OBJECTIVE -We sought to study the optimal management of hyperglycemia in nonintensive care unit patients with type 2 diabetes, as few studies thus far have focused on the subject.RESEARCH DESIGN AND METHODS -We conducted a prospective, multicenter, randomized trial to compare the efficacy and safety of a basal-bolus insulin regimen with that of sliding-scale regular insulin (SSI) in patients with type 2 diabetes. A total of 130 insulin-naive patients were randomized to receive glargine and glulisine (n ϭ 65) or a standard SSI protocol (n ϭ 65). Glargine was given once daily and glulisine before meals at a starting dose of 0.4 units ⅐ kg Ϫ1 ⅐ day Ϫ1 for blood glucose 140 -200 mg/dl or 0.5 units ⅐ kg Ϫ1 ⅐ day Ϫ1 for blood glucose 201-400 mg/dl. SSI was given four times per day for blood glucose Ͼ140 mg/dl. RESULTS -The mean admission blood glucose was 229 Ϯ 6 mg/dl and A1C 8.8 Ϯ 2%. A blood glucose target of Ͻ140 mg/dl was achieved in 66% of patients in the glargine and glulisine group and in 38% of those in the SSI group. The mean daily blood glucose between groups ranged from 23 to 58 mg/dl, with an overall blood glucose difference of 27 mg/dl (P Ͻ 0.01). Despite increasing insulin doses, 14% of patients treated with SSI remained with blood glucose Ͼ240 mg/dl. There were no differences in the rate of hypoglycemia or length of hospital stay.CONCLUSIONS -Treatment with insulin glargine and glulisine resulted in significant improvement in glycemic control compared with that achieved with the use of SSI alone. Our study indicates that a basal-bolus insulin regimen is preferred over SSI in the management of non-critically ill, hospitalized patients with type 2 diabetes. Diabetes Care 30:2181-2186, 2007H yperglycemia in hospitalized patients is a common, serious, and costly health care problem with profound medical consequences. Increasing evidence indicates that the development of hyperglycemia during acute medical or surgical illness is not a physiologic or benign condition but is a marker of poor clinical outcome and mortality (1-3). Extensive evidence from observational studies, including our own, indicates that in hospitalized patients with critical illness, hyperglycemia is associated with an increased risk of complications and mortality (3-9). Prospective randomized trials in critically ill patients have shown that intensive glucose control reduces the risk of multiorgan failure, systemic infections, and short-and longterm mortality. Effective management of hyperglycemia is also associated with a decreased length of intensive care unit and hospital stay (4,6,8 -10) and decreased total hospitalization cost (11). The importance of glycemic control on outcome is not limited to patients in critical care areas but also applies to patients admitted to general surgical and medical wards. In such patients, the presence of hyperglycemia has been associated with prolonged hospital stay, infection, disability after hospital discharge, and death (1,5,12). In general surgery patients, the relative risk for serious postopera...

Treatment with basal/bolus regimen with detemir once daily and aspart before meals results in equivalent glycemic control and no differences in the frequency of hypoglycemia compared to a split-mixed regimen of NPH and regular insulin in patients with type 2 diabetes.

OBJECTIVETo compare the safety and efficacy of insulin analogs and human insulins both during acute intravenous treatment and during the transition to subcutaneous insulin in patients with diabetic ketoacidosis (DKA).RESEARCH DESIGN AND METHODSIn a controlled multicenter and open-label trial, we randomly assigned patients with DKA to receive intravenous treatment with regular or glulisine insulin until resolution of DKA. After resolution of ketoacidosis, patients treated with intravenous regular insulin were transitioned to subcutaneous NPH and regular insulin twice daily (n = 34). Patients treated with intravenous glulisine insulin were transitioned to subcutaneous glargine once daily and glulisine before meals (n = 34).RESULTSThere were no differences in the mean duration of treatment or in the amount of insulin infusion until resolution of DKA between intravenous treatment with regular and glulisine insulin. After transition to subcutaneous insulin, there were no differences in mean daily blood glucose levels, but patients treated with NPH and regular insulin had a higher rate of hypoglycemia (blood glucose <70 mg/dl). Fourteen patients (41%) treated with NPH and regular insulin had 26 episodes of hypoglycemia and 5 patients (15%) in the glargine and glulisine group had 8 episodes of hypoglycemia (P = 0.03).CONCLUSIONSRegular and glulisine insulin are equally effective during the acute treatment of DKA. A transition to subcutaneous glargine and glulisine after resolution of DKA resulted in similar glycemic control but in a lower rate of hypoglycemia than with NPH and regular insulin. Thus, a basal bolus regimen with glargine and glulisine is safer and should be preferred over NPH and regular insulin after the resolution of DKA.

BACKGROUND:Inpatient hyperglycemia in adult patients with and without a history of diabetes is a predictor of poor clinical outcome. No previous studies, however, have examined the association of hyperglycemia and clinical outcome in children admitted to a community pediatric hospital.METHODS:The study was a retrospective observational cohort of pediatric patients admitted to a community children's hospital from January 2004 to August 2004. Medical records of 903 consecutive children admitted to critical and non–critical care areas were reviewed. Of them, 342 patients (38%) had no blood glucose measurements during their hospital stay. In the remaining patients, we determined the prevalence of hyperglycemia and examined the association of hyperglycemia with clinical outcome.RESULTS:A total of 406 patients (75%) had an admission blood glucose ≤120 mg/dL (mean ± SEM 98 ± 1 mg/dL), 103 children (19%) had an admission blood glucose level of 121–179 mg/dL (mean 143 ± 2 mg/dL), and 32 patients (5.9%) had a blood glucose level ≥180 mg/dL (mean 260 ± 18 mg/dL). Seventeen patients (13%) had a known history of diabetes prior to admission. Children with hyperglycemia were more likely to be admitted to the ICU (P < .001) and had a longer length of ICU stay (P < .001), but admission hyperglycemia was not associated with longer hospital stay or higher hospital mortality.CONCLUSIONS:Hyperglycemia is present in one‐fourth of children admitted to the hospital, most of them without a history of diabetes prior to admission. Hyperglycemia was associated with a greater need for ICU care and longer ICU stay but not with increased in‐hospital mortality. Journal of Hospital Medicine 2008;3:212–217. © 2008 Society of Hospital Medicine.

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