from the bedside to a central monitoring device in the nursing station, and whether a glucose telemetry system can prevent hypoglycemic events.

METHODS

We present pilot data on 5 consecutive insulin treated general medicine patients with type 2 diabetes (T2DM) whose glucose values were observed with CGM (DEXCOM) and the results were transmitted to a central nursing station monitoring system using DEXCOM Follow and Share 2 software. CGM alarms were set-up at glucose <85 mg/dl.

RESULTS

Duration of CGM observation was 4.0 ± 1.6 days (mean ± SD). During CGM, the overall time spent within blood glucose (BG) target of 70-179 mg/dl was 64.68 ± 15% (mean ± SD), on hypoglycemia (<70 mg/dl) was 0.30% ± 0.39, and time spent on hyperglycemia (≥180 mg/dl) was 35.02% ± 15.5. Two patients had 3 actions of prevention of potential hypoglycemia (CGM BG <70 mg/dl for >20 minutes) captured by alarm. No patients had CGM glucose value <54 mg/dl.

CONCLUSIONS

This pilot study indicates that the use of CGM values in hospitalized patients can be successfully transmitted to a monitoring device in the nursing station, improving patient surveillance in insulin treated patients with diabetes.

Physicians' real-world experience with IDegLira: results of a European survey

OBJECTIVE

This study aimed to build on the current clinical findings and investigate physicians' experiences and level of satisfaction in using insulin degludec/liraglutide (IDegLira) to treat patients with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

This multicountry, European online survey included respondents from primary (n=132) and secondary (n=103) care and examined physicians' use, confidence and satisfaction with IDegLira. To standardize responses, 24 of 28 questions pertained to an 'average patient' with T2D who has no major comorbidities, aged 35-70 years, with average cognitive ability/normal mental status and body mass index ≥25 kg/m².

RESULTS

The majority (70%) of respondents prescribe IDegLira in the same visit they first mention it, with uncontrolled glycated hemoglobin (HbA1c) (44%) and weight gain (22%) being the most common reasons. On average, physicians reported that patients weighed 95 kg and the HbA1c level was 9.0% at initiation. Physicians also reported the average HbA1c target set was 7.1%; 76% of patients achieved their target. On average, patients achieved their HbA1c target in <6 months, and the average dose of IDegLira in patients in glycemic control was 28 dose steps. Respondents were more satisfied with IDegLira than basal-bolus therapy across all parameters assessed, including reaching HbA1c targets (59%), number of injections (77%) and avoiding weight gain (84%). Correspondingly, 77% of physicians reported that IDegLira had more potential to improve patient motivation compared with basal-bolus to reach target blood glucose levels.

CONCLUSIONS

Real-world experience of IDegLira is consistent with previous trials/studies, with no major differences between primary and secondary care. Importantly, the majority of respondents were more/much more satisfied with IDegLira than with basal-bolus therapy.

Clinical characteristics and outcomes of symptomatic and asymptomatic hypoglycemia in hospitalized patients with diabetes

IMPORTANCE

The frequency and impact of asymptomatic hypoglycemia in hospitalized patients with diabetes is not known.

OBJECTIVE

We determined the clinical characteristics and hospital outcomes of general medicine and surgery patients with symptomatic and asymptomatic hypoglycemia.

RESEARCH DESIGN AND METHODS

Prospective observational study in adult patients with diabetes and blood glucose (BG) <70 mg/dL. Participants were interviewed about signs and symptoms of hypoglycemia using a standardized questionnaire. Precipitating causes, demographics, insulin regimen, and complications data during admission was collected.

RESULTS

Among 250 patients with hypoglycemia, 112 (44.8%) patients were asymptomatic and 138 (55.2%) had symptomatic hypoglycemia. Patients with asymptomatic hypoglycemia were older (59±11 years vs 54.8±13 years, p=0.003), predominantly males (63% vs 48%, p=0.014), and had lower admission glycosylated hemoglobin (8.2%±2.6 % vs 9.1±2.9%, p=0.006) compared with symptomatic patients. Compared with symptomatic patients, those with asymptomatic hypoglycemia had higher mean BG during the episode (60.0±8 mg/dL vs 53.8±11 mg/dL, p<0.001). In multivariate analysis, male gender (OR 2.08, 95% CI 1.13 to 3.83, p=0.02) and age >65 years (OR 4.01, 95% CI 1.62 to 9.92, p=0.02) were independent predictors of asymptomatic hypoglycemia. There were no differences in clinical outcome, composite of hospital complications (27% vs 22%, p=0.41) or in-hospital length of stay (8 days (IQR 4-14) vs 7 days (IQR 5-15), p=0.92)) between groups.

CONCLUSIONS

Asymptomatic hypoglycemia was common among insulin-treated patients with diabetes but was not associated with worse clinical outcome compared with patients with symptomatic hypoglycemia. Older age and male gender were independent risk factors for asymptomatic hypoglycemia.

A Systematic Approach for the Prevention and Reduction of Hypoglycemia in Hospitalized Patients

PURPOSE OF REVIEW

Hypoglycemia and severe hypoglycemia (SH) in the inpatient setting are associated with poor outcomes. This review is designed to highlight approaches to predict and prevent inpatient hypoglycemia that has been successfully implemented focusing on developing overlapping policies and procedures that allow safe glycemic management to occur at all levels of the institution.

RECENT FINDINGS

Standardizing point-of-care (POC) testing, nursing protocols, meal delivery, and formulary restriction are useful tools to prevent hypoglycemia. Informatics and real-time alert processes are highly effective tools to reduce hypoglycemia but require a significant investment in time and infrastructure as well as clear policies on how alerts are acted upon. Computerized dosing support technology and continuous glucose monitoring (CGM) technology are an emerging area of investigation showing promising results. Inpatient hypoglycemia is often predictable and preventable and requires institutional support to deliver targeted and safe diabetes care. This requires each institution to do periodic reassessment of policies and technologies. Future research needs to focus on the cost/benefits of interventions including studies of automated dosing algorithms as well as CGM in higher-risk patient populations.

Management of hyperglycemia in the neurosurgery patient

Hyperglycemia is associated with adverse outcomes in patients who are candidates for or underwent neurosurgical procedures. Specific concerns and settings that relate to these patients are preoperative glycemic control, intraoperative control, management in the neurological intensive care unit (NICU), and postoperative control. In each of these settings, physicians have to ensure appropriate glycemic control to prevent or minimize adverse events. The glycemic control is usually managed by a neurohospitalist in co-management with the neurosurgery team pre- and post-operatively, and by the neurocritical care team in the setting of NICU. In this review article, we outline current standards of care for neurosurgery patients with diabetes mellitus and/or and hyperglycemia and discuss results of most recent clinical trials. We highlight specific concerns with regards to glycemic controls in these patients including enteral tube feeding and parenteral nutrition, the issues of the transition to the outpatient care, and management of steroid-induced hyperglycemia. We also note lack of evidence in some important areas, and the need for more research addressing these gaps. Where possible, we provide suggestions how to manage these patients when there is no underlying guideline.

Management of Type 1 Diabetes in the Hospital Setting

PURPOSE OF REVIEW

The purpose of this article was to review recent guideline recommendations on glycemic target, glucose monitoring, and therapeutic strategies, while providing practical recommendations for the management of medical and surgical patients with type 1 diabetes (T1D) admitted to critical and non-critical care settings.

RECENT FINDINGS

Studies evaluating safety and efficacy of insulin pump therapy, continuous glucose monitoring, electronic glucose management systems, and closed loop systems for the inpatient management of hyperglycemia are described. Due to the increased prevalence and life expectancy of patients with type 1 diabetes, a growing number of these patients require hospitalization every year. Inpatient diabetes management is complex and is best provided by a multidisciplinary diabetes team. In the absence of such resource, providers and health care staff must become familiar with the features of this condition to avoid complications such as severe hyperglycemia, ketoacidosis, hypoglycemia, or glycemic variability. We reviewed most recent guidelines and relevant literature in the topic to provide practical recommendations for the inpatient management of patients with T1D.

Influencing factors of glycemic variability in hospitalized type 2 diabetes patients with insulin therapy: A Strobe-compliant article

Previous studies have shown that glucose fluctuation is closely related to oxidative stress and diabetic complications. However, only few studies have evaluated the influencing factors of glycemic variability (GV) in type 2 diabetes (T2D) patients so far.This was a cross-sectional study design. A total of 366 cases of hospitalized patients with T2D using insulin therapy, whom received continuous glucose monitoring from January 2014 to December 2016, were enrolled for this study. The evaluation variables of GV included standard deviation of blood glucose, coefficient of variation (CV%), mean amplitude of glycemic excursion, and absolute means of daily differences.In 366 T2D patients with insulin therapy, 148 were used multiple daily injections (MDI) insulin regimen; 144 were on premixed insulin injection; and 74 were treated with continuous subcutaneous insulin injection. Compared with MDI insulin regimen, patients on premixed insulin injection have less insulin dose per day, lower mean blood glucose, and better glycated hemoglobin (HbA1c) (all P <.05). Generalized linear model showed that family history of diabetes, duration of diabetes, higher HbA1c, and higher level of aspartate aminotransferase and high-density lipoprotein cholesterol were positively associated with GV parameters. Otherwise, serum levels of C-peptide, premixed insulin injection, history of cardiovascular disease, and serum concentration of uric acid were inversely associated with GV parameters.Dysfunction of pancreatic β-cell and better insulin sensitivity were independent contributors to the fluctuation of blood glucose. Moreover, premixed insulin therapy may obtain better glucose control and lower within-day and day-to-day glucose variability for Chinese T2D patients with insulin therapy.

COMPARISON OF EFFICACY AND SAFETY OF GLARGINE AND DETEMIR INSULIN IN THE MANAGEMENT OF INPATIENT HYPERGLYCEMIA AND DIABETES

OBJECTIVE

Glargine and detemir insulin are the two most commonly prescribed basal insulin analogues for the ambulatory and inpatient management of diabetes. The efficacy and safety of basal insulin analogues in the hospital setting has not been established.

METHODS

This observational study compared differences in glycemic control and outcomes in non-intensive care unit patients with blood glucose (BG) >140 mg/dL who were treated with glargine or detemir, between January 1, 2012, and September 30, 2015, in two academic centers.

RESULTS

Among 6,245 medical and surgical patients with hyperglycemia, 5,749 received one or more doses of glargine, and 496 patients received detemir during the hospital stay. There were no differences in the mean daily BG (glargine, 182 ± 46 mg/dL vs. detemir, 180 ± 44 mg/dL; P = .70). There were no differences in mortality, hospital complications, or re-admissions between groups (all, P>.05). After adjusting for potential confounders, there was no statistically significant difference in hypoglycemia rates between treatment groups. Patients treated with detemir required higher total daily basal insulin doses (0.27 ± 0.16 units/kg/day vs. 0.22 ± 0.15 units/kg/day; P<.001). Glargine-treated patients had statistically longer length of stay; however, this difference may not be clinically relevant (6.8 ± 7.4 days vs. 6.0 ± 6.3 days; P<.001).

CONCLUSION

Our study indicates that treatment with glargine and detemir results in similar inpatient glycemic control in general medicine and surgery patients. Detemir treatment was associated with higher daily basal insulin dose and number of injections. A prospective randomized study is needed to confirm these findings.

ABBREVIATIONS

BG = blood glucose BMI = body mass index CI = confidence interval eGFR = estimated glomerular filtration rate HbA1c = glycated hemoglobin ICD-9 = International Classification of Diseases, ninth revision ICU = intensive care unit IQR = interquartile range LOS = length-of-stay OR = odd ratio.

Switch to Combined GLP1 Receptor Agonist Lixisenatide with Basal Insulin Glargine in Poorly Controlled T2DM Patients with Premixed Insulin Therapy: A Clinical Observation and Pilot Study in Nine Patients

INTRODUCTION

To prove the feasibility and safety of a conversion to once-daily injected GLP1 agonist (lixisenatide) and long-acting basal insulin analogue (glargine) in patients with T2DM and poorly controlled glycemia previously treated with multiple injections of premixed insulins (iPremix) in an outpatient setting.

METHODS

Nine patients with T2DM currently receiving iPremix formulations and poor glycemic control were switched to once-daily injected lixisenatide (Lixi) and basal insulin analogue glargine (iGlar) for a 12-week period. Efficacy was defined as A1c reduction of at least 0.4% and weight loss of 0.5 kg or higher.

RESULTS

Five of nine patients achieved A1c reductions of 0.4% (4 mmol/mol) or higher and six of nine patients a weight loss of 0.5 kg or higher. A mean A1C reduction of 0.5% ± 0.5% (6 mmol/mol) and mean weight loss of -1.4 ± 3.6 kg were observed in all patients. Total daily insulin dose after 12 weeks declined from 56 ± 26 IU with iPremix formulations to 47 ± 17 IU in patients taking combined iGlar and Lixi. Corrections with fast acting insulin glulisine (iGlu) were necessary in two patients on a regular basis and in four patients on an irregular basis (2.3 IU mean total daily dose). Two patients did not need additional iGlu. Postprandial glucose profiles were lower in the combined group compared with iPremix throughout the day, which resolved in the afternoon. No metabolic derangements occurred. Mild hypoglycemia and gastrointestinal symptoms were the most often reported adverse events affecting three patients.

CONCLUSION

The conversion to once-daily injected GLP1 agonist Lixi and basal iGlar could safely be performed in an outpatient setting and was associated with better postprandial glycemic control throughout the day, except dinner, compared to iPremix.

CLINICAL TRIAL REGISTRATION

EU clinical trials register EudraCT number 2013-005334-37 and ClinicalTrials.gov NCT02168491.

FUNDING

Sponsored by the Medical University of Vienna and in part supported by Sanofi-Aventis.

Management of Inpatient Hyperglycemia and Diabetes in Older Adults

Adults aged 65 years and older are the fastest growing segment of the U.S. population, and their number is expected to double to 89 million between 2010 and 2050. The prevalence of diabetes in hospitalized adults aged 65-75 years and over 80 years of age has been estimated to be 20% and 40%, respectively. Similar to general populations, the presence of hyperglycemia and diabetes in elderly patients is associated with increased risk of hospital complications, longer length of stay, and increased mortality compared with subjects with normoglycemia. Clinical guidelines recommend target blood glucose between 140 and 180 mg/dL (7.8 and 10 mmol/L) for most patients in the intensive care unit (ICU). A similar blood glucose target is recommended for patients in non-ICU settings; however, glycemic targets should be individualized in older adults on the basis of a patient's clinical status, risk of hypoglycemia, and presence of diabetes complications. Insulin is the preferred agent to manage hyperglycemia and diabetes in the hospital. Continuous insulin infusion in the ICU and rational use of basal-bolus or basal plus supplement regimens in non-ICU settings are effective in achieving glycemic goals. Noninsulin regimens with the use of dipeptidyl peptidase 4 inhibitors alone or in combination with basal insulin have been shown to be safe and effective and may represent an alternative to basal-bolus regimens in elderly patients. Smooth transition of care to the outpatient setting is facilitated by providing oral and written instructions regarding timing and dosing of insulin as well as education in basic skills for home management.

Perioperative Hyperglycemia Management: An Update

An association between perioperative hyperglycemia and adverse outcomes has been established in surgical patients, 1 -3 with morbidity being reduced in those treated with insulin.5 -6 A practical treatment algorithm and literature summary is provided for surgical patients with diabetes and hyperglycemia.

Basal insulin therapy is associated with beneficial effects on postoperative infective complications, independently from circulating glucose levels in patients admitted for cardiac surgery

•

The effect of insulin per se on infective complications during cardiac surgery was evaluated.

•

Eight hundred twelve patients were included.

•

Insulin therapy decreased infections independently from glycemic levels.

•

Basal + premeal insulin therapy is well tolerated without severe hypoglycemia cases.

Background

Although hyperglycemia is a strong predictor of postoperative infective complications (PIC), little is known about the effect of basal insulin therapy (BIT) per se on PIC.

Aim

To evaluate if there is an association between BIT, independent of glucose levels, and a possible improvement of PIC during the perioperative cardiosurgery period (PCP).

Methods

In 812 patients admitted for cardiac intervention and treated with a continuous intravenous insulin infusion (CIII) for hyperglycemic levels (>130 mg/dl), a retrospective analysis was performed during the PCP (January 2009–December 2011). Upon transfer to the cardiac surgery division, if fasting glucose was ≥130 mg/dl, a basal + premeal insulin therapy was initiated (121 patients, group 1); for <130 mg/dl, a premeal insulin alone was initiated (691 patients, group 2).

Findings

Compared with group 2, group 1 showed reductions in PIC (2.48% vs 7.96%, p < 0.049; odds ratio: 0.294; 95% CI: 0.110–0.780), C-Reactive Protein (p < 0.05) and white blood cell (p < 0.05) levels despite glucose levels and CIII that were higher during the first two days after surgery (179.8 ± 25.3 vs 169.5 ± 10.6 mg/dl, p < 0.01; 0.046 ± 0.008 vs 0.037 ± 0.015 U/kg/h, p < 0.05, respectively). Normal glucose levels were achieved in both groups from day 3 before the discharge. The mean length of hospital duration was 18% lower in group 1 than in group 2 (7.21 ± 05.08 vs 8.76 ± 9.08 days, p < 0.007), providing a significant impact on public health costs.

Conclusions

Basal + preprandial insulin therapy was associated with a lower frequency of PIC than preprandial insulin therapy alone, suggesting a beneficial effect of basal insulin therapy on post-surgery outcome.

Initiation and Intensification Strategies in Type 2 Diabetes Management: A Comparison of Basal Plus and Premix Regimens

The progressive nature of type 2 diabetes (T2D) often results in the need for initiation and subsequent intensification of insulin treatment to achieve glycemic control. The aim of this review is to examine published clinical evidence that has directly compared two recommended treatment approaches in patients with T2D: (1) a 'basal plus' regimen, whereby 1-2 injections of prandial insulin are added to basal insulin; or (2) the use of once- or twice-daily premix insulin analogs, which contain both basal and prandial insulin in a single injection. Broadly, the available evidence suggests that both basal plus and premix regimens are comparable in terms of efficacy and safety when used for insulin initiation in insulin-naïve patients and intensification in patients who have failed on basal insulin; instances of greater glycemic control are observed with premix insulin; however, these are often accompanied by increases in hypoglycemia and/or weight relative to basal plus treatment, and results should be interpreted within the context of total insulin doses used. Relatively low numbers of patients achieved glycemic control when both regimens were used for insulin intensification following failure of basal insulin, suggesting that a full basal-bolus regimen and/or the use of different treatments is clinically indicated in certain patients. In summary, the current review argues that both basal plus and premix insulin regimens are relatively efficacious and safe options for patients with T2D during both insulin initiation in insulin-naïve patients and intensification in patients who have failed on basal insulin. This emphasizes the important role of patient-centered factors in clinical decision-making.

FUNDING

Novo Nordisk.

Premixed Insulin Analogue Compared with Basal-Plus Regimen for Inpatient Glycemic Control

BACKGROUND

No previous studies have investigated the use of a premixed insulin analogue in a hospital setting.

OBJECTIVE

To compare the efficacy and safety of treatment with premixed insulin analogue (insulin lispro mix 75/25, LM75/25) with the basal-plus regimen with insulin glargine in hospitalized patients with type 2 diabetes (T2D).

MATERIALS AND METHODS

A randomized clinical trial in hospitalized patients with T2D and glucose >140 mg/dL on admission was performed. A total of 54 patients were randomized to receive insulin LM75/25 or glargine. In both groups, a correction dose of lispro was administered before meals. Insulin dose was adjusted to obtain a mean blood glucose (BG) between 100 and 140 mg/dL.

RESULTS

Improvement in the mean BG after the first day of treatment was similar in both groups (P = 0.470). Glycemic control at the end of follow-up was similar between the group with insulin LM75/25 (131.3 ± 28.4 mg/dL) and insulin glargine (143.8 ± 32.5 mg/dL, P = 0.153). The aim of a BG concentration of <140 mg/dL was obtained in 72% of the patients in the premixed insulin analogue group and 56% of patients in the basal-plus group (P = 0.239). There was no difference in the frequency of hypoglycemia between groups (7 vs. 10, P = 0.529).

CONCLUSION

Results of this trial indicate that the use of a premixed insulin analogue is as effective and safe as the basal-plus regimen to achieve glycemic control.

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.