Pilot and Revision of a Basal-Bolus Dosing Guideline for the Management of Hyperglycemia in Noncritically Ill Adult Patients

2014 ◽  
Vol 28 (6) ◽  
pp. 504-510
Author(s):  
Germin Fahim ◽  
Evangelia Davanos ◽  
Karina Muzykovsky ◽  
Rochelle Rubin
Keyword(s):  
Standard Of Care ◽  
Adult Patients ◽  
Institutional Review Board ◽  
Target Range ◽  
Total Daily Dose ◽  
Institutional Review ◽  
Daily Dose ◽  
Before And After ◽  
Bolus Insulin ◽  
Basal Bolus

The use of basal-bolus insulin (BBI) regimens for the treatment of inpatient hyperglycemia has become standard of care. The purpose of this study was to develop and evaluate a newly piloted dosing guideline and utilize the results to adjust it prior to its implementation hospital-wide. This was an institutional review board approved, prospective, and multiphase study. An interdisciplinary team was developed and created a dosing guideline, which was followed by a 3-month, single-unit pilot of the guideline in noncritically ill adult patients. The resulting data were used to revise the guideline. Forty-three patients were included. There was a significant decrease in median blood glucose (BG) with use of the guideline (219 mg/dL [162-281] vs 190 mg/dL [136-246], P < .05) in patients not utilizing it. There was also a significant increase in the number of values within the target range of 70 to 180 mg/dL (30.2% vs 41.4%, P < .05). Moreover, there was comparable hypoglycemia before and after the intervention (1.6% vs 2.4%, P = .51). Based on these results, the dosing factor used for the total daily dose of insulin was increased in certain populations. Use of a BBI dosing guideline is safe and effective in decreasing BG values in noncritically ill patients at our institution.

scholarly journals Clinical Evaluation of Basal-Bolus Therapy Delivered by the V-Go® Wearable Insulin Delivery Device in Patients with Type 2 Diabetes: A Retrospective Analysis

Pharmacy ◽  
2020 ◽  
Vol 8 (4) ◽  
pp. 215
Author(s):  
Trisha Zeidan ◽  
Carla Nikkel ◽  
Beth Dziengelewski ◽  
Stephanie Wu ◽  
Aleda M. H. Chen
Keyword(s):  
Type 2 Diabetes ◽  
Daily Injection ◽  
Total Daily Dose ◽  
Diabetes Clinic ◽  
Multiple Daily Injection ◽  
Daily Dose ◽  
Study Completion ◽  
Glycemic Targets ◽  
Basal Bolus

Insulin therapy is frequently required to achieve glycemic targets (A1c) in type 2 diabetes (T2D); however, clinicians and patients face barriers with the complexities of multiple daily injection regimens. Patch-like wearable insulin devices, such as V-Go, may simplify and optimize this complexity. This study evaluated the change in A1C and insulin total daily dose (TDD) in a suboptimally-controlled (not achieving A1C targets) T2D population after switching to V-Go. A retrospective chart analysis at a diabetes clinic was performed to evaluate change in A1c measurements from baseline (V-Go initiation) to end of study observation. Of the 139 patients enrolled, A1C significantly decreased from baseline (−1.5 ± 1.79%; p < 0.001). Patients prescribed insulin at baseline (n = 122) used significantly less insulin TDD (−8 u/day; p = 0.006). The percentage of patients meeting the target of A1C < 8% increased from 14% at baseline to 48% at study completion (p = 0.008). Patients prescribed a basal-bolus regimen prior to V-Go achieved an A1C reduction of 1.5 ± 2.0% (p < 0.0001) and experienced the greatest reduction in TDD (−24 u/day; p < 0.0001). Thus, patients switching to V-Go from a variety of therapies at baseline experienced reductions in A1C while using less insulin, with a reduction in clinically relevant hypoglycemia, indicating the potential benefit of V-Go in optimizing and simplifying T2D care.

Efficacy of an educational program for patients with pancreatic and biliary cancers, and their caregivers.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. e18221-e18221
Author(s):  
Reiko Makihara Ando ◽  
Chikako Doutani ◽  
Sayaka Kanehira ◽  
Mariko Nishizawa ◽  
Kyoko Hirata ◽  
...  
Keyword(s):  
Classroom Environment ◽  
Educational Program ◽  
Prospective Observational Study ◽  
Institutional Review Board ◽  
Informational Needs ◽  
Institutional Review ◽  
Distress Level ◽  
Before And After ◽  
Baseline Knowledge ◽  
The Mean

e18221 Background: We first introduced an educational program delivered in a classroom environment for patients with pancreatic and biliary cancers and their caregivers in 2007. Physicians, pharmacists, nurses, clinical psychotherapists, dietitians, and medical social workers attended and talked about their specialties. We conducted a prospective observational study from Jan. 2016 through Dec. 2016 to assess the efficacy of this educational program. Methods: This study was approved by our institutional review board and informed consent was obtained from all the participants. The 2-hour program included an overview of disease and information about treatment and management. The participants completed a questionnaire assessing their knowledge and including the Distress Thermometer both before and after the program. In addition, the participants completed a questionnaire regarding their satisfaction with the program to assess their informational needs. Results: Thirty-three patients and 50 caregivers were enrolled. Although no significant differences were seen in the mean baseline knowledge levels of the patients and caregivers, the mean baseline distress level was greater for the caregiver than for the patients. After attending the program, both the knowledge and distress levels were significantly improved for both the two groups. Regarding the satisfaction questionnaire, more than 90% of the participants reported being satisfied with the contents of the program and responded that the program was useful for their life. However, the percentage of respondents who reported being satisfied with hearing other participants’ stories was less than 40%. Conclusions: This study suggests that an educational program can improve knowledge and distress levels in patients and caregivers. We are planning to improve our program to further satisfy the needs of patients and caregivers, such as providing an opportunity to communicate with other participants, and to perform further evaluations.

scholarly journals Humán inzulinról glargininzulin-alapú bázis-bolus kezelésre váltott betegek glykaemiás állapotának javulása a váltás után

2018 ◽  
Vol 159 (29) ◽  
pp. 1201-1207
Author(s):  
Erzsébet Nagy ◽  
Gábor Kovács
Keyword(s):  
Blood Glucose ◽  
Glycaemic Control ◽  
Insulin Glargine ◽  
Control Method ◽  
Fasting Blood Glucose ◽  
Postprandial Blood Glucose ◽  
Efficacy Analysis ◽  
Before And After ◽  
Bolus Insulin ◽  
Basal Bolus

Abstract: Introduction: The effectiveness of human and analogue insulins is similar but the latter have more advantageous pharmacokinetic features, leading to an improvement in hypoglycaemia and come closer to achieving the physiologic insulin profile. Aim: To demonstrate that switching from a human basal-bolus insulin treatment to an insulin glargine-based basal-bolus regimen can achieve a better glycaemic control. Method: This 3-month prospective, non-interventional study, including a 12-month retrospective data collection phase, enrolled patients who were switched to the insulin glargine- – 100 U/mL – based basal-bolus treatment at the time of enrolment if they were inadequately controlled and had at least one additional HbA1c result in the 12 months before the switch. Of 1513 patients 1181 had the data that were needed for the efficacy analysis. Results: The mean age of the efficacy population was 58.3 years and 48.1% were male. Their mean HbA1c levels remained unchanged in the year before the switch: it was 8.8 ± 1.4% at 12 months prior to the switch and 8.8 ± 1.2% at the switch, but decreased significantly to 7.7 ± 1.0% (p<0.001) after 3 months. Between the baseline and 3 months, the fasting blood glucose and the postprandial blood glucose improved significantly (from 10.0 ± 3.2 mmol/L to 7.4 ± 1.9 mmol/L, p<0.001 and from 11.1 ± 2.8 mmol/L to 8.8 ± 1.7 mmol/L, p<0.001, respectively). Insulin doses were increased both before and after the switch. Conclusions: Switch to an insulin glargine-based basal-bolus regimen could achieve a significant improvement in the glycaemic control in patients who were inadequately controlled prior to the switch. Orv Hetil. 2018; 159(29): 1201–1207.

scholarly journals Insulin Basal Dose Is Associated With Better Metabolic Control in Type 1 Diabetes Children and Adolescents

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A660-A660
Author(s):  
Abril Arellano-Llamas ◽  
Luz Elena Mejía-Carmona ◽  
Alicia Rojas-Zacarias ◽  
Oscar Ochoa-Romero ◽  
Irene Díaz-Rodríguez
Keyword(s):  
Type 1 Diabetes ◽  
Metabolic Control ◽  
Basal Insulin ◽  
Glycated Hemoglobin ◽  
Insulin Dose ◽  
Real Life ◽  
Total Daily Dose ◽  
Daily Dose ◽  
Basal Bolus

Abstract Basal insulin dose in type 1 diabetes has been established empirically, since 2011 all guidelines suggest insulin basal dose less than 50% of total insulin dose in the pediatric population. However, in real life, basal dose indication has not changed in all patients in the basal-bolus treatment scheme. Objective: To measure how the physician indicates in real-life basal insulin dose in pediatric patients with type 1 diabetes in the basal-bolus scheme, and correlate this dose with metabolic control measured by glycated hemoglobin. Methods. This was a retrospective study, subjects include pediatric T1D (2 to 16 years, non-obese, using insulin more than 0.3 UI/Kg/d), more than 1 year of diagnostic, none of them in ketoacidosis, attended during 2019. The protocol was revised and accepted in the institution. Data were analyzed with Kruskal-Wallis, U Mann Withney, Pearson correlation test. Results: There were 141 subjects, male (51%), median age 13.3 years (3.6-15.9), median evolution time since diagnosis 8 years (1-14), pre-pubertal (Tanner stage 1, 22%), total daily dose 1.02 UI/Kg/d (0.3-2.19 UI/Kg/d). Basal insulin was glargine 50.4%, and NPH 49.6%, prandial insulin was lispro 66.7%, and regular human 29.8%. Children using 50% or less basal insulin of total insulin dose was 40.4%. The basal dose was 38% of total insulin dose in children less than 6 years, and 59% in children older than 6 years. (p=0.033). Glycated hemoglobin was less than 7.5% in 12.8%. The persons with glycated hemoglobin less than 7.5% used less basal insulin 0.38 u/kg/d, than those with higher glycated hemoglobin 0.57 U/kg/d (p=0.02) with no impact in total insulin dose (0.86 vs 1.05 UI/Kg/d, p=0.129). The correlation of the percentage of insulin basal dose and glycated hemoglobin was 0.279, p=0.001, meaning, more basal insulin, worse diabetes control. Conclusion: Lower basal insulin dose percentage from total daily dose is associated with better metabolic control in children treated with the basal-bolus scheme. There is high clinical inertia in the indication of basal insulin in older children.

scholarly journals Pressure-based Compression Guidance of the Breast in Digital Breast Tomosynthesis Using Flexible Paddles Compared to Conventional Compression

2020 ◽  
Vol 2 (6) ◽  
pp. 541-551
Author(s):  
Monique G J T B van Lier ◽  
Jerry E de Groot ◽  
Serge Muller ◽  
Gerard J den Heeten ◽  
Kathy J Schilling
Keyword(s):  
Digital Breast Tomosynthesis ◽  
Control Device ◽  
Institutional Review Board ◽  
Target Range ◽  
Compression Pressure ◽  
Breast Tomosynthesis ◽  
Breast Compression ◽  
Institutional Review Board Approval ◽  
Institutional Review ◽  
Breast Thickness

Abstract Objective We investigated the effect of introducing a pressure-based flexible paddle on compression parameters and user and patient experience of digital breast tomosynthesis (DBT) combined with patient-assisted compression or technologist compression. Methods After institutional review board approval, women with a DBT appointment who gave informed consent received pressure-based flexible paddle breast compression. Eight lights on the paddle were illuminated (1.9 kPa per light) as pressure was applied, aiming for an 8–13.9 kPa target range. The compression level was applied by the technologist or the participant utilizing a remote control device. The participant’s and technologist’s experiences were assessed by a questionnaire. Compression parameters were compared to previous examinations. Comparative statistics were performed using t-tests. Results Pressure-based compression (PBC) was judged to be similar or more comfortable compared with previous traditional exams (80%, 83/103), and 87% (90/103) of participants would recommend PBC to friends. Pressure variability decreased for craniocaudal (CC) views (-55%, P &lt; 0.001) and mediolateral oblique (MLO) views (-34%, P &lt; 0.0001). Subgroup analysis showed a similar glandular dose for CC views, while breast thickness was reduced (-3.74 mm, P &lt; 0.0001). For MLO views, both glandular dose (-0.13 mGy, P &lt; 0.0001) and breast thickness were reduced (-6.70 mm, P &lt; 0.0001). Mean compression parameters were similar for technologist compression and patient-assisted examinations. Conclusion Use of the pressure-based flexible paddle in DBT, with or without patient-assisted compression, improved participant and technologist experience and reduced compression pressure variability, mean breast thickness, and glandular dose.

Sedation with alfentanil versus fentanyl in patients receiving extracorporeal membrane oxygenation: outcomes from a single-centre retrospective study

Perfusion ◽  
2019 ◽  
Vol 35 (2) ◽  
pp. 104-109
Author(s):  
Mike Barker ◽  
Alison A Dixon ◽  
Luigi Camporota ◽  
Nick A Barrett ◽  
Ruth Y Y Wan
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Patient Outcomes ◽  
Total Daily Dose ◽  
Patient Demographics ◽  
Membrane Oxygenation ◽  
Published Evidence ◽  
Daily Dose ◽  
Before And After ◽  
Analgesic Agents ◽  
Score Apache

Introduction: In November 2016, our institution switched from alfentanil to fentanyl for analgesia and sedation in adult patients receiving extracorporeal membrane oxygenation. There is no published evidence comparing the use of alfentanil with fentanyl for sedation in extracorporeal membrane oxygenation patients. We conducted a retrospective observational study to explore any significant differences in patient outcomes or in the prescribing of adjunct sedatives before and after the switch. Methods: Patients were retrospectively identified from a prospectively recorded database of all patients who received extracorporeal membrane oxygenation at our institution between January 2016 and October 2017. Patients included those sedated with alfentanil or fentanyl. The total daily doses of intravenous opioids (alfentanil or fentanyl) were calculated for each patient, and the prescribing of adjunctive sedative or analgesic agents was recorded. Patient demographics, extracorporeal membrane oxygenation modality, clinical outcomes including mortality and length of intensive care and hospital stay were recorded. Results: A total of 174 patients were identified, 69 on alfentanil and 95 on fentanyl. There was no difference found between groups for mode of extracorporeal membrane oxygenation, age, Acute Physiology and Chronic Health Evaluation 2 score (APACHE II) and Charlson score, except for body mass index (p = 0.002). No differences in patient outcomes was observed between groups, although patients in the alfentanil group received a significantly higher median total daily dose of adjuvant sedatives (quetiapine (p = 0.016) and midazolam (p = 0.009)). Conclusions: No differences in patient outcomes were found between extracorporeal membrane oxygenation patients sedated with alfentanil compared with fentanyl. There was a statistically significant reduction in some adjunctive sedatives in patients managed with a fentanyl-based regimen. Prospective studies are required to confirm these results.

scholarly journals Analysis of continuous glucose tracking data in people with Type 1 Diabetes (T1DM) after Covid-19 Vaccination reveals unexpected link between immune and metabolic response, augmented by adjunctive oral medication

2021 ◽  
Author(s):  
Adrian Heald ◽  
Rustam Rea ◽  
Linda Horne ◽  
Ann Metters ◽  
Tom Steele ◽  
...  
Keyword(s):  
Type 1 Diabetes ◽  
Metabolic Response ◽  
Glucose Monitoring ◽  
Primary Outcome Measure ◽  
Target Range ◽  
Older Individuals ◽  
Oral Hypoglycaemic Agents ◽  
Before And After ◽  
Bolus Insulin

Introduction The COVID-19 vaccination programme is under way. Anecdotal evidence is increasing that some people with Type 1 Diabetes Mellitus (T1DM) experience temporary instability of blood glucose (BG) levels post-vaccination which normally settles within 2-3 days. We report an analysis of BG profiles of 20 individuals before and after vaccination. Methods We examined the BG profile of 20 consecutive adults (18 years of age or more) with T1DM using the FreeStyle® Libre flash glucose monitor in the period immediately before and after COVID-19 vaccination. The primary outcome measure was percentage(%) BG readings in the designated target range 3.9-10mmmol/L as reported on the LibreView portal for 7 days prior to the vaccination (week -1) and the 7 days after the vaccination (week +1). Results There was a significant decrease in the %BG on target following the COVID-vaccination for the 7 days following vaccination (mean 45.2% ±se 4.2%) vs pre-COVID-19 vaccination (mean 52.6% ±se 4.5%). This was mirrored by an increase in the proportion of readings in other BG categories 10.1-13.9%/ ≥14%. There was no significant change in BG variability in the 7days post COVID-19 vaccination. This change in BG proportion on target in the week following vaccination was most pronounced for people taking Metformin/Dapagliflozin+basal bolus insulin (-23%) vs no oral hypoglycaemic agents (-4%), and median age <53 vs ≥53 years (greater reduction in %BG in target for older individuals (-18% vs -9%)). Conclusion In T1DM, we have shown that COVID-19 vaccination can cause temporary perturbation of BG, with this effect more pronounced in patients talking oral hypoglycaemic medication plus insulin, and in older individuals. This may have consequences for patients with T2DM who are currently not supported by flash glucose monitoring.

scholarly journals Analysis of “Comparison an Electronic Glycemic Management System Versus Provider Managed Subcutaneous Basal Bolus Insulin Therapy in the Hospital Setting”

2016 ◽  
Vol 11 (1) ◽  
pp. 17-19
Author(s):  
Silvia Leitgeb ◽  
Julia K. Mader
Keyword(s):  
Blood Glucose ◽  
Glycemic Control ◽  
Insulin Therapy ◽  
Management System ◽  
Positive Impact ◽  
Hospital Setting ◽  
Before And After ◽  
Bolus Insulin ◽  
Basal Bolus ◽  
Glycemic Management

Safety and efficacy of a nurse-directed electronic glycemic management system (eGMS) in comparison to basal-bolus subcutaneous insulin therapy managed by providers has been evaluated recently by Aloi et al. They included 993 non–critically ill patients across 9 different hospitals in a retrospective observational crossover study and compared mean blood glucose, number of hypoglycemic events <40 mg/dl and <70 mg/dl and the percentage of blood glucose in target (140-180 mg/dl) before, during and after the use of eGMS. Conclusion was that eGMS can lead to better glycemic control with less hypoglycemic events compared to provider managed basal-bolus insulin therapy (before and after eGMS). Although some limitations exist, the authors made a strong case that eGMS has positive impact on glycemic control in hospitalized patients with diabetes.

Reliability of Inpatient CGM: Comparison to Standard of Care

2021 ◽  
pp. 193229682110621
Author(s):  
Catherine Price ◽  
Gillian Ditton ◽  
Gregory B. Russell ◽  
Joseph Aloi
Keyword(s):  
Real Time ◽  
Standard Of Care ◽  
Mean Difference ◽  
Absolute Difference ◽  
Subcutaneous Insulin ◽  
Insulin Administration ◽  
Hypoglycemic Event ◽  
Bolus Insulin ◽  
Basal Bolus

Background: Optimal inpatient glycemic management targets a blood glucose (BG) of 140-180 mg/dL and is an important safety measure for hospitalized patients with hyperglycemia. Traditional barriers to appropriate insulin administration include incorrect timing of prandial insulin administration, failure to administer basal insulin to persons with insulin deficiency/type 1 diabetes mellitus (DM), and inaccurate insulin dosing or timing resulting in hypoglycemia. Given the ongoing rapid assimilation of technology to manage our patients with DM, we investigated the use of continuous glucose monitoring (CGM) in the inpatient setting as a potential solution to traditional barriers to optimal hyperglycemia management for inpatient care. In this study, we evaluated the efficacy of use of inpatient CGM for insulin dosing in comparison with current standard of care and whether CGM could aid in minimizing hypoglycemic events. Methods: This study evaluated the use of Abbott professional (blinded) Freestyle Libre CGMs in participants treated with basal bolus insulin administered with subcutaneous insulin (basal bolus therapy [BBT]: n = 20) or on intravenous insulin (IVI) infusions (n =16) compared with standard point of care (POC) BG measurements. All participants on IVI were admitted with a diagnosis of diabetic ketoacidosis (DKA). The CGM data was not available in real time. Sensors were removed at the time of discharge and data uploaded to Libre View. Continuous BG data were aggregated for each subject and matched to POC BG or lab chemistry values within five minutes. The POC BG results were assessed for comparability (CGM vs standard BG testing). Data were further analyzed for clinical decision-making for correction insulin. Results: The overall mean absolute relative difference including both IVI and BBT groups was 22.3% (SD, 9.0), with a median of 20.0%. By group, the IVI arm mean was 19.6% (SD, 9.4), with a median of 16.0%; for BBT, the arm mean was 24.6% (SD, 8.1), with a median 23.4%. Using the Wilcoxon two-sample test, the means were not different ( P = .10), whereas the medians were ( P = .015). The CGM consistently reported lower glucose values than POC BG in the majority of paired values (BBT arm mean difference = 44.8 mg/dL, IVI mean difference = 19.7 mg/dL). Glucose results were in agreement for the group 83% of the time with Bland-Altman Plot of Difference versus the mean of all glucometric data. Analysis of correction dose insulin using either CGM or POC BG values resulted in a negligible difference in calculated insulin dose recommended in those receiving subcutaneous insulin. Corrective doses were based on weight and insulin sensitivity (type 1 vs type 2 DM). Participants initially on IVI were included in a data set of BBT once IVI therapy ceased and basal bolus insulin regimen was started. The data of all basal bolus therapy participants with 1142 paired values of CGM versus POC glucose were used. The dosing difference was less for CGM than POC BG in the majority of paired values, and there was an absolute difference in dose of insulin of only 1.34 units. In the IVI group with 300 paired values of CGM versus POC glucose, there was an absolute difference in dose of insulin of only 0.74 units. About a third of the patients studied in the BBT arm experienced a hypoglycemic event with POC BG <70 mg/dL. If used in real time, CGM would have identified a hypoglycemic event for our patients on average 3 hours and 34 minutes before it was detected by standard POC BG. Two participants incurred severe nocturnal hypoglycemia during the study with POC BG <54 mg/dL with hypoglycemia detected on CGM up to 3 hours and 42 minutes before POC testing. Conclusions: These results suggest that the use of inpatient CGM arrives at similar correction insulin dosing. The routine use of CGM for inpatients would consistently underestimate the BG compared with POC BG and could aid in minimizing and predicting hypoglycemia in the hospital setting. Our data support that the model of adoption of real-time inpatient CGM technology is anticipated to have significant impact in the clinical setting in efforts to maintain adequate glycemic control targeting BG 140-180 mg/dL while minimizing the frequency of hypoglycemic events.

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