Comparison of Basal-Bolus and Premixed Insulin Regimens in Hospitalized Patients With Type 2 Diabetes

Abstract

OBJECTIVEPremixed insulin is a commonly prescribed formulation for the outpatient management of patients with type 2 diabetes. The safety and efficacy of premixed insulin formulations in the hospital setting is not known.RESEARCH DESIGN AND METHODSIn a prospective, open-label trial, we randomized general medicine and surgery patients to receive a basal-bolus regimen with glargine once daily and glulisine before meals (n = 33) or premixed human insulin (30% regular insulin and 70% NPH insulin) twice daily (n = 39). Major outcomes included differences in daily blood glucose (BG) levels and frequency of hypoglycemic events (<70 mg/dL) between treatment groups.RESULTSAt the first prespecified interim analysis, the study was stopped early because of an increased frequency of hypoglycemia >50% in patients treated with premixed human insulin. A total of 64% of patients treated with premixed insulin experienced one or more episodes of hypoglycemia compared with 24% in the basal-bolus group (P < 0.001). There were no differences in mean daily BG level after the first day of insulin treatment (175 ± 32 vs. 179 ± 43 mg/dL, P = 0.64) between groups. A BG target between 80 and 180 mg/dL before meals was achieved in 55.9% of BG readings in the basal-bolus group and 54.3% of BG readings in the premixed insulin group (P = 0.23). There was no difference in the length of hospital stay or mortality between treatment groups.CONCLUSIONSInpatient treatment with premixed human insulin resulted in similar glycemic control but in significantly higher frequency of hypoglycemia compared with treatment with basal-bolus insulin regimen in hospitalized patients with diabetes.

Perioperative Hyperglycemia Management

“…62 NPH and regular insulin, or premixed (70/30) formulations, demonstrate equivalent blood glucose control when compared to basal bolus regimens, but are associated with higher rates of hypoglycemia in patients with poor oral intake. 64,65 …”

Comparison of Efficacy and Safety of Glargine and Detemir Insulin in the Management of Inpatient Hyperglycemia and Diabetes

“…The results of several randomized controlled trials have shown that treatment with basal-bolus regimens with insulin analogs improves glycemic control and reduces the rate of hospital complications in patients with T2D compared to sliding-scale insulin regimens (9–11). In addition, the use of basal insulin analogs results in similar glycemic control but in lower rates of hypoglycemia in hospitalized patients with type 1 and type 2 diabetes compared to treatment with NPH (12, 23) and premixed insulin formulations (14). Based on these studies, the use of basal insulin analogs -glargine and detemir- has become the preferred insulin formulations in the hospital setting.…”

“…Several randomized controlled trials using subcutaneous basal-bolus insulin regimens have reported better glycemic control and reduction of complications with this approach compared to sliding-scale insulin in patients with type 2 diabetes (9–11). Insulin glargine and detemir are the most commonly used basal insulin formulations, and have been associated with lower glycemic variability and less severe hypoglycemia compared to neutral protamine hagedorn insulin (NPH) or premixed insulin formulations (12–14). …”

14. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2018

“…While there is evidence for using premixed insulin formulations in the outpatient setting (32), a recent inpatient study of 70/30 NPH/regular insulin versus basal-bolus therapy showed comparable glycemic control but significantly increased hypoglycemia in the group receiving premixed insulin (33). Therefore, premixed insulin regimens are not routinely recommended for in-hospital use.…”