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

Umpierrez et al. Diabetes Care 2013 Feb 22
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:

1. 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)*
2. 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)*
3. 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

* In patients >70 years of age and those with a serum creatinine >2.0 mg/dL, the starting TDD in the basal bolus group was reduced to 0.3 units/kg in the basal bolus, and TDD of glargine reduced to 0.15 units/kg in the basal plus regimen.

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.

Blood glucose control for ICU patients

NEJM Article (Sept 20, 2012)

Hypoglycemia and Risk of Death in Critically Ill Patients

In critically ill patients, intensive glucose control leads to moderate and severe hypoglycemia, both of which are associated with an increased risk of death. 

Understanding Low Sugar from NICE-SUGAR (Commentary):

Given the current stage of evolution in inpatient insulin therapy, what are the best glucose targets for patients admitted to the ICU? In many hospitals, maintaining blood glucose at levels similar to those in the conventional-control group of the NICE-SUGAR population is safe and similar to other recommendations (140 to 180 mg per deciliter).

Key Points:

• ICU patients were randomized to intensive (target BS 81-108 mg/dL) vs conventional (target BS 180 mg/dL) blood glucose control.
• Mean BS in intensive control gp = 115 mg/dL vs conventional gp = 144 mg/dL
• Intensive control gp had 2.6% absolute increased risk of death in 90d vs conventional gp (NNH = 38). 
• Moderate hypoglycemia (blood glucose level, 41–70 mg/dL) was significantly more common in the intensive-control group than in the conventional control group (74% vs. 16%). 
• Almost all (93%) of the 223 patients who experienced severe hypoglycemia (blood glucose level <40 mg/dL) were in the intensive-control group. 
• Hypoglycemia was associated with longer ICU stay, longer hospital stay, and mortality. 
• Patients with worse outcomes included those who experienced more than one episode of hypoglycemia and those with severe hypoglycemia despite not having received insulin (reflecting that hypoglycemia can result from severe illness). 
• The adjusted hazard ratios for death were 1.41 in patients with moderate hypoglycemia and 2.10 in patients with severe hypoglycemia.