Glycemic control with a basal-bolus insulin protocol in hospitalized diabetic patients treated with glucocorticoids: a retrospective cohort study

Abstract

BackgroundImproved glycemic control is the desired outcome after the discharge of patients with diabetes. We aimed to determine the efficacy of a basal-bolus insulin protocol in hospitalized patients with diabetes treated with glucocorticoids.MethodsA retrospective cohort study compared the glycemic control of 150 hospitalized patients with diabetes and elevated inflammatory markers who were either treated with (n = 61) or without glucocorticoids (n = 89). All patients were treated with a basal-bolus regimen.ResultsGlycosylated hemoglobin A1C (HbA1C) levels, mode of diabetes treatment before admission, length of hospitalization and inflammatory markers were similar in both groups of patients (treated and untreated with glucocorticoid). There was a trend toward female predominance in the glucocorticoid-treated group. Mean daily glucose levels were higher in patients taking glucocorticoids when compared with untreated patients (12.5 ± 2.7 mmol/l vs. 10.9 ± 2.4 mmol/l, p < .0001), and significantly higher at 5:00 PM (13.1 ± 3.4 vs. 10.2 ± 3 mmol/l, p < .0001), and 8:00 P.M. (13.9 ± 4.1 mmol/l vs. 11 ± 3.1 mmol/l, p < 0.001) . No difference was detected between the two groups in prandial and basal insulin doses during hospitalization. Overall, 64% of patients in the glucocorticoid-treated group versus 39% in the untreated group had inadequate glycemic control during hospitalization (p = 0.003).ConclusionA significantly higher percentage of patients with diabetes who were treated with glucocorticoids during hospitalization did not achieve glycemic control with a basal-bolus insulin protocol. These patients had significantly higher mean blood glucose levels due to elevated levels in the afternoon and evening. New basal-bolus protocols with appropriate adjustments of short acting insulin are needed to treat patients with diabetes on glucocorticoid therapy.

Incidence and control of steroid-induced hyperglycaemia in hospitalised patients at a tertiary care centre for lung diseases

“…We conclude that in the large majority of patients, particularly in the group with pre-existing DM, SIH control could have been optimised, either by adjusting insulin dosing more promptly, or potentially changing antidiabetic regimen. Undertreatment of SIH has been a recognised issue also in previous studies [ 19 ]. A hospital protocol for the treatment of SIH has been developed at the University Clinic Golnik during the study, which may improve SIH control in the future (Supplementary Fig.…”

“…In previous studies, average BG levels, and, in some cases, hypoglycaemic events, were used to assess SIH control [ 19 , 29 , 30 ], which in our opinion do not necessarily demonstrate adequate management of hyperglycaemia. A patient with a mean BG level within the reference range might have had elevated BG levels on some readings and normoglycaemic or even hypoglycaemic levels on others.…”

“…Three types of SIH can be distinguished, namely exacerbation of an existing type 2 diabetes mellitus (DM), newly discovered DM, and transient hyperglycaemia in patients without pre-existing DM [ 17 , 18 ]. With a morning daily dose of GC, SIH occurs more frequently in the afternoon and evening hours, followed by a gradual decrease in overnight BG levels [ 4 , 16 , 19 – 21 ]. Its onset is usually within the first week of treatment with GC, but it can also occur 2–4 weeks after starting GC [ 17 , 22 ].…”

“…The risk for SIH increases with higher dose of GC and longer duration of treatment, but does not depend on the type of GC, taking equivalent doses into account [ 14 , 19 , 23 ]. Other factors associated with SIH include pre-existing DM, impaired fasting glycaemia or glucose tolerance, family history of DM, previous gestational diabetes, obesity, polycystic ovarian disease, advanced age, elevated C-reactive protein levels and the Charlson Comorbidity Index [ 14 , 18 ].…”

“…Other factors associated with SIH include pre-existing DM, impaired fasting glycaemia or glucose tolerance, family history of DM, previous gestational diabetes, obesity, polycystic ovarian disease, advanced age, elevated C-reactive protein levels and the Charlson Comorbidity Index [ 14 , 18 ]. Existing data regarding the influence of these factors on SIH control is very limited [ 19 ].…”