Managing hyperglycemia and diabetes in patients receiving enteral feedings: A health system approach

Abstract

Evidence of poor outcomes in hospitalized patients with hyperglycemia has led to new and revised guidelines for inpatient management of diabetes. As providers become more aware of the need for better blood glucose control, they are finding limited guidance in the management of patients receiving enteral nutrition. To address the lack of guidelines in this population, Duke University Health System has developed a consistent practice for managing such patients. Here, we present our practice strategies for insulin use in patients receiving enteral nutrition. Essential factors include assessing the patients’ history of diabetes, hyperglycemia, or hypoglycemia and timing and type of feedings. Insulin practices are then designed to address these issues keeping in mind patient safety in the event of abrupt cessation of nutrition. The outcome of the process is a consistent and safe method for glucose control with enteral nutrition.

Management of hospitalized type 2 diabetes mellitus patients

“…[28] However, there is only a prospective study that has compared the effectiveness and risk of hypoglycemia between basal insulin versus sliding-scale regular insulin, and showed that use of sliding-scale regular insulin is not sufficient in most diabetics and requires addition of NPH insulin. For that, the early addition of glargine or NPH insulin is secure and useful, and it is preferred over slidingscale regular insulin isolated.…”

“…[32][33][34] Another approach is to use sliding-scale regular insulin regimens. [28] Brought to you by | MIT Libraries Authenticated Download Date | 5/12/18 7:15 AM…”

“…[35] There are a lot of strategies in insulin treatment for managing hyperglycemia in patients with enteral nutrition and it is important to individualize each case keeping in mind the type and amount of nutrition, previous and recent blood glucose control. Sliding-scale regular insulin can be an initial option in some patients, [28] but the addition of basal insulin is necessary in the majority of diabetic patients. [35] In conclusion, with continuous enteral nutrition, a good management technique can be to administer a basal insulin once daily (glargine, determir) or twice a day (determir/ NPH) together with a rapid-acting insulin in divided dose every 4 hours or preferably, for less injections, a regular insulin divided dose every 6 hours.…”

“…Hospitalization produces insulin resistance and together with delivery of glucose and gluconeogenic substrates via enteral contribute to hyperglycemia. [28,30] Hyperglycemia can be treated with the use of diabeticspecific formulas and different insulin regimens. Although some institutions do not have recommendations about this, [31] diabetic-specific formulas have been suggested in patients with persistent hyperglycemia.…”

“…However, there is little literature available with specific recommendations for this situation. [28] Enteral nutrition: Enteral nutrition increases the risk of hyperglycemia in hospitalized T2DM patients. Before beginning enteral nutrition, it is important to know the metabolic status, previous control of diabetes, and insulin requirements.…”