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For glucose control, balance is key

An expert offers tips on finding the right insulin combination

By Jennifer Kearney-Strouse

From the July ACP Hospitalist, copyright © 2008 by the American College of Physicians

Although tight glucose control is considered a quality measure in hospitalized patients, some of the data to support it are conflicting and the evidence of its benefit outside the intensive care unit (ICU) is lacking, according to Stephen Clement, MD. At his Internal Medicine 2008 session “Diabetes and Hospitalization: The Evidence for New Inpatient Glucose Targets,” Dr. Clement, associate professor at Georgetown University Hospital in Washington, D.C., reviewed the available studies and offered practical tips for controlling blood glucose in the hospital.

Two trials by Van den Berghe and colleagues, published in the New England Journal of Medicine in 2001 and 2005, found that meticulous blood glucose control reduced risk of poor outcomes in the ICU. But no randomized, controlled trials have been performed outside the ICU, Dr. Clement said. In addition, a study by Brunkhorst and colleagues published in the New England Journal of Medicine this year found that intensive insulin therapy increased hypoglycemia-related adverse events in critically ill patients with severe sepsis.

So what should clinicians do while they’re waiting for new data? The best they can, Dr. Clement said.

“Try to keep some kind of a balance,” he recommended. “Part of what we’re learning here is that technically doing these insulin drips and keeping the sugars at 110 [mg/dL] without causing hypoglycemia is really really hard.”

According to Dr. Clement, patients most likely to be insulin deficient and to require basal insulin in the hospital include those with:

• Known type 1 diabetes mellitus;
• A history of pancreatectomy or pancreatic dysfunction;
• A history of wide fluctuations in blood glucose values; and
• A history of insulin use for more than five years.

“The reason [sliding scale] doesn’t work by itself is because it treats things after the event. I consider sliding-scale alone as very sloppy management.” —Stephen Clement, MD

One of the points Dr. Clement stressed most strongly was the danger of relying on sliding-scale insulin, which he said should be considered just a small piece of the overall puzzle. “The reason [sliding scale] doesn’t work by itself is because it treats things after the event,” Dr. Clement said. “I consider sliding-scale alone as very sloppy management.”

With increases in the daily insulin requirement attributed to illness, stress or treatment, patients’ needs will vary widely by individual, Dr. Clement noted. “You just have to look at the sugars every day and make daily adjustments either upwards or downwards,” he said. Physicians should also remember that patients’ insulin needs will decrease as their clinical condition improves, Dr. Clement said.

All insulin regimens use the same basic matrix, according to Dr. Clement. Programmed insulin is divided into basal insulin or nutritional insulin. Basal insulin can be given as neutral protamine Hagedorn insulin (NPH) or as long-acting insulin analogues; Dr. Clement recommended the latter because they don’t peak and they last longer. Long-acting insulin analogues should be used for supplemental insulin as well, Dr. Clement said.

For enteral nutrition, physicians can use short-acting insulin as a dose-finding regimen, Dr. Clement said. In patients on continuous enteral regimens, he advised giving half the insulin as basal insulin and half as regular insulin every four to six hours during the feeding period; with bolus enteral regimens, he advised giving half as basal and half as regular insulin.

“This gives the nurse at the bedside the flexibility that they can hold a dose,” he said.

For patients receiving total parenteral nutrition, Dr. Clement recommended using a separate IV insulin infusion for 24 hours to determine the daily insulin requirement, then adding approximately 80% of that amount to the next bag. However, a reduced dose may be appropriate if the patient is prone to hypoglycemia or if his or her health status is improving, he noted.

In cases where physicians are transitioning a patient from IV to subcutaneous insulin, Dr. Clement offered the following do’s and don’ts:

• Do overlap subcutaneous and IV insulin by at least two to three hours to minimize “hyperglycemia escape.”
• Don’t switch to oral agents alone from IV insulin.
• Do arrange for follow-up of patients who have never been on insulin before.
• Do ensure adequate food intake when switching patients to subcutaneous insulin.

Dr. Clement stressed that inpatient glucose control is a team effort that requires education of physicians, nurses and patients.

“Keep in mind how big this whole operation is,” he said. “Everyone needs to be involved: you as the hospitalist, your surgery colleagues, the pharmacist, the dietitian, the nurse. But keep in mind that the patient is always at the center of the whole team.”

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated