Role of Insulin: Perspectives

The pancreas in a non-diabetic patient invariably produces a lesser quantum of insulin (basal production). Insulin furnishes glucose homeostasis by keeping the plasma glucose worth in an optimum class throughout the day. It assists transport blood glucose into the body cells where the glucose is metabolized to generate energy. Regular insulin is inserted pre-meal to abrupt the postprandial ascend in glucose levels. It figures hexamers after insertion into the subcutaneous space sluggishing its absorption. Ultra-fast acting commences to act 4-7 minutes before regular apidra and lasts for around 3 hours. The absorption rate of lente insulin is downgraded by the extension of zinc to the insulin preparation. Long-acting insulins furnish basal insulin coverage. Atrophy of subcutaneous fat owing to applicability of further greater accumulated insulin preparations of neutral potenz hydrogen.

To Compare Metformin Vs Insulin in Gestational Diabetes in Terms of Neonatal Hypoglycemia

Aim: To compare metformin vs insulin in Gestational Diabetes in terms of neonatal hypoglycemia. Methodology: Study design: Randomized controlled trial Setting: Obstetrics / Gynecology Unit-l, Holy Family Hospital, Rawalpindi. Duration of study: 6 months i.e. 10-11-2017 to 10-05-2018 Data collection procedure: 240 patients were randomly allotted into two groups; A & B. Group A received metformin and group B received regular insulin. Patient was admitted at 36 wks onwards. Neonatal hypoglycemia was measured and entered in structured Performa. All the data was entered and analyzed through SPSS version 22. Results: In this study, the mean ± sd ages of patients were 28.7±5.05 years in insulin group while 28.01±4.37years in metformin group. Mean neonatal blood sugar level was 51.58±11.77mg/dl in insulin group while 57.37±10.61mg/dl in metformin group. The difference was significant (p<0.05). In this study, neonatal hypoglycemia was noted in 28 (23.3%) cases with insulin while in 1 (0.8%) case with metformin. The difference was significant (p<0.05). Conclusion: Metformin has better outcome than insulin in terms of less number of neonatal hypoglycemia. Key words: Gestational Diabetes, Metformin, Insulin, Neonatal Hypoglycemia

Subcutaneous regular insulin use for the management of diabetic ketoacidosis in resource limited setting

Objectives The standard recommendation of insulin therapy for patients with DKA is the administration of slow continuous intravenous (IV) regular insulin. Currently subcutaneous insulin is being recommended as an alternative treatment of DKA in mild and moderate cases in resource-limited settings. The purpose of this study was to assess the effectiveness and safety of six-hourly subcutaneous regular insulin use for the treatment of DKA among children with type one diabetes mellitus. Methods A retrospective cohort study was conducted among 224 DKA episodes which occurred in 161 children who were treated at St. Paul’s Hospital Millennium Medical College in Addis Ababa, Ethiopia, from November 2015 to November 2020. Results Majority (68.8%) of the episodes occurred in newly diagnosed cases. The median time for urinary ketones clearance was 24 h. DKA severity was found to be the only significant predictor of time to DKA resolution. Only 13 (5.8%) were treated at the pediatric intensive care unit (PICU), and 27 (12.1%) developed complications during management. No death or neurological complications observed. Conclusions The six-hourly subcutaneous regular insulin use was found to be safe and effective alternative to slow IV insulin infusion for the treatment of DKA in a non PICU setting. As it resulted in minimum morbidity and no mortality, we recommend its use in the treatment of DKA irrespective of its severity. It can also decrease the health care cost and patients’ inconvenience.

A randomized trial to investigate the efficacy and safety of insulin glargine in hyperglycemic acute stroke patients receiving intensive care

This pilot, randomized, open-label controlled study compared the basal–bolus regimens of insulin glargine (IG) and neutral protamine Hagedorn (NPH) insulin in stroke patients with hyperglycemia receiving intensive care. The study recruited acute stroke patients requiring intensive care within 72 h (h) of onset and had blood glucose > 200 mg/dL. 50 patients received IG (n = 26) or NPH (n = 24) with added short-acting prandial regular insulin over a 72-h period. The primary end point was the percentage of glucose within 80–180 mg/dL assessed through continuous glucose monitoring. The baseline characteristics were comparable, except the IG had higher glucose pre-randomization than the NPH (290.69 ± 82.31 vs. 246.04 ± 41.76 mg/dL, P = 0.021). The percentage of time with glucose between 80 and 180 mg/dL was 45.88 ± 27.04% in the IG and 53.56 ± 22.89% in the NPH (P = 0.341) and the percentage of glucose reduction was 31.47 ± 17.52% in the IG and 27.28 ± 14.56% in the NPH (P = 0.374). The percentage of time with glucose < 60 mg/dL was 0.14 ± 0.49% in the IG and 0.47 ± 1.74% in the NPH. Poststroke outcomes were not significantly different. In conclusion, IG is safe and equally effective as an NPH-based basal-bolus regimen for acute stroke patients with hyperglycemia receiving intensive care.Trial registration ClinicalTrials.gov, NCT02607943. Registered 18/11/2015, https://clinicaltrials.gov/ct2/show/NCT02607943.

Transportation of a commercial premixed intravenous insulin product through a pneumatic tube system

Purpose Delivery of insulin products via pneumatic tubes is often avoided in health systems, as agitation may cause insulin proteins to destabilize, resulting in loss of function through denaturation, aggregation, or other processes. The actual loss of potency due to delivery via pneumatic tubes has not been reported for new, ready-to-use insulin products. Methods Samples were drawn from 7 commercial intravenous (IV) bags containing a 100 units/100 mL premixed solution of regular insulin in sodium chloride injection (Myxredlin, Baxter). The bags were then exposed to 7 unique long-distance pneumatic tube routes. The post-transportation bags were visually inspected for evidence of foaming. Samples were drawn from the post-transportation bags and insulin concentrations were analyzed via an enzyme immunoassay and compared to pretransportation concentrations. Results All seven post-transportation insulin samples were within 10% of their respective pretransportation sample. No foaming was observed in any of the Myxredlin bags after transportation through the pneumatic tube system. Conclusion Transporting 100 unit/100 mL Myxredlin i.v. bags through a pneumatic tube system does not result in a clinically significant loss of potency. Therefore, delivery of this drug product via a pneumatic tube system to patient care areas can be considered in daily practice.

Hyperglycemia Requiring Insulin Among Pediatric Patients Diagnosed With Hemophagocytic Lymphohistiocytosis

Introduction: Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder marked by massive cytokine release due to macrophage and T-cell activation. Hallmarks of the diagnosis include fever, splenomegaly, cytopenias, hypertriglyceridemia, hypofibrinogemia, and elevations in ferritin and soluble IL-2 receptor. Given HLH is associated with critical illness, elevation in inflammatory markers, and treated with glucocorticoids, the development of hyperglycemia during its course is not unexpected. However, detailed descriptions of the severity of hyperglycemia and strategies in insulin management among HLH patients are lacking. We describe 10 years’ experience at a single tertiary pediatric health center with HLH patients who developed insulin dependent hyperglycemia. Objectives: To describe the demographics, clinical and laboratory findings, treatment regimens, and outcomes for children with HLH treated with insulin due to hyperglycemia. Study Design: Retrospective chart review from 2010 through 2019 of youth 0 to 21 years of age who required insulin therapy during or shortly after a hospitalization where they were diagnosed with HLH using established criteria. Descriptive statistics were used to characterize the population of interest. Results: Of 30 patients diagnosed with HLH, 33% (n=10) required insulin therapy. Half (n=5) were female and half (n=5) male. The mean age was 8.4 years (7.8 months - 17 years). The majority (80%) were non-Hispanic white. Mean BMI at admission was 53rd percentile (5th - 87th percentile). Max serum glucose ranged from 267 to 725 mg/dL (mean 421 mg/dL). Marked inflammation was present (max CRP 2.6 - 44.9 mg/dL, max ferritin 1,091 - 90,219 ng/mL). All were treated with dexamethasone, doses ranging from 5 to 11 mg/m2/day and duration from 2 to 70 days. Most (90%) received parenteral nutrition (PN) with a mean max GIR of 8 mg/kg/min (SD=2.7). Intravenous infusions of regular insulin were used in 80% of patients, though 2 patients were later transitioned to long and short acting subcutaneous insulin. Mean duration of IV insulin therapy was 9.5 days (2–24 days); however, 2 patients died while on IV insulin therapy. The majority (70%) needed insulin within 5 days of starting steroids. Two patients (20%) were treated with subcutaneous insulin only (no IV). Only 1 patient was discharged home on insulin therapy. Mean hospital stay was 60 days (10–202 days). Mortality was 50% (n=5). Conclusions: One-third of pediatric HLH patients required insulin during their hospitalization for severe hyperglycemia likely secondary to multiple factors including glucocorticoid use, parenteral nutrition, inflammation, and severe illness. Insulin is typically started within 5 days of initiating steroid therapy, limited to IV infusions, and often is not needed by the time of discharge. Risk of mortality is very high.

Characterization of Patients With Type 2 Diabetes Mellitus and COVID-19

The coronavirus is a pathogen that mainly attacks the human respiratory system Previous coronavirus outbreaks (CoV) include severe acute respiratory syndrome (SARS), the clinical spectrum of COVID19 is very broad ranging from mild symptoms to ARDS to multiple organ failure and death. A history of DM2, advanced age and other comorbidities are considered predictors of higher morbidity and mortality, it is also known that blood glucose and DM levels are independent predictors of morbidity and mortality in patients with SARS. It should be remembered that patients with DM2 suffer from a chronic low grade inflammation that could facilitate the cytokine storm which in turn would be the cause of severe cases of COVID 19 pneumonia and the eventual death of many patients. Glucocorticoids have a stimulating and inhibitory effect on the immune response according to the moment in which it is administered and its circulating levels insulin therapy has been shown to decrease inflammation. For the control of glycemia the objectives must be individualized. Glycemic and individualized targets for non critical hospitalized patients have been established by different scientific societies such as ADA and AACE and Endocrine Society. In Honduras the protocol for the clinical management of adult patients with COVID 19 was developed to establish and standardize timely treatment in patients with suspected or confirmed COVID 19 which consists of the MAIZ scheme and the MAIZ scheme AAA. A retrospective longitudinal descriptive study was carried out with a review of the data obtained from 32 patients diagnosed with DM2 and COVID19 during the months of June through September 2020 at the CAMI Comprehensive Medical Care Clinic located in the city of Tegucigalpa Honduras collecting epidemiological and clinical data. The results of the research show that of the 32 patients with DM2 and COVID 19, 59% (19) belong to the male gender and 41% (13) to the female gender, with an average age of 60 years. In the COVID19 severity classification the evaluated patients presented in the following condition mild 25% (8), moderate 69% (22) and severe 6% (2). The diagnostic method used was detection of anti SARS CoV2 antibodies 56% (17) and TR-PCR 43% (14). 75% (24) received steroids, 8.69% (2) of the patients who used steroids in their management had hyperglycemia and required management with regular insulin. 100% (32) of the patients who were treated recovered without registering any death. Conclusions: are that the pathophysiological factors of DM2 in relation to the immune system of patients can be a determining factor to present a degree of severity greater than that presented by the general population that falls ill with COVID19. Adequate glycemic control can determine a better prognosis in the evolution of the disease despite its degree of severity.