Insulin regimens for non‐critically ill hospitalised adults assessed

By Editor
7th December 2018

A study assessing the best insulin strategy for non‐critically hospitalised adults with diabetes has been unable to determine the most appropriate regimen.

Researchers investigated the effects of sliding scale insulin (SSI), which is currently the most commonly used method, for people with the condition in hospital but not critically ill due to uncertainty about which strategy provides the best outcomes.

The international study, published in the Cochrane Database of Systematic Reviews, looked at insulin therapy provided by different strategies, including SSI, basal‐bolus insulin and other modalities.

Investigators identified eligible trials by searching large databases as well as the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and trial registers.

They also examined reference lists of identified randomised controlled trials (RCT) and systematic reviews as well as contacted trial authors.

They included RCTs comparing SSI with other strategies for glycaemic control in non‐critically ill hospitalised adult participants of any sex with diabetes mellitus.

Two review authors independently extracted data, assessed trials for risk of bias and evaluated the overall certainty of evidence utilising the GRADE instrument. They then synthesised data using a random‐effects model meta‐analysis with 95% prediction intervals, if possible, or descriptive analysis, as appropriate.

Summarising the results, the researchers said: “Six trials compared SSI with a basal‐bolus insulin scheme, three of which investigating 64% of all participants in this category also applying an SSI approach in the bolus comparator part. One trial had a basal insulin‐only comparator arm, and the remaining trial used continuous insulin infusion as the comparator. For our main comparison of SSI versus basal‐bolus insulin, the results were as follows. Four trials reported mortality data. One out of 268 participants in the SSI group (0.3%) compared with two out of 334 participants in the basal‐bolus group (0.6%) died (low‐certainty evidence). Severe hypoglycaemic episodes, defined as blood glucose levels below 40 mg/dL (2.2 mmol/L), showed a risk ratio (RR) of 0.22, 95% confidence interval (CI) 0.05 to 1.00; P = 0.05; 5 trials; 667 participants; very low‐certainty evidence.

“The 95% prediction interval ranged between 0.02 and 2.57. All nine severe hypoglycaemic episodes were observed among the 369 participants on basal‐bolus insulin (2.4%). The mean length of hospital stay was 0.5 days longer for the SSI group, 95% CI ‐0.5 to 1.4; P = 0.32; 6 trials; 717 participants; very low‐certainty evidence. The 95% prediction interval ranged between ‐1.7 days and 2.7 days. Adverse events other than hypoglycaemic episodes, such as postoperative infections, showed a RR of 1.16, 95% CI 0.25 to 5.37; P = 0.85; 3 trials; 481 participants; very low‐certainty evidence. The mean blood glucose levels ranged across basal‐bolus groups from 156 mg/dL (8.7 mmol/L) to 221 mg/dL (12.3 mmol/L). The mean blood glucose level in the SSI groups was 14.8 mg/dL (0.8 mmol/L) higher (95% CI 7.8 (0.4) to 21.8 (1.2); P < 0.001; 6 trials; 717 participants; low‐certainty evidence). The 95% prediction interval ranged between ‐3.6 mg/dL (‐0.2 mmol/L) and 33.2 mg/dL (1.8 mmol/L). No trial reported on diabetes‐related mortality or socioeconomic effects.”

Researchers from Canada’s McMaster University, Hospital Civil de Guadalajara in Mexico, Hospital Universitario 12 de Octubre and Institute of Biomedical Research Sant Pau both in Spain as well as University of Connecticut based in America too part in the study.

They concluded: “We are uncertain which insulin strategy (SSI or basal‐bolus insulin) is best for non‐critically hospitalised adults with diabetes mellitus. A basal‐bolus insulin strategy in these patients might result in better short‐term glycaemic control but could increase the risk for severe hypoglycaemic episodes.

“The certainty of the body of evidence comparing SSI with basal‐bolus insulin was low to very low and needs to be improved by adequately performed, well‐powered RCTs in different hospital environments with well‐educated medical staff using identical short‐acting insulins in both intervention and comparator arms to compare the rigid SSI approach with flexible insulin application strategies.”

To access the study, click here.

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