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Glycemic control not improved with bedtime insulin supplementation
Insulin supplementation used to avoid mild to moderate hyperglycemia at bedtime did not improve glycemic control, according to a study recently published in Diabetes Care.
“This study challenges current clinical guidelines for the management of inpatient hyperglycemia in non-ICU settings, which recommend bedtime insulin supplementation to correct mild-moderate hyperglycemia,” the researchers wrote. “Eliminating the routine use of bedtime insulin supplementation may have the potential to simplify glycemic control for patients with mild-moderate bedtime hyperglycemia in the inpatient setting.”
The prospective, randomized controlled study assessed the difference in outcomes between 206 hospital inpatients who were given bedtime supplemental insulin (n=106) to improve blood glucose levels greater than 7.8 mmol/L and patients who did not receive supplementation (n=100). Patients were admitted to either Grady Memorial Hospital or Emory University Hospital in Atlanta as general medical and surgery patients with type 2 diabetes receiving a basal-bolus regimen. Patients with a blood glucose level greater than 19.4 mmol/L received a supplement regardless of their allotted group. Researchers measured each patient’s point-of-care blood glucose levels before every meal, at bedtime and at 3:00 in the morning for 10 days.
The primary outcome was the difference between average fasting glucose levels in the supplement group and no-supplement group before breakfast. The secondary outcomes were the difference in blood glucose levels before lunch, before dinner, at bedtime, and at 3:00 a.m.
According to the results, an intention-to-treat analysis showed that patients who received a bedtime supplement did not have a better blood glucose level before breakfast than patients who did not receive a supplement (P = 0.76).
There was no difference in average blood glucose levels between the groups before lunch (P = 0.36), dinner (P = 0.12), at bedtime (P = 0.19) and at 3:00 a.m. (P = 0.69).
Because only 66% of the bedtime supplemental group needed treatment, an as-treated analysis was performed. Similarly, results showed no difference in overall fasting blood glucose levels (P = 0.92), blood glucose levels at 3:00 a.m. (P = 0.19), and blood glucose levels at bedtime (P = 0.41). The as-treated analysis did not differ in hypoglycemia (blood glucose < 3.9 mmol/L) between the supplement and no-supplement groups (P = 0.37) compared with both groups in the intention-to-treat analysis (P = 0.50).
Five patients (8%) in the no-supplement group received a bedtime insulin supplement due to high blood glucose levels. An analysis excluding these patients did not show a difference in glycemic control, hypoglycemia rates or insulin dose requirements.
Overall, the results were similar regardless of sex (P = 0.71), race (P = 0.38), BMI (P = 0.60), duration of diabetes (P = 0.12), and length of hospital stay (P = 0.50).
In other outcomes, approximately three quarters of patients in both groups who had hypoglycemia experienced hypoglycemic episodes between dinner and early morning whether or not they used a bedtime insulin supplement. – by Stephanie Viguers
Disclosure: Researchers report relationships with Abbott, Boehringer Ingelheim, Eli Lilly, EndoBarrier, Janssen, Merck, Novo Nordisk, and Sanofi. See the study for a full list of financial disclosures.