Journal Watch Summary:
In
non–critically ill hospitalized patients, a single daily dose of basal
insulin plus corrective short-acting doses was equivalent to basal bolus
insulin therapy.
Randomized, controlled
trials in patients admitted to general medical and surgical services
have shown that a basal bolus insulin regimen results in superior
glycemic control and fewer complications than does
sliding scale insulin (SSI; JW Hosp Med Apr 4 2011).
Accordingly, in a recent consensus guideline,
experts recommended that clinicians adopt the basal bolus regimen as the
preferred approach in non–critically ill hospitalized patients (JW
Hosp Med Apr 4 2011). However, some clinicians have been reluctant
to use this approach because of its complexity and their fear of
inducing hypoglycemia.
In a U.S. multicenter
trial, researchers randomized 375 hospitalized patients with type 2
diabetes to one of three insulin regimens:
- Basal bolus regimen with glargine given once daily and glulisine given before meals, plus additional corrective glulisine SSI as needed for BS > 140 ( total daily dose (TDD) of 0.5 units/kg divided with half as insulin glargine once daily and half as insulin glulisine be-fore meals)*
- Basal plus regimen with glargine given once daily, plus corrective glulisine SSI before meals as needed for BS > 140 (0.25 units/kg of glargine plus corrective doses of glulisine before meals)*
- Regular SSI alone for BS > 140
- The goal of insulin therapy was to maintain fasting and premeal glucose concentrations between 100 and 140 mg/dL
- Insulin protocol available at: http://care.diabetesjournals.org/content/suppl/2013/02/19/dc12-1988.DC1/DC121988SupplementaryData.pdf
The basal plus regimen
resulted in glycemic control similar to that with the basal bolus
regimen, and both were superior to SSI alone. Hypoglycemia (blood
glucose level, <70 mg/dL) occurred in 16%, 13%, and 3%
of patients in the basal bolus, basal plus, and SSI groups,
respectively. However, rates of severe hypoglycemia (blood glucose
level, <40 mg/dL) were <1% in all three groups.
Excluded: history of hyper-glycemic crises, patients with hyperglyce-mia without a known history of diabetes, patients admitted to or expected to re-quire ICU admission, patients undergo-ing cardiac surgery, patients receiving corticosteroid therapy, patients with clinically relevant hepatic disease or impaired renal function (serum creatinine >3.0 mg/dL), patients with a history of diabetic ketoacidosis, pregnancy.
Comment:
Although this study was not powered to evaluate hospital complications,
it gives the practicing clinician another viable approach for treating
type 2 diabetes in non–critically ill hospitalized
patients. Clinicians now have the option of "basal plus," which seems to
be just as effective as "basal bolus," but is less complex and easier
to implement.