Transitioning Safely from Intravenous to Subcutaneous Insulin

Current Diabetes Reports

Volumn 15, Issue 5, 2015, Pages

  Kreider, Kathryn Evans ^a   Lien, Lillian F ^b  

^a DUKE UNIVERSITY MEDICAL CENTER   (United States)

^b UNIVERSITY OF MISSISSIPPI SCHOOL OF MEDICINE   (United States)

Author keywords

Inpatient diabetes management; Insulin; Insulin infusion; Intravenous (IV) insulin transition; Subcutaneous (SQ)

Indexed keywords

GLUCOCORTICOID; INSULIN; ISOPHANE INSULIN; LONG ACTING INSULIN; PIG INSULIN; SHORT ACTING INSULIN;

BLOOD GLUCOSE MONITORING; BOLUS INJECTION; CORTICOSTEROID THERAPY; DIABETIC PATIENT; DRUG SAFETY; DRUG USE; END STAGE RENAL DISEASE; ENTERIC FEEDING; GLYCEMIC CONTROL; HUMAN; INSULIN DEPENDENT DIABETES MELLITUS; INSULIN INFUSION; INSULIN PUMP; INSULIN TREATMENT; PATIENT CARE; REVIEW; CLINICAL DECISION MAKING; DOSE RESPONSE; INTRAVENOUS DRUG ADMINISTRATION; SUBCUTANEOUS DRUG ADMINISTRATION;

ADMINISTRATION, INTRAVENOUS; BLOOD GLUCOSE SELF-MONITORING; CLINICAL DECISION-MAKING; DOSE-RESPONSE RELATIONSHIP, DRUG; HUMANS; INJECTIONS, SUBCUTANEOUS; INSULIN;

EID: 84924778361     PISSN: 15344827     EISSN: 15390829     Source Type: Journal    
DOI: 10.1007/s11892-015-0595-4     Document Type: Review

References (70)

1. Inzucchi SE. Clinical practice. Management of hyperglycemia in the hospital setting. N Engl J Med. 2006;355(18):1903–11.
2. Evans KJ, Thompson J, Spratt SE, et al. The implementation and evaluation of an evidence-based protocol to treat diabetic ketoacidosis: a quality improvement study. Adv Emerg Nurs J. 2014;36(2):189–98.
3. Mabrey ME, Lien LF. IV insulin infusions: how to use an “insulin drip” (Chapter 3). In: Lien LF, Cox ME, Feinglos MN, Corsino L, editors. Glycemic control in the hospitalized patient: a comprehensive clinical guide. 1st ed. New York: Springer; 2010. p. 17–27.
4. Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125(5):1007–21.
5. Kelly JL, Hirsch IB, Furnary AP. Implementing an intravenous insulin protocol in your practice: practical advice to overcome clinical, administrative, and financial barriers. Semin Thorac Cardiovasc Surg. 2006;18(4):346–58.
6. Furnary AP, Braithwaite SS. Effects of outcome on in-hospital transition from intravenous insulin infusion to subcutaneous therapy. Am J Cardiol. 2006;98(4):557–64.
7. Furnary AP, Zerr KJ, Grunkemeier GL, et al. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67(2):352–60. discussion 60-2.
8. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19):1359–67.
9. Krikorian A, Ismail-Beigi F, Moghissi ES. Comparisons of different insulin infusion protocols: a review of recent literature. Curr Opin Clin Nutr Metab Care. 2010;13(2):198–204.
10. Hemerson P, Banarova A, Izakovic M, et al. Transitioning postoperative cardiovascular surgery patients from intravenous to subcutaneous insulin: an improvement project. J Clin Outcomes Manag JCOM. 2011;18(12):563–7.
11. Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335–43.
12. Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med. 2012;40(12):3251–76. These guidelines approach IV management for the critically ill patient comprehensively, including the transition to SQ. Understanding the needs of this population is essential for safe IV insulin transitions.
13. Nazer LH, Chow SL, Moghissi ES. Insulin infusion protocols for critically ill patients: a highlight of differences and similarities. Endocr Pract. 2007;13(2):137–46.
14. Bode BW, Braithwaite SS, Steed RD, et al. Intravenous insulin infusion therapy: indications, methods, and transition to subcutaneous insulin therapy. Endocr Pract. 2004;10 Suppl 2:71–80.
15. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15(4):353–69.
16. Avanzini F, Marelli G, Donzelli W, et al. Transition from intravenous to subcutaneous insulin: effectiveness and safety of a standardized protocol and predictors of outcome in patients with acute coronary syndrome. Diabetes Care. 2011;34(7):1445–50.
17. Donaldson S, Villanuueva G, Rondinelli L, et al. Rush university guidelines and protocols for the management of hyperglycemia in hospitalized patients: elimination of the sliding scale and improvement of glycemic control throughout the hospital. Diabetes Educ. 2006;32(6):954–62.
18. Braithwaite SS. The transition from insulin infusions to long-term diabetes therapy: the argument for insulin analogs. Semin Thorac Cardiovasc Surg. 2006;18(4):366–78.
19. McDonnell ME, Alexanian SM, White L, et al. A primer for achieving glycemic control in the cardiac surgical patient. J Card Surg. 2012;27(4):470–7.
20. Dickerson RN, Wilson VC, Maish GO, et al. Transitional NPH insulin therapy for critically ill patients receiving continuous enteral nutrition and intravenous regular human insuli. JPEN J Parenter Enteral Nutr. 2013;37(4):506–16. This article describes the safe use of NPH insulin a special population of patients. The use of NPH may be considered in patients who are requiring enteral tube feedings and can be dosed safely to match the tube feeding regimen.
21. Lien LF, Angelyn Bethel M, Feinglos MN. In-hospital management of type 2 diabetes mellitus. Med Clin N Am. 2004;88(4):1085–105.
22. McDonnell ME, Umpierrez GE. Insulin therapy for the management of hyperglycemia in hospitalized patients. Endocrinol Metab Clin N Am. 2012;41(1):175–201.
23. Braithwaite DT, Umpierrez GE, Braithwaite SS. A quadruply-asymmetric sigmoid to describe the insulin-glucose relationship during intravenous insulin infusion. J Healthc Eng. 2014;5(1):23–53.
24. Stahnke A, Struemph K, Behnen E, et al. Pharmacy management of postoperative blood glucose in open heart surgery patients: evaluation of an intravenous to subcutaneous insulin protocol. Hosp Pharm. 2014;49(2):164–9. This article highlights the importance hospital adherence to SCIP measures and the importance of effective transitions for cardiac patients to avoid sternal wound infections. The protocol in this institution did not improve SCIP measures but led to fewer sternal wound infections and less hypoglycemia.
25. Dombrowski NC, Karounos DG. Pathophysiology and management strategies for hyperglycemia for patients with acute illness during and following a hospital stay. Metabolism. 2013;62(3):326–36.
26. Dungan K, Hall C, Schuster D, et al. Comparison of 3 algorithms for basal insulin in transitioning from intravenous to subcutaneous insulin in stable patients after cardiothoracic surgery. Endocr Pract. 2011;17(5):753–8. This article demonstrated that a lower amount of insulin (approximately 50% of previous IV basal requirements) led to equally effective and safe transition, compared to patients who were transitioned at 80% of daily requirements.
27. Oo YH, Karam JG, Resta CA. Extreme insulin resistance in a patient with diabetes ketoacidosis and acute myocardial infarction. Case Rep Endocrinol. 2013;2013:520904.
28. O’Malley CW, Emanuele M, Halasyamani L, et al. Bridge over troubled waters: safe and effective transitions of the inpatient with hyperglycemia. J Hosp Med. 2008;3(5 Suppl):55–65.
29. Yogi-Morren D, Lansang MC. Management of patients with type 1 diabetes in the hospital. Curr Diabetes Rep. 2014;14(2):458.
30. Wang CCL, Draznin B. Insulin use in hospitalized patients with diabetes: navigate with care. Diabetes Spectr. 2013;26(2):124–30.
31. Pichardo-Lowden A, Gabbay RA. Management of hyperglycemia during the perioperative period. Curr Diabetes Rep. 2012;12(1):108–18.
32. Silinskie KM, Kirshner R, Hite MS. Converting continuous insulin infusion to subcutaneous insulin glargine after cardiac surgery using percentage-based versus weight-based dosing: a pilot trial. Ann Pharmacother. 2013;47(1):20–8. This study explored the use of weight based dosing (0.5 units/kg) for transitioning patients as opposed to percent-based dosing (50% of total utilization). The results suggested that BG control was similar in both groups. Though further trials are needed, this may provide an additional method of deciding an appropriate insulin dose.
33. Schmeltz LR, DeSantis AJ, Schmidt K, et al. Conversion of intravenous insulin infusions to subcutaneously administered insulin glargine in patients with hyperglycemia. Endocr Pract. 2006;12(6):641–50.
34. Ahmann AJ. Inpatient management of hospitalized patients with type 2 diabetes. Curr Diabetes Rep. 2004;4(5):346–51.
35. Barnard K, Batch BC, Lien LF. Subcutaneous insulin: a guide for dosing regimens in the hospital (Chapter 2). In: Lien LF, Cox ME, Feinglos MN, Corsino L, editors. Glycemic control in the hospitalized patient: a comprehensive clinical guide. 1st ed. New York: Springer; 2010. p. 7–16.
36. Crawford K. Guidelines for care of the hospitalized patient with hyperglycemia and diabetes. Crit Care Nurs Clin N Am. 2013;25(1):1–6.
37. Browning LA, Dumo P. Sliding-scale insulin: an antiquated approach to glycemic control in hospitalized patients. Am J Health Syst Pharm. 2004;61(15):1611–4.
38. Umpierrez GE, Palacio A, Smiley D. Sliding scale insulin use: myth or insanity? Am J Med. 2007;120(7):563–7.
39. Umpierrez GE, Smiley D, Zisman A, et al. Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients with type 2 Diabetes (RABBIT 2 trial). Diabetes Care. 2007;30(9):2181–6.
40. Datta S, Qaadir A, Villanueva G, et al. Once-daily insulin glargine versus 6-hour sliding scale regular insulin for control of hyperglycemia after a bariatric surgical procedure: a randomized clinical trial. Endocr Pract. 2007;13(3):225–31.
41. Umpierrez GE, Hor T, Smiley D, et al. Comparison of inpatient insulin regimens with detemir plus aspart versus neutral protamine hagedorn plus regular in medical patients with type 2 diabetes. J Clin Endocrinol Metab. 2009;94(2):564–9.
42. Hermansen K, Fontaine P, Kukolja KK, et al. Insulin analogues (insulin detemir and insulin aspart) versus traditional human insulins (NPH insulin and regular human insulin) in basal-bolus therapy for patients with type 1 diabetes. Diabetologia. 2004;47(4):622–9.
43. Bartley PC, Bogoev M, Larsen J, et al. Long-term efficacy and safety of insulin detemir compared to Neutral Protamine Hagedorn insulin in patients with Type 1 diabetes using a treat-to-target basal-bolus regimen with insulin aspart at meals: a 2-year, randomized, controlled trial. Diabet Med. 2008;25(4):442–9.
44. Riddle MC, Rosenstock J, Gerich J. The treat-to-target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care. 2003;26(11):3080–6.
45. Rosenstock J, Dailey G, Massi-Benedetti M, et al. Reduced hypoglycemia risk with insulin glargine: a meta-analysis comparing insulin glargine with human NPH insulin in type 2 diabetes. Diabetes Care. 2005;28(4):950–5.
46. Baldwin D, Apel J. Management of hyperglycemia in hospitalized patients with renal insufficiency or steroid-induced diabetes. Curr Diabetes Rep. 2013;13(1):114–20.
47. Wallia A, Molitch ME. Insulin therapy for type 2 diabetes mellitus. JAMA. 2014;311(22):2315–25.
48. Metchick LN, Petit Jr WA, Inzucchi SE. Inpatient management of diabetes mellitus. Am J Med. 2002;113(4):317–23.
49. Hsia E, Seggelke S, Gibbs J, Hawkins M, Draznin B. Subcutaneous administration of glargine to diabetic patients receiving insulin infusion prevents rebound hyperglycemia. J Clin Endocrinol Metab. 2012;97(9):3132–7. This article suggests that adding glargine on to the IV insulin drip can be an effective way to transition hospitalized patients with fluctuating insulin requirements. The results suggest that the addition of glargine (0.25 units/kg within 12 hours of infusion initiation) can prevent rebound hyperglycemia after the drip has been discontinued. The suggestions in this article are easily implemented.
50. Weant KA, Ladha A. Conversion from continuous insulin infusions to subcutaneous insulin in critically ill patients. Ann Pharmacother. 2009;43(4):629–34.
51. Rosenstock J, Schwartz SL, Clark Jr CM, et al. Basal insulin therapy in type 2 diabetes: 28-week comparison of insulin glargine (HOE 901) and NPH insulin. Diabetes Care. 2001;24(4):631–6.
52. Yeldandi RR, Lurie A, Baldwin D. Comparison of once-daily glargine insulin with twice-daily NPH/regular insulin for control of hyperglycemia in inpatients after cardiovascular surgery. Diabetes Technol Ther. 2006;8(6):609–16.
53. Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27(2):553–91.
54. Mabrey ME, Cox ME, Lien LF. Hypoglycemia (Chapter 10). In: Lien LF, Cox ME, Feinglos MN, Corsino L, editors. Glycemic control in the hospitalized patient: a comprehensive clinical guide. 1st ed. New York: Springer; 2010. p. 91–9.
55. Lien LF, Spratt SE, Woods Z, et al. Optimizing hospital use of intravenous insulin therapy: improved management of hyperglycemia and error reduction with a new nomogram. Endocr Pract. 2005;11(4):240–53.
56. McCrea D. Management of the hospitalized diabetes patient with an insulin pump. Crit Care Nurs Clin N Am. 2013;25(1):111–21.
57. Cook CB, Boyle ME, Cisar NS, et al. Use of continuous subcutaneous insulin infusion (insulin pump) therapy in the hospital setting: proposed guidelines and outcome measures. Diabetes Educ. 2005;31(6):849–57.
58. Bailon RM, Partlow BJ, Miller-Cage V, et al. Continuous subcutaneous insulin infusion (insulin pump) therapy can be safely used in the hospital in select patients. Endocr Pract. 2009;15(1):24–9.
59. Leonhardi BJ, Boyle ME, Beer KA, et al. Use of continuous subcutaneous insulin infusion (insulin pump) therapy in the hospital: a review of one institution’s experience. J Diabetes Sci Technol. 2008;2(6):948–62.
60. Noschese ML, DiNardo MM, Donihi AC, et al. Patient outcomes after implementation of a protocol for inpatient insulin pump therapy. Endocr Pract. 2009;15(5):415–24.
61. Morviducci L, Di Flaviani A, Lauria A, et al. Continuous subcutaneous insulin infusion (CSII) in inpatient setting: unmet needs and the proposal of a CSII unit. Diabetes Technol Ther. 2011;13(10):1071–4.
62. Hawkins K, Donihi AC, Korytkowski MT. Glycemic management in medical and surgical patients in the non-ICU setting. Curr Diabetes Rep. 2013;13(1):96–106.
63. Cochran S, Miller E, Dunn K, et al. EndoTool software for tight glucose control for critically ill patients. Crit Care Med. 2006;34 Suppl 2:A68.
64. Messenger C, A. D, Hockley D. Housewide use of EndoTool® computer-based IV insulin management improves glycemic control. ANA 6th Annual Nursing Quality Conference: Improving the Odds on Quality; January 25, Las Vegas, NV2012.
65. Davidson PC, Steed RD, Bode BW. Glucommander: a computer-directed intravenous insulin system shown to be safe, simple, and effective in 120,618 h of operation. Diabetes Care. 2005;28(10):2418–23.
66. Newton CA, Smiley D, Bode BW, et al. A comparison study of continuous insulin infusion protocols in the medical intensive care unit: computer-guided vs. standard column-based algorithms. J Hosp Med. 2010;5(8):432–7.
67. Halpin L, Henry L, Dunning E, et al. Comparison of blood glucose management strategies to achieve control following cardiac surgery (computerized versus paper). AACN Adv Crit Care. 2010;21(2):146–51.
68. Wilson M, Weinreb J, Hoo GW. Intensive insulin therapy in critical care: a review of 12 protocols. Diabetes Care. 2007;30(4):1005–11.
69. Boutin JM, Gauthier L. Insulin infusion therapy in critically ill patients. Can J Diabetes. 2014;38(2):144–50.
70. Palazzo A, Smith B, Shoun F, et al. Use of the eGlycemic management system by glytec provides safe and effective transition from iv to subq insulin therapy. Diabetes technology meeting; November 6–8. Diabetes Technology Society: Bethesda; 2014.