A Randomized Trial of Two Weight-Based Doses of Insulin Glargine and Glulisine in Hospitalized Subjects With Type 2 Diabetes and Renal Insufficiency

Abstract

OBJECTIVERenal insufficiency may increase the risk of hypoglycemia in hospitalized patients with diabetes who are treated with insulin. We randomized inpatients with type 2 diabetes and chronic renal failure to treatment with two different dose levels of insulin glargine and glulisine and studied control of hyperglycemia and the frequency of hypoglycemia.RESEARCH DESIGN AND METHODSWe conducted a multicenter, prospective, randomized trial to compare the efficacy of once-daily glargine and three-times daily glulisine at 0.5 vs. 0.25 units/kg/day. A total of 107 subjects had type 2 diabetes for >1 year, had a glomerular filtration rate <45 mL/min but did not require dialysis, and had an initial blood glucose (BG) >180 mg/dL. Doses were adjusted based on four-times daily BG measurements for 6 days.RESULTSMean BG on the first day was 196 ± 71 mg/dL in the group receiving 0.5 units/kg (0.5 group) and 197 ± 55 mg/dL in the group receiving 0.25 units/kg (0.25 group; P = 0.94). On days 2 to 6, mean BG was 174 ± 52 mg/dL in the 0.5 group and 174 ± 46 mg/dL in the 0.25 group (P = 0.96). There were no significant differences between groups in the percentage of BG values within the target range of 100 to 180 mg/dL on any of the 6 study days. In the 0.5 group, 30% experienced hypoglycemia (BG <70 mg/dL) compared with 15.8% of the 0.25 group (P = 0.08).CONCLUSIONSReduction of initial glargine/glulisine insulin weight-based dosing in hospitalized patients with diabetes and renal insufficiency reduced the frequency of hypoglycemia by 50% without compromising the control of hyperglycemia.

Impaired Glucose and Insulin Homeostasis in Moderate-Severe CKD

“…With this caveat, our results call into question whether decreasing insulin requirements among patients with diabetes and advanced CKD can be explained by decreased renal insulin clearance alone. 5,6,30 Differences in mean whole-body insulin clearance by CKD status were modest in our study, even at the lowest eGFRs. Our data suggest that nonrenal insulin clearance may decrease in patients with advanced CKD who develop progressive insulin resistance.…”

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

“…Typically, basal insulin dosing schemes are based on body weight, with some evidence that patients with renal insufficiency should be treated with lower doses (34). An insulin regimen with basal and correction components is necessary for all hospitalized patients with type 1 diabetes, with the addition of nutritional insulin if the patient is eating.…”

13. Diabetes Care in the Hospital

“…Typically basal insulin dosing schemes are based on body weight, with some evidence that patients with renal insufficiency should be treated with lower doses (15).…”