PREVENTION AND MANAGEMENT OF INSULIN-ASSOCIATED HYPOGLYCEMIA IN HOSPITALIZED PATIENTS

Abstract

Objective: To determine whether appropriate therapeutic changes in insulin doses are made to prevent and manage insulin-associated hypoglycemic events in non-critically ill hospitalized patients.

Methods: This retrospective study was conducted in hospitalized adults on medical or surgical floors with insulin-associated hypoglycemia, excluding treatment with insulin infusions, insulin pumps, and parenteral nutrition. The first hypoglycemic event after 48 hours of admission was the index event. Over the 1-year study period, a total of 457 insulin-associated hypoglycemic events were included as index events.

Results: An indication for an insulin dose adjustment was identified in 32 and 42% of patients on day -2 and day -1, respectively, before the index hypoglycemic event, of which 35 and 55%, respectively, had an insulin dose reduction ≥10%. Following the hypoglycemic event, 44% of patients had an insulin dose reduction of ≥20%. Therapeutic reduction of the total daily insulin dose by ≥20% was associated with increased odds of normoglycemia and lower odds of hyperglycemia but was not associated with lower odds of recurrent hypoglycemia on the day following the index hypoglycemic event. There was a high prevalence of hypoglycemic risk factors in this population, with kidney disease and nil per os status being the most prevalent contributing factors.

Conclusion: Adherence to the current practice recommendation to reduce insulin doses in patients with borderline hypoglycemia and following overt hypoglycemia was modest. Further studies are needed to understand the associated risks and to define appropriate therapeutic changes for insulin treated patients with borderline and overt hypoglycemia.

Abbreviations: AKI = acute kidney injury BG = blood glucose CKD = chronic kidney disease ESRD = end-stage renal disease ICU = intensive care unit NPH = Neutral Protamine Hagedorn NPO = nil per os OR = odds ratio TDD = total daily dose.

Fig. 1

Study eligibility criteria. BG = blood glucose; ICU = intensive care unit; SQ = subcutaneous.

Fig. 2

Blood glucose (BG) pattern over study window. Days were defined as 24-hour timeframes back or forward from the index event (rather than calendar days) as follows: day −2 (−24 to −48 hours before the index event), day −1 (−24 hours to time of index event), index hypoglycemic event (reference time point 0), day +1 (time of event to 24 hours after), and day +2 (24 hours to 48 hours after event). For day −2, day −1, day +1, and day +2, the median and interquartile range (IQR) of the day weighted-mean BG (DWMBG) are shown. For the index event, the median and IQR of the single index hypoglycemic BG value is shown. On day −2, day −1, day +1, and day +2, the median (IQR) DWMBG values were 169 (136, 212), 145 (119, 186), 144 (116, 185), and 157 (126, 198) mg/dL, respectively. The DWMBG was derived from a stable number of measured BG readings throughout the study period; the mean ± SD number of BG measurements in relation to each day were 4 ± 1.2 (day −2), 4 ± 1.0 (day −1), 1 ± 0 (index event), 4 ± 1.1 (day +1), and 4 ± 1.3 (day +2). Closed circles represent outliers.

Fig. 3

Peak and nadir blood glucose (BG) values antecedent to hypoglycemic event.