Inpatient and Outpatient Insulin Therapy in Treating Diabetes Mellitus

There is a great deal of evidence that tight glycemic control in the intensive care unit after surgery, especially cardiovascular surgery, shortens the duration of hospitalization and prevents complications. There are notable clinical and economic benefits. Components of effective inpatient glycemic control are: minimizing the use of sliding scale insulin, minimizing the risk of hyperglycemia with a basal/bolus insulin regimen, having an insulin infusion protocol designed to achieve target glucose levels in the 80 mg/dL to 110 mg/dL range, and having a transition protocol from insulin infusion therapy to sub-Q insulin.

In the outpatient setting, patients with type 1 diabetes should not be restricted to only one type of insulin. A better option for these patients is a long-acting insulin, such as Lantus or Levemir once or twice daily, combined with a short-acting or inhaled insulin before mealtimes. Patients who require bigger doses may require only one dose, but those requiring smaller doses only may need two doses. In patients with type 2 diabetes, oral agents are often not enough over time, so insulin is necessary to achieve a glycohemoglobin level of 6.5% or lower. Long-acting insulin should be an integral part of the program. If long-acting insulin alone is insufficient, additional short-acting insulin at mealtimes is needed. Premixed analogs (70/30 or 75/25) may also be useful. Multiple injections daily provide patients with more flexibility. Patients in both the inpatient and outpatient settings benefit from tight glycemic control.

In this conversation, two diabetes experts, Dr. Alan Gerber and Dr. Glenn Cunningham, join Dr. Carlos Hamilton to discuss current issues regarding insulin therapy.

Related References/Reading:

1. Van den Berghe G. Beyond diabetes: saving lives with insulin in the ICU. Int J Obes Relat Metab Disord. 2002;26 (Suppl):S3-S8.