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Glargine/glulisine insulin regimen preferred for diabetic surgical patients

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Basal bolus glargine insulin once daily plus glulisine before meals effectively manages general surgery patients with type 2 diabetes, investigators report.

Compared to sliding scale regular insulin given four times daily, the basal bolus regimen results in better glycemic control and fewer complications, according to a report in Diabetes Care online January 12th.

The first author Dr. Guillermo E. Umpierrez, from Emory University in Atlanta, Georgia, and colleagues note that most diabetics admitted for surgery have poor glycemic control, which they say is not usually dealt with properly for fear of hypoglycemia.

In their study, the 211 patients with diabetes had baseline blood glucose levels between 140 and 400 mg/dL (mean 190 mg/dL, with mean A1c of 7.72). The investigators randomized them to the basal bolus regimen (n = 104) with insulins glargine and glulisine (Lantus and Apidra, Sanofi-Aventis) or to regular insulin (Novolin R, Novo Nordisk, n = 107). [

The basal bolus routine started at a daily dose of 0.5 units/kg, half as glargine once daily and half as glulisine before meals. The authors reduced the daily dose to 0.3 units/kg in patients age 70 and older or with a serum creatinine of 2.0 mg/dL or higher.

Regular insulin doses were adjusted to a sliding scale; if three consecutive blood glucose values were over 240 mg/dL, the patient was changed to the basal bolus regimen. Thirteen patients required this switch, after which their glycemic control rapidly improved.

In nearly every measure the glargine/glulisine performed better than regular insulin. It resulted in lower mean fasting glucose (155 vs 165 mg/dL, p = .037), lower mean daily glucose (157 vs 176 mg/dL, p < .001), and a higher proportion of glucose readings < 140 mg/dL (53% vs 31%, p < .001).

The basal bolus insulin also led to a lower frequency of complications including wound infection, pneumonia, bacteremia, respiratory failure, and acute renal failure (8.6% vs 24.3%, p = .003).

Among 13 patients in the basal bolus group and 21 in the regular insulin group admitted to the intensive care unit (ICU), the length of ICU stay was shorter in the basal bolus group (3.19 vs 1.23 days, p = .003).

However, basal bolus insulin was linked to a higher frequency of hypoglycemia (<70 mg/dL, 23.1% vs 4.7%, p M .001). Nevertheless, the difference between groups in severe hypoglycemia (< 40 mg/dL) was not statistically significant.

In 2007, Dr. Umpierrez and colleagues published a similar paper involving type 2 diabetics admitted to general medicine wards. As with surgical patients, a glargine/glulisine regimen provided better glycemic control with fewer complications than normal insulin given on a sliding scale.

Thus they conclude,