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ORIGINAL ARTICLE
Year : 2021  |  Volume : 19  |  Issue : 1  |  Page : 8-11

Evidence generation for postprandial Insulin administration for better management of diabetes in noncritically iII patients


Department of Medicine, SBKS MIRC, Sumandeep Vidyapeeth, Vadodara, Gujarat, India

Date of Submission29-Jun-2020
Date of Decision29-Jul-2020
Date of Acceptance10-Aug-2020
Date of Web Publication13-Jan-2021

Correspondence Address:
Dr. Divya Lalwani
Sumandeep Vidyapeeth Medical Institute and Research Centre, Waghodiya, Vadodara - 391 760, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_107_20

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  Abstract 


Introduction: Previously, premeal sliding scale insulin regimen was used to control sugar levels in hospitalized type-2 diabetes patients. However, the now recommended basal-bolus regimen also failed to show any substantial advantage over the traditional sliding scale regimen in the latest Cochrane review. Methodology: In this retrospective cohort study, data were collected from two groups of patients who received basal with premeal bolus regimen and those who received modified sliding scale regimen (basal with both pre- and lower dose postprandial insulin by sliding scale). The data collected were analyzed to compare the mean reduction in blood glucose level, number of hypoglycemic episodes, and mean hospital stay among the two groups. Results: A total of forty patients were included in the study. Twenty received basal with both pre- and postprandial insulin correction by sliding scale and other twenty received basal insulin with postmeal bolus correction regimen. The mean hospital stay in sliding scale with postprandial insulin correction was 3.9 ± 2.2 days, and in other group, it was 6.1 ± 4.47 days. Two out of twenty patients in the sliding scale with postprandial insulin group, whereas six out of twenty patients in the other group had hypoglycemic events. Conclusion: Basal with both pre- and postmeal (low dose) insulin by sliding scale might be an answer to the concerns of faster attainment of euglycemia in hospitalized type-2 diabetes patients with minimal risk of hypoglycemia. We plan a prospective study with a larger sample size to substantiate the evidence.

Keywords: Diabetes mellitus, noncritically ill in patients, postprandial insulin, type-2 diabetes


How to cite this article:
Lalwani D, Muley A, Mahida H. Evidence generation for postprandial Insulin administration for better management of diabetes in noncritically iII patients. Curr Med Issues 2021;19:8-11

How to cite this URL:
Lalwani D, Muley A, Mahida H. Evidence generation for postprandial Insulin administration for better management of diabetes in noncritically iII patients. Curr Med Issues [serial online] 2021 [cited 2021 Jan 15];19:8-11. Available from: https://www.cmijournal.org/text.asp?2021/19/1/8/306928




  Introduction Top


Prompt euglycemia is required in patients hospitalized for uncontrolled type-2 diabetes.[1],[2] Sliding scale insulin (SSI) is now discouraged because of hypoglycemia and inefficacy.[3],[4],[5] The basal-bolus regimen also failed to show a substantial advantage over SSI in the latest Cochrane review.[6]

In uncontrolled type-2 diabetes, we have been using basal with both pre- and postmeal insulin bolus by sliding scale and observed that the euglycemic state was achieved faster with lesser hypoglycemia. This study was done to assess the effect of basal with both pre- and postmeal bolus insulin by sliding scale in controlling blood glucose in hospitalized type-2 diabetes patients.

Aims and objectives

The aim was to compare the effect of basal-bolus insulin regimen with sliding scale pre- and postmeal insulin regimen in noncritically ill type-2 diabetic hospitalized patients with regard to the duration of hospital stay, number of hypoglycemic events, and 24 h fluctuation of blood sugar.


  Methodology Top


This study was a retrospective cohort study conducted from September 2019 to February 2020 in a tertiary care hospital after getting approval from the institutional ethics committee.

Inclusion criteria

Patients aged 18 years and above who had been admitted to the general medicine ward with diagnosis of type-2 diabetes mellitus (DM) who had been treated with either basal with sliding scale regimen (with pre- and postmeal insulin correction) or basal-bolus insulin regimen with only premeal insulin correction were included in the study.

Exclusion criteria

Critically ill patients requiring intensive care unit admission, patients with type I diabetes, acute hyperglycemia treated with intravenous insulin infusion on hospital admission, and patients on corticosteroid therapy were all excluded from the study.

The following data were collected from the records: first random blood sugar reading of the patients, the regimen suggested, five times sugar levels daily: fasting, prelunch, 2 h postlunch, predinner, and 2 h postdinner, and days to achieve the euglycemic state. The data thus collected were divided in two groups according to the insulin regimen given: one group which received basal insulin with both pre- and postprandial insulin correction and other group which received basal insulin with premeal insulin correction only. To avoid hypoglycemia, the postmeal insulin given was four units lesser than that according to the sliding scale for premeal insulin. The data collected were analyzed with regard to four main outcomes: duration to control blood sugar, duration of hospital stay, number of hypoglycemic events during the hospital stay, and 24 h fluctuation in blood sugar level on days 1, 2, and 3 of hospital admission. This was a descriptive study, hence descriptive statistics were used. Values of mean ± standard deviation and range are given as per the indication. The statistics were done using Microsoft Excel 2007.


  Results Top


A total of forty patients were included in the study; out of which, twenty patients (50%) received basal-bolus insulin regimen with pre- and postprandial insulin (in low dose) correction according to sliding scale and twenty patients (50%) received basal-bolus insulin regimen with only premeal insulin correction. The baseline characters of the two groups were similar [Table 1].
Table 1: Baseline characteristics of the study groups

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Duration to achieve euglycemic state

The duration to control blood glucose was shorter by almost 2 days in patients on sliding scale pre- and postmeal insulin than in patients on basal-bolus regimen with only premeal correction [Table 2].
Table 2: Duration to achieve euglycemic state

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The number of hypoglycemic events was much less in the patients on sliding scale regimen with pre- and postmeal insulin correction as compared with the patients on basal-bolus regimen with only premeal insulin [Table 3]. The duration of hospital stay was also shorter in the patients on sliding scale with pre- and postmeal insulin as compared with the patients on basal-bolus regimen with premeal insulin [Table 4]. Fluctuation in blood sugar level on days 1, 2, and 3 of hospital admission was similar in the two groups [Table 5].
Table 3: Number of hypoglycemic events during hospital stay

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Table 4: Duration of hospital stay

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Table 5: Fluctuation in blood glucose

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  Discussion Top


DM is a metabolic disorder resulting from a defect in insulin secretion, function, or both.[6] It is the most common chronic disease in low-, middle-, and high-income countries. It is estimated that in 2030, diabetes prevalence will be 4.4% (for all age groups), affecting approximately 366 million people worldwide.[7],[8]

Type-2 diabetes is characterized by a variable degree of insulin resistance and deficiency. To prevent long-term morbidity and mortality, such patients eventually require insulin therapy.[9] Insulin therapy is also required to control the sugar level in hospitalized patients. It is important to achieve a prompt euglycemic state in patients hospitalized for uncontrolled DM or preoperative patients with uncontrolled diabetes.[1],[2] Strategies used to achieve glycemic control in hospitalized diabetics are basal-bolus insulin (recommended) and SSI. SSI, sometimes called correctional insulin, is an intervention characterized by a subcutaneous administration of regular or rapid-acting insulin analogs before each meal by a predefined sliding scale depending upon the blood sugar level.[1],[2] Once the most frequently used therapies for the metabolic control of diabetic inpatients, SSI is now discouraged because of two main reasons:[3] (1) Increased incidence of hypoglycemia. (2) It does not resemble physiological insulin secretion. Several nonsystematic review articles addressed the SSI scheme[4],[5] and found that this strategy may be associated with poor glycemic control causing more complications (higher infection rate, increased mortality, and prolonged hospital stay).

The recommended basal-bolus regimen involves taking a longer acting form of insulin to keep blood glucose levels stable through periods of fasting and separate injections of shorter acting insulin to prevent rises in blood glucose levels resulting from meals.[10] However, the recommended basal-bolus regimen also failed to show substantial advantage over the traditional sliding scale regimen in the latest Cochrane review.[6]

DM is the most common chronic disease in low-, middle-, and high-income countries.[7],[8] Given the potential public health relevance, we did this study to find an easy solution to the problem, i.e., post prandial also (in lower dose) as compared to only premeal insulinby sliding scale to gain faster control with no increased risk of hypoglycemia. From our study, the duration to control blood sugar and thereby the duration of hospital stay were considerably shorter in patients on SSI with both pre- and postmeal correction. The number of hypoglycemic events was also less in patients who were given both pre- and postmeal sliding scale regimen as compared with only premeal correction regimen.

Previously, six trials reported data on length of hospital stay[11],[12],[13],[14],[15],[16] where the mean length of hospital stay in the SSI group was longer than that in the basal-bolus regimen, however none of them had used postprandial correction along with premeal. Five trials reported on severe hypoglycemic episodes[12],[13],[14],[15],[16] showed a higher incidence of hypoglycemia in patients on basal-bolus regimen as seen in this study. Six trials reported on the mean glucose level during hospital stay[11],[12],[13],[14],[15],[16] showed that the mean blood glucose level in the SSI groups was 14.8 mg/dL (0.8 mmol/L) higher than the basal-bolus regimen groups. In these trials also, only premeal correction was given.

Thus, this study shows the advantage of postmeal correction added to premeal correction in terms of time to achieve euglycemia, duration of hospital stay, and number of hypoglycemic events. However, this was a pilot study with small sample size. Hence, a Randomised control trial (RCT) with appropriate sample size is warranted to confirm the findings.


  Conclusion Top


Basal with both pre- and postmeal (low dose) bolus insulin by sliding scale might be an answer to the concerns of faster attainment of euglycemia in hospitalized type-2 diabetes patients with minimal risk of hypoglycemia.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require the Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is IRB Min no: SVIEC/ON/Medi/SRP/20023. We also certify that we have not plagiarized the contents in this submission and have done a plagiarism check.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Umpierrez GE, Hellman R, Korytkowski MT, Kosiborod M, Maynard GA, Montori VM, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: An endocrine society clinical practice guideline. J Clin Endocrinol Metab 2012;97:16-38.  Back to cited text no. 1
    
2.
Lien LF, Cox ME, Feinglos MN, Corsino. Glycemic control in the hospitalized patient. In: Lien LF, Cox ME, Feinglos MN, Corsino L, editors. New York: Springer Science Business Media, LLC, Springer New York; 2011. p. 1-45.  Back to cited text no. 2
    
3.
Lee YY, Lin YM, Leu WJ, Wu MY, Tseng JH, Hsu MT, et al. Sliding-scale insulin used for blood glucose control: A meta-analysis of randomized controlled trials. Metabolism 2015;64:1183-92.  Back to cited text no. 3
    
4.
Umpierrez GE, Palacio A, Smiley D. Sliding scale insulin use: Myth or insanity? Am J Med 2007;120:563-7.  Back to cited text no. 4
    
5.
Bellido V, Suarez L, Rodriguez MG, Sanchez C, Dieguez M, Riestra M, et al. Comparison of basal-bolus and premixed insulin regimens in hospitalized patients with type 2 diabetes. Diabetes Care 2015;38:2211-6.  Back to cited text no. 5
    
6.
Colunga-Lozano LE, Gonzalez Torres FJ, Delgado-Figueroa N, Gonzalez-Padilla DA, Hernandez AV, Roman Y, et al. Sliding scale insulin for non-critically ill hospitalised adults with diabetes mellitus. Cochrane Database Syst Rev 2018;11:CD011296.  Back to cited text no. 6
    
7.
Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: Global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract 2011;94:311-21.  Back to cited text no. 7
    
8.
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.  Back to cited text no. 8
    
9.
McCarthy MI. Genomics, type 2 diabetes, and obesity. N Engl J Med 2010;363:2339-50.  Back to cited text no. 9
    
10.
Miller DB. Why won't the sliding scale go away? Can J Diabetes 2011;35:340-3.  Back to cited text no. 10
    
11.
Korytkowski MT, Salata RJ, Koerbel GL, Selzer F, Karslioglu E, Idriss AM, et al. Insulin therapy and glycemic control in hospitalized patients with diabetes during enteral nutrition therapy: A randomized controlled clinical trial. Diabetes Care 2009;32:594-6.  Back to cited text no. 11
    
12.
Said E, Farid S, Sabry N, Fawzi M. Comparison on efficacy and safety of three inpatient insulin regimens for management of non-critical patients with type 2 diabetes. Pharmacol Pharm 2013;4:556.  Back to cited text no. 12
    
13.
Schroeder JE, Liebergall M, Raz I, Egleston R, Ben Sussan G, Peyser A, et al. Benefits of a simple glycaemic protocol in an orthopaedic surgery ward: A randomized prospective study. Diabetes Metab Res Rev 2012;28:71-5.  Back to cited text no. 13
    
14.
Umpierrez GE, Smiley D, Zisman A, Prieto LM, Palacio A, Ceron M, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care 2007;30:2181-6.  Back to cited text no. 14
    
15.
Umpierrez GE, Smiley D, Jacobs S, Peng L, Temponi A, Mulligan P, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care 2011;34:256-61.  Back to cited text no. 15
    
16.
Umpierrez GE, Smiley D, Hermayer K, Khan A, Olson DE, Newton C, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: Basal plus trial. Diabetes Care 2013;36:2169-74.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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