Comparative effectiveness and safety of a pharmacist-managed protocol for the transition from intravenous to subcutaneous insulin

Purpose: To evaluate the effectiveness and safety of a pharmacist-managed protocol for transitioning critically ill patients from intravenous (iv) to subcutaneous insulin compared with a provider-managed process. Method(s): This single-center, retrospective, observational study included patients admitted to the medical or surgical/trauma intensive care unit who received a continuous infusion of iv insulin from January 2019 to April 2021. Patients were excluded if they were less than 18 years of age, pregnant, incarcerated, or received iv insulin for the diagnosis of diabetic ketoacidosis, hyperglycemic hyperosmolar state, calcium channel blocker or beta blocker overdose, or hypertriglyceridemia. The primary outcome was the percentage of blood glucose (BG) concentrations within the target range of 70-150 mg/dL from 0 to 48 h following transition to subcutaneous insulin. Secondary outcomes included percentage of BG concentrations within goal range following transition at 0-12 h and 12-24 h, incidence of hypo- and hyperglycemia, and percentage of patients requiring dose adjustments after initial transition. Result(s): A total of 110 unique patients were included with 70 patients in the provider-managed group and 40 patients in the pharmacist-managed group. On average, pharmacists transitioned patients to 63% basal insulin based on their 24-h total day dose of insulin. The pharmacist-managed group achieved glycemic control in 53% of transitions at 12 h, 40% at 24 h, and 47% from 0 to 48 h, while the provider group achieved glycemic control in 25% of transitions at 12 h, 12% at 24 h, and 18% from 0 to 48 h (p < 0.001 for all time points). As for safety end points, the pharmacist-managed group demonstrated lower rates of hypoglycemia (p = 0.001), severe hypoglycemia (p = 0.332), hyperglycemia (p < 0.001), and severe hyperglycemia (p < 0.001) compared with the provider-managed group. Conclusion(s): Pharmacists can effectively and safely transition critically ill patients from iv to subcutaneous insulin utilizing a standardized protocol.Copyright © 2023 Pharmacotherapy Publications, Inc.

Clinical characteristics and management of hyperglycaemia during and after dexamethasone therapy in coronavirus inpatients at a large urban district general hospital

Background: In June 2020, dexamethasone use was approved for hospitalised coronavirus (covid-19) patients in the United Kingdom. Hyperglycaemia in this group has been associated with increased mortality, leading to a national guidance in managing it. Aims: To assess variability in managing hyperglycaemia during dexamethasone therapy and glycaemic outcomes post dexamethasone in covid-19 patients. Method: Retrospective data analysis was performed for 150 dexamethasone-treated covid-19 adult, non-pregnant patients admitted between June and December 2020. We looked at baseline clinical characteristics, adherence to guidance in managing hyperglycaemia and insulin requirement on discharge. Results: Of the 150 patients, 117 (78%) were known to have type 2 diabetes. Of the 27 (18%) not known to have diabetes, 24 had a glycated haemoglobin of 42mmol mol-1 or more, suggesting undiagnosed diabetes and the majority (38%) were White. Prior to dexamethasone, 121 (81%) were not on insulin. After the first dose, 82% had a blood glucose check within 12 hours, 79% had a blood glucose of more than 12mmol l-1 within 24 hours and only 50% had the recommended four times daily blood glucose checks. Of the 121 insulin naive patients, only 52% were managed with the recommended twice daily Neutral Protamine Hagedorn insulin, while 27 (22%) needed insulin on discharge. Of those 27 patients, 44% were White, 26% were Asian and 26% had not declared their ethnicity. Conclusions: Our data show a notable variability in managing hyperglycaemia in dexamethasone-treated covid-19 patients. In this cohort, a high proportion of insulin naive patients required insulin on discharge, suggesting a high risk for progression of diabetes.

A clinical audit to assess the quality of glycaemic surveillance and treatment for hyperglycaemia in patients with and without diabetes receiving dexamethasone for covid-19 pneumonitis

Aims: To assess the quality of glycaemic surveillance and treatment of hyperglycaemia in patients with covid-19 treated with dexamethasone between a diabetic specialty ward (DW) and a respiratory ward (RW). Methods: 50 patients met inclusion criteria: covid-19 positive, treated with dexamethasone, based on a DW or RW. Data collected during November 2021 included frequency of capillary blood glucose (CBG) and ketone monitoring and treatment of hyperglycaemia. Anonymised data was collated and analysed using Microsoft Excel. Results were assessed against NHS trust and national guidelines. Recommendations assessed: • CBG monitoring four-times daily (QDS) on commencement of Dexamethasone • Ketone checks if CBG >12mmol/L • If two consecutive CBG readings >12mmol/L in 24 hours, start Humulin-I if insulin-naive or increase existing insulin dose. Results: CBG was checked QDS consistently in 16% of patients (26% DW, 4% RW). Ketones were not checked at all in 26% of patients who had at least one CBG reading of more than 12mmol/L (20% DW, 33% RW). 63% of patients who had two consecutive CBG readings of more than 12mmol/L were either started on Humulin-I or had their existing insulin dose increased (69% DW, 50% RW). Summary: Consistent glycaemic monitoring was seen in a minority of patients across both wards, with the DW achieving better results. These results reinforce the need for early involvement from the diabetes team and for improvement in education for non-diabetic speciality wards. Actions to be taken;present findings at departmental meeting, provide education for staff via posters, develop a hospital reminder system prompting QDS CBG monitoring when dexamethasone is prescribed.

Euglycemic diabetic ketoacidosis in a young adult associated with the use of SGLT2 inhibitors

Introduction: In 2015, the FDA warned the risk of euglycemic diabetic ketoacidosis (eDKA) as an adverse effect of SGLT-2 inhibitors (SGLT2i), with a frequency of < 0.1%. We present the case of a patient with type 2 diabetes mellitus (T2D) who developed eDKA with empagliflozin. Case Description: A 34-year-old man with a history of obesity, hypothyroidism and T2D 5 years ago, with regular medication of metformin 850mg bid and levothyroxine 100ug/d. He was admitted to the emergency room due to dyspnea, abdominal pain, vomiting, and drowsiness. He reported that from 4 days before his admission, he took the combination of empagliflozin/metformin 12.5/1000mg bid due to blood glucose of 385mg/dL. Analytical: leukocytes: 12940 x mm3, hemoglobin: 16,5 g/dL, platelets: 219000 x mm3, sodium: 130 mmol/L, potassium: 4,29 mmol/L, glucose: 179 mg/dl, creatinine: 0,89 mg/dl, urea : 22,1 mg/dl, test for COVID-19 (-);arterial blood gases test: pH 7,13;pC02 13;HCO3 4,2;Gap Anion: 13,8;Lactate: 1,2;Osm: 269. Ketonuria: 4+. With the diagnosis of eDKA he was managed in emergency with EV hydration, EV bicarbonate, and EV infusion of insulin. In the Endocrinology service: A1c: 9.4%, C-peptide: 6.72ng/ml, cGFR (CKD-EPI): 119 mL/min/1.73 m2, LDL: 30 mg/dL, HDL: 33 mg/dL, triglycerides: 148 mg/dl. He was discharged with nutritional medical therapy, NPH-insulin: 40UI/d, metformin 850 tid. In follow-up by teleconsultation, home self-monitoring showed capillary blood glucose between 80-130mg/dL. Discussion: the eDKA due to SGLT2i is uncommon in patients with T2D;factors that were identified in some of the reports as possible triggers for ketoacidosis were certain serious illnesses, a reduced intake of food and fluids, and a reduced insulin dose. The remission time for eDKA is similar to other cases reported in the literature. In view of the increased use of these drugs and the risk of eDKA in patients with T2D, we must consider this adverse effect when prescribing some iSGLT2.