Efficacy of basal‐bolus insulin regimens in the inpatient management of non‐critically ill patients with type 2 diabetes: A systematic review and meta‐analysis

Abstract

Hyperglycemia during hospitalization is associated with increased rates of complications and longer hospital stays. Various insulin regimens are used in the inpatient diabetes management of non-critically ill patients. In this systematic review and meta-analysis, we aimed to assess the efficacy and safety of basal-bolus insulin therapy (BBI) by summarizing evidence from studies of BBI versus sliding scale insulin therapy (SSI) in the management of hospitalized non-critically ill type 2 diabetes patients. We searched MEDLINE, EMBASE, Scopus, and the Cochrane Library for studies comparing BBI therapy with SSI therapy in hospitalized non-critically ill patients with type 2 diabetes. Primary outcome was mean daily blood glucose (BG) during admission. Secondary outcomes were incidence of hypoglycemia and length of hospital stay. Results of included randomized controlled trials (RCT) were pooled and meta-analysed to provide estimates of the efficacy of BBI therapy. Five RCTs and seven observational studies were included in the review. Meta-analysis of RCTs showed significantly lower mean daily BG with BBI than SSI. Mean difference in daily BG between the two regimens ranged from 14 to 29 mg/dl. BBI therapy was associated with increased risk of mild hypoglycemia (BG ≤ 70 mg/dl, RR 5.75; 95% CI 2.79-11.83), (BG ≤ 60 mg/dl, RR 4.21; 95% CI 1.61-11.02) compared with SSI therapy. There was no difference in risk of severe hypoglycemia (BG ≤ 40 mg/dl) and no difference in mean length of stay. In conclusion, basal-bolus insulin in the inpatient diabetes management results in significantly lower mean daily BG than sliding scale insulin but is associated with increased risk of mild hypoglycemia.

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“…Conventional insulin therapy is less responsive to alterations in insulin requirements, and despite frequent blood glucose monitoring and regular adjustment of insulin doses, tighter glycaemic control with conventional therapy is associated with increased risk of hypoglycaemia and related adverse medical outcomes. [15][16][17] Our study shows that overnight insulin requirements were higher in patients receiving nutritional support than in previous closed-loop inpatient studies, 8,11 probably due to the timing and duration of the feed compared with patients with standard oral intake. This increased insulin requirement coupled with fear among health-care professionals of hypoglycaemia and associated adverse outcomes-especially overnight-might contribute to the prevalent hyperglycaemia in the control group.…”

“…The mean Charlson Comorbidity Index score was higher in the closed-loop group than in the control group (appendix). Total hospital stay was longer in the control group (median 32 days [IQR 25-47]) than in the closedloop group (18 days [14-26]; p=0•013); however, length of hospital stay from study enrolment to discharge was similar between groups (15 days in the control group vs 10 days [6][7][8][9][10][11][12][13][14][15][16][17][18][19] in the closed-loop group; p=0•13).…”

Efficacy and Safety of Insulin Degludec for Hyperglycemia Management in Noncritical Hospitalized Patients with Diabetes: An Observational Study

“…Different trials have been conducted to identify the best therapies for the hospital setting, and different basal-bolus regimens or basal-oral therapies have been compared to SSI [ 8 – 13 ]. A recent meta-analysis [ 21 ] showed that a significantly lower mean daily BG was achieved with basal-bolus schemes than with SSI, with no difference in the risk of severe hypoglycemia or in mean length of stay, but an increased risk of mild hypoglycemia. The increased risk of mild hypoglycemia can be explained by a pool of factors, such as fasting conditions before laboratory tests, lack of appetite due to disease, and short-acting and basal insulin therapy.…”

Inpatient Diabetes and Hyperglycemia Management Protocol in the COVID-19 Era

“…We suggest considering basal insulin with correction scale instead of correction scale only; this is based on the ADA recommendations and multiple studies that were included in a meta-analysis. 5,8 Prandial insulin should be considered if needed to treat postprandial hyperglycemia. For correction scale insulin, we suggest using an approach included in Table 2, but other approaches are available and may be used.…”