Insulin Regimens to Treat Hyperglycemia in Hospitalized Patients on Nutritional Support: Systematic Review and Meta-Analyses

Abstract

Background: The best insulin regimen to treat hyperglycemia in hospitalized patients on nutritional support (NS) is unclear. Methods: We searched electronic databases to identify cohort studies or randomized clinical trials in order to evaluate the efficacy of different insulin regimens used to treat hyperglycemia in hospitalized patients on NS on diverse outcomes: mean blood glucose (MBG), hypoglycemia, length of stay in hospital, and mortality. Results: Seventeen studies from a total of 5,030 were included. Enteral Group included 8 studies; 1,203 patients using rapid, glargine, NPH, or Premix insulin; MBG 108-225 mg/dL; hypoglycemia 0-13%. In indirect meta-analyses, NPH insulin ranked best for glucose control (MD 95% CI -2.50 mg/dL [2.65 to -2.35]). Parenteral Group included 4 studies; 228 patients using regular and glargine or NPH insulin; MBG 137-202 mg/dL; hypoglycemia 0-40%. In meta-analyses comparing regular insulin added to parenteral nutrition bag with glargine, MBG (MD 95% CI -3.78 mg/dL [-11.93 to 4.37]; I² = 0%) or hypoglycemia frequency (RR 95% CI 1.37 [0.43-4.32]; I² = 70.7%) did not differ. The description related to hospital length of stay and mortality was inconsistent between groups. Conclusions: The best insulin regimen to treat hyperglycemia in hospitalized patients on NS has not been established; best results using insulin regimens with NPH in enteral nutrition do not seem to be clinically relevant.

Differences in Glycemic Control in Diabetic and Non-diabetic Patients with Parenteral Nutrition Using a Basal plus Correction Insulin Regimen: An Observational, Retrospective Study

“…Only one study has compared these strategies in surgical patients receiving PN [ 18 ], and the results confirm that both glargine insulin and regular insulin in the PN are effective modalities for BG control. Moreover, a recent meta-analysis confirms that the most fitting insulin regimen to treat hyperglycemia in hospitalized patients on nutritional support has not been established [ 17 ]. Accordingly, there is a lack of standardized protocols for monitoring and therapy in this population, and strategies are those recommended for hospitalized non-critically ill patients [ 5 , 12 , 13 , 20 , 26 ].…”

“…Subcutaneous insulin administration, intravenous insulin infusion and addition of insulin to the PN bag have been shown to be effective in managing hyperglycemia in these patients [ 5 , 13 , 15 , 16 ]. However, there are few data from clinical trials comparing different strategies [ 17 ], particularly in non-critically ill patients [ 18 , 19 ]. Furthermore, insulin protocols vary widely between institutions.…”

<p>Effect of Adding Insulin Glargine on Glycemic Control in Critically Ill Patients Admitted to Intensive Care Units: A Prospective Randomized Controlled Study</p>

“…They recommended additional RCTs with a focus on hard outcomes and severe hypoglycemia, beyond hyperglycemia per se, and thus it is not yet possible to establish the best insulin regimen for management of dysglycemia in critically ill patients. 7 Controlling BG levels in critically ill patients can be challenging, as there are so many factors that affect glycemic control. Interruptions in nutrition, tapering of steroids or vasopressors, renal replacement therapies, sepsis, and fluctuating stress levels can lead to high variability in BG levels in these patients.…”

“…6 On the other hand, long-acting insulin formulations are not generally considered because of the altered pharmacokinetic and pharmacodynamic properties of the drug. 7 Insulin glargine has a lower peak effect, with an onset of action of around 2 hours. Although the risk of hypoglycemia is lower than other long-acting insulin preparation, this risk is not zero.…”

Monitoring of glucose metabolism in patients receiving enteral nutrition

“…Difficulties in metabolic glycemic control in patients with previously diagnosed diabetes requiring continuous enteral nutrition therapy (CENT) were noted by Hijaze and Szalat [29]. Verçosa Viana et al [30] also analyzed the literature regarding insulin therapy in patients with nutritional support (NS) [30]. Attempts are made to determine the composition of the food used in nutrition support in oncological patients [31].…”