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Background: Continuous intravenous insulin infusion (CII) following coronary artery bypass graft (CABG) surgery reduces postoperative complications and hospitalization duration. Because of limited data evaluating outcomes of CII with revised glycemic targets (110-140 mg/dL) in cardiac surgery, this study compared efficacy and safety of two different CII protocols having revised targets., Subjects and Methods: This is a retrospective study comparing two different protocols between August 2009 and March 2010. Protocol 1 consists of four algorithms, and Protocol 2 is a table to adjust CII. Blood glucose (BG) and CII rates were recorded for 48 h postoperatively or CII discontinuation. Efficacy was defined by the percentage of BG values in the target range, and safety was defined by the percentage of BG values<40 and 40-69 mg/dL., Results: Protocol 1 (n=117) patients were older (65 vs. 61 years; P=0.006) and had more CABG and fewer valve procedures compared with Protocol 2 (n=130). There were no differences in baseline BG level (149±40.6 vs. 151±38.1 mg/dL), body mass index (30±6.3 vs. 30±6.4 kg/m(2)), hematocrit (28% vs. 28%), percentage of diabetes patients (32% vs. 31%), percentage of patients with glomerular filtration rate of <30 mL/min (5% vs. 6%), CII duration (42 [9-48] vs. 40 [14-48] h), total insulin units received (99 [15-376] vs. 114 [12-457]), hourly insulin rate (median of average rate [range], 2.59 [0-21) vs. 2.96 [0-25] units/h), percentage of BG values 110-140 mg/dL, <40 mg/dL, 40-69 mg/dL, and >180 mg/dL, and BG coefficient of variation (21±6.5 vs. 21±6.1). Shorter time to goal (3.32 [0.22-19.35] vs. 5.03 [0.92-19.80] h; P=0.018) and lower mean BG level (127±12.2 vs. 133±12.1 mg/dL; P<0.001) were noted with Protocol 1., Discussion: CII protocols targeting 110-140 mg/dL were effective in achieving revised targets with low hypoglycemia. Despite differences in mean BG level and time to target, each hospital continued using its existing protocols and identified areas for improvement.

Study Objective: To identify the incidence of and risk factors associated with hypoglycemia in hospitalized patients taking sulfonylureas., Design: Nested case-control study., Setting: Tertiary care academic medical center., Patients: Adults who received a sulfonylurea during hospitalization between November 1, 2008, and October 31, 2009. Case patients were those who experienced at least one episode of hypoglycemia, defined as a blood glucose level less than 70 mg/dl; potential control patients were those who did not experience hypoglycemia. One hundred seventeen cases were matched in a 1:1 ratio with controls based on sex and the number of days treated with a sulfonylurea in the hospital. For case patients, the index date was defined as the date of first blood glucose level less than 70 mg/dl. The number of days that the patient was taking the sulfonylurea before the index date was determined, and this same number was used to define the index date for the matched controls., Measurements and Main Results: Overall, 19% of patients who received a sulfonylurea experienced at least one episode of hypoglycemia: 22% receiving glyburide, 19% receiving glimepiride, and 16% receiving glipizide. Variables included in the multivariate regression were age 65 years or older, glomerular filtration rate (GFR)≤ 30 ml/min/1.73 m(2) , and treatment with glipizide, glyburide, or concurrent intermediate- or long-acting insulin. Age 65 years or older (odds ratio [OR] 3.07, p < 0.001), intermediate- or long-acting insulin (OR 3.01, p=0.002), and GFR of 30 ml/minute/1.73 m(2) or lower (OR 3.64, p=0.006) were predictors of hypoglycemia. Cases were less likely than controls to receive glipizide (OR 0.44, p=0.005)., Conclusion: Hospitalized patients at increased risk for sulfonylurea-related hypoglycemia were those aged 65 years or older, those with a GFR of 30 ml/minute/1.73 m(2) or lower, and those who received concurrent intermediate- or long-acting insulin during inpatient sulfonylurea therapy. Sulfonylureas should be avoided or used with caution in these patients., (© 2012 Pharmacotherapy Publications, Inc. All rights reserved.)

The objective of this opinion paper was to identify and describe the role of pharmacists in ensuring safe and optimal management of patients with glycemic excursions in the inpatient setting. The role of the pharmacist includes involvement in admission medication history and reconciliation, formulary management of glucose‐lowering medications and devices, individual patient medication management, discharge transition of care, and interprofessional collaboration with other health care providers. Recommendations are based on review of published guidelines and literature focusing on the management of patients with hypo‐ and hyperglycemia in the hospital as well as during the time of transition to and from the inpatient setting. [ABSTRACT FROM AUTHOR]

Insufficient knowledge of insulin and oral diabetes medications contribute to mismanagement with resulting hyperglycemia in the hospital. To address this, a Diabetes Order Set (DOS) with prescribing guidelines and standardized order forms for insulin and oral diabetes medications was implemented following educational sessions with clinical staff. This Quality Improvement project was a retrospective review comparing diabetes management on two hospital units: one where the order set had been implemented (n=35) and one where it had not (n=35). Glycemic control and appropriateness of diabetes management as assessed by a blinded expert panel was measured in these 70 consecutive medical/surgical patients having 3 days of capillary blood glucose data (CBG) and orders for diabetes medication. Satisfaction by physicians and non-physician practitioners (n=23); nurses (n=24); and clerical staff (n=5) was measured by questionnaire. Basal/bolus insulin was prescribed more frequently (48% vs 11%, p=<.001) on the DOS unit while appropriateness of diabetes management was similar on the 2 units (91% vs 80%, p =.137). Inappropriate management was most often related to inadequate dosing adjustments for hyperglycemia (10/30, 33%) and inappropriate use of sliding scale insulin (6/30, 20%). A similar number of patients experienced mild hypoglycemia (40-69 mg/dl) on both units and there were no episodes of severe hypoglycemia (<40 mg/dl). Corticosteroid therapy was more frequent on the DOS unit (46% vs. 17%, p = .01). After adjusting for corticosteroid use, no difference (p=0.127) was found in the frequency of CBG >250 mg/dl on the DOS unit vs. the control unit (10/19, 53% vs. 8/29, 28%). The surveyed clinicians and staff liked the DOS (81%) and felt it improved patient care (88%). A DOS with prescribing guidelines is associated with more frequent use of scheduled insulin without an increase in hypoglycemia or hyperglycemia. The high degree of acceptance by hospital personnel can be attributed to multidisciplinary support and education that accompanied the implementation. [ABSTRACT FROM AUTHOR]