Basal-Bolus Insulin Therapy May Not Be the Optimal Strategy in a "Real-World" Hospital Setting for Inpatient Hyperglycemia Management

Background: American Diabetes Association (ADA) guidelines recommend a basal bolus correction insulin regimen as the preferred method of treatment for non–critically ill hospitalized patients. However, achieving ADA glucose targets safely, without hypoglycemia, is challenging. In this study we evaluated the safety and efficacy of basal bolus subcutaneous (SubQ) insulin therapy managed by providers compared to a nurse-directed Electronic Glycemic Management System (eGMS). Method: This retrospective crossover study evaluated 993 non-ICU patients treated with subcutaneous basal bolus insulin therapy managed by a provider compared to an eGMS. Analysis compared therapy outcomes before Glucommander (BGM), during Glucommander (DGM), and after Glucommander (AGM) for all patients. The blood glucose (BG) target was set at 140-180 mg/dL for all groups. The safety of each was evaluated by the following: (1) BG averages, (2) hypoglycemic events <40 and <70 mg/dL, and (3) percentage of BG in target. Result: Percentage of BG in target was BGM 47%, DGM 62%, and AGM 36%. Patients’ BGM BG average was 195 mg/dL, DGM BG average was 169 mg/dL, and AGM BG average was 174 mg/dL. Percentage of hypoglycemic events <70 mg/dL was 2.6% BGM, 1.9% DGM, and 2.8% AGM treatment. Conclusion: Patients using eGMS in the DGM group achieved improved glycemic control with lower incidence of hypoglycemia (<40 mg/dL and <70 mg/dl) compared to both BGM and AGM management with standard treatment. These results suggest that an eGMS can safely maintain glucose control with less hypoglycemia than basal bolus treatment managed by a provider.

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Effect of basal insulin therapy with glargine U300 versus basal bolus insulin therapy in hospitalized patients with type 2 diabetes. Real-world study from India

Clinical Diabetology ◽

10.5603/dk.a2021.0011 ◽

2021 ◽

Author(s):

Asis Mitra ◽

Saswati Ray ◽

Sushma Jayan

Keyword(s):

Type 2 Diabetes ◽

Insulin Therapy ◽

Real World ◽

Basal Insulin ◽

Hospitalized Patients ◽

Bolus Insulin ◽

Basal Bolus

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Inpatient hyperglycemia management: the opportunities of a new basal insulin

Italian Journal of Medicine ◽

10.4081/itjm.2016.681 ◽

2016 ◽

Vol 10 (2) ◽

pp. 103 ◽

Cited By ~ 3

Author(s):

Natalino Simioni

Keyword(s):

Insulin Therapy ◽

Basal Insulin ◽

Hospital Setting ◽

Insulin Analogues ◽

Diabetic Patients ◽

Potential Clinical Benefit ◽

Sliding Scale ◽

Bolus Insulin ◽

Basal Bolus

The management of hospitalized diabetic patients for any cause is often difficult and affected not only by the comorbidities of the patient but also by the hospital setting. It is well known that at the admission the antidiabetic drugs should be discontinued on behalf of insulin therapy with insulin analogues, as a function of a basal-bolus insulin approach according to the phenotype of the patient, type of nutrition (enteral or parenteral rather than oral), or concomitant hyperglycemic therapy (<em>e.g.</em>, steroid). The average stay of diabetic patients hospitalized for any cause is significantly correlated with both the number of hypoglycemia and hyperglycemia. Compared to patients treated with sliding scale patients using a custom algorithm show a significant reduction in the number of hypoglycemia and hyperglycemia episodes and in the length of stay. We analyze the clinical profile of a novel basal insulin, degludec, and explore the potential clinical benefit for diabetic inpatient. The continuation of insulin therapy at home in the immediate post-hospitalization (if necessary), also correlates with a reduction in the rate of re-hospitalization, which combined with close follow-up diabetes can result in a reduction of chronic complications.

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

Journal of Diabetes Science and Technology ◽

10.1177/1932296816677296 ◽

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.

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Outcomes of “Real World” Insulin Strategies in the Management of Hospital Hyperglycemia

Journal of the Endocrine Society ◽

10.1210/jendso/bvab101 ◽

2021 ◽

Author(s):

Archana R Sadhu ◽

Bhargavi Patham ◽

Aisha Vadhariya ◽

Soumya G Chikermane ◽

Michael L Johnson

Keyword(s):

Insulin Therapy ◽

Real World ◽

Glucose Control ◽

Initial Therapy ◽

The Real ◽

Sliding Scale ◽

Long Acting ◽

Bolus Insulin ◽

Mean Glucose ◽

Basal Bolus

Abstract Context Guidelines recommend scheduled long acting basal and short acting bolus insulin several times daily to manage inpatient hyperglycemia. In the “real world”, insulin therapy is complicated, with limited data on comparative effectiveness of different insulin strategies. Objective Evaluate the association of different insulin strategies with glucose control and hospital outcomes, after adjustment for patient and physician factors that influence choice of therapy. Design Retrospective, observational. Setting Academic hospital. Patients Non-critically ill hospitalized medical/surgical patients (n=4,558) receiving subcutaneous insulin ≥75% of the admission. Interventions Insulin therapy was grouped into 3 strategies within the first 48 hours: basal-bolus (BB: scheduled long and short/rapid n=2,358), sliding scale (SS: short/rapid acting n=1,855), or basal only (BO: long only: n=345). Main Outcome Measure(s) Glucose control: hypo-, hyper-, euglycemic days, mean glucose. Hospitalization: mortality, length of stay (LOS), readmissions. Results Initial therapy with BB was associated with more hypoglycemic (2.40 (CI:2.04,2.82) (P< 0.001)) and fewer euglycemic days (0.90 (CI:0.85,0.97) (P=0.003)) than SS, whereas BO was associated with fewer hyperglycemic days ((0.70 (0.62,0.79) (P<0.001)), lower mean glucose (-18.03 (CI:-22.46, -12.61) (P< 0.001)) and more euglycemic days (1.22 (CI:1.09,1.37), (P< 0.001)) compared to SS. No difference in mortality, LOS and readmissions was found. However, decreased LOS was observed in the subgroup with a medical DRG (0.93 (CI:0.89,0.97) (P<0.001)). Conclusion BO had a more favorable hyperglycemia profile than SS. BB, on the other hand showed worse glycemic control as compared to SS. In the real-world hospital, BO may be a simpler and more effective insulin strategy.

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