Insulin Schemes for Type 2 Diabetes Control

On the first 4 to 6 h, the use of NPH insulin present a pronounced action peak on the postprandial glucose metabolism, and the rest of its basal action last 12 to 18 h, its cover the postprandial requirements of the first two meals of the day (breakfast and lunch) administering 2/3 of the total dose, and the requirements for the dinner with 1/3 of the total dose at the night. This is considered a good scheme for handling hyperglycemia, and its possible to have less hypoglycemia episodes, which are possible if an ultra-rapid-acting insulin is added and adequate intake is not performed due to multiple factors related to hospitalization.

Today it is uncertain whether there is any clear benefit of using Glargine plus Lantus insulin over NPH insulin in hospitalized patients with type 2 diabetes. Currently, both Glargine and NPH based regimen is practiced in inpatient hospital facilities. Current practice of inpatient insulin regimen is based on the physicians familiarity with a particular insulin type and personal preference rather than evidenced based knowledge. Glargine plus ultrafast insulin are two types of insulin that are more expensive compared to NPH with incidental benefits in hospitalized patients. There are reports in the literature about the incidence of hypoglycemia with this scheme. The current research proposal is to compare these two schemes in the treatment of hospitalized patients with diabetes in a hospital of the second level of care in Mexico.

• NPH insulin (Drug), also known as NPH: NPH insulin twice daily, 2/3 in the morning and 1/3 in the night. A correctional dose of lispro insulin will be given for any blood glucose >180 mg/dL.
• Glargine and Lispro insulin (Drug), also known as Glargine and Lispro: Half of the total Glargine and Lispro insulin dose will be given as glargine once daily, either in the morning or in the evening, depending on when the patient was enrolled. The other half of the total daily insulin dose was given as Lispro; doses were divided equally between breakfast, lunch, and dinner.

Primary outcomes

• Differences in the Mean Daily Blood Glucose Between a Basal-bolus Scheme and NPH Schemes of Insulin. [Fasting blood glucose was taken every day, before breakfast, up to 4 weeks; postprandial glucose was taken every day, 2 hours after breakfast, 2 hours after lunch, and 2 hours after dinner, up to 4 weeks; glucose early morning was taken 3 am, up to 4 week]: To determine the differences in the mean daily blood glucose measured in mg/dl, between a basal-bolus scheme and NPH schemes of insulin measured by the mean daily blood glucose.

Secondary outcomes

• the Number of Participants With Mild and Severe Hypoglycemic Events [Duration of hospital stay, up to 4 weeks.]: To measure the number of participants with mild and severe hypoglycemic events
• Number of Participants With Sustained Glycemic Control During Hospital Stay [blood glucose was taken every day, up to 4 weeks.]: Sustained glycemic control were the number of participants who not had: discharged before sustained control, critical status suspension, death before control, bad attachment to the protocol, interruption due to more than 2 hypoglycemic events during their hospital stay.

Sex: All, ages: 18 Years to 100 Years

Inclusion Criteria:

* Patients between 18 and 100 years old.
* History of type 2 diabetes mellitus (DM2) or that upon admission is diagnosed by values of glycated haemoglobin (HbA1) > 6.5%
* Fasting central glucose before randomization between 140mg/dl and 400mg/dl
* Non-critical patients hospitalized in the service of Internal Medicine (MI), General Surgery (CG) and Traumatology (TyO).
* Patients receiving a diabetic diet orally
* Treated with diet alone, o any combination of oral anti-diabetic agents or insulin treatment with any dosage before admission.

Exclusion Criteria:

* Parenteral nutrition
* Hyperglycemia without a known history of diabetes
* Impaired renal function (glomerular filtration rate less than 30)
* Diabetic ketoacidosis and hyperosmolar state
* Type 1 Diabetes mellitus
* Pregnancy
* Patients on treatment with more than 10mg prednisone or steroid boluses.
* Known hypopituitarism or adrenal insufficiency
* Hyperglycaemia due to stress (negative antecedent of DM2, hyperglycemia and HbA1 <6.5)
* Severe liver disease (Child-Pugh C score)
* Acute pancreatitis
* Patients with sepsis or multiple organ failure
* Candidates for intensive care unit

Participant flow

Outcome results

• Differences in the Mean Daily Blood Glucose Between a Basal-bolus Scheme and NPH Schemes of Insulin. (Primary), Mean, mg/dl: NPH Insulin Group 129.6 +/- 23.6; Glargine and Lispro Insulin Group 135 +/- 22.6
• the Number of Participants With Mild and Severe Hypoglycemic Events (Secondary), Count of participants, Participants: NPH Insulin Group 15; Glargine and Lispro Insulin Group 15
• Number of Participants With Sustained Glycemic Control During Hospital Stay (Secondary), Count of participants, Participants: NPH Insulin Group 30; Glargine and Lispro Insulin Group 20

Adverse events

Time frame: 4 weeks

Other adverse events by term

Limitations and caveats: Although the patients had an oral diet, the prolonged stay due to complications not associated with DM2 reduced their caloric intake. The physiological scheme is more demanding, making it difficult to stick to the ideal conditions of the study.

• Umpierrez GE, Smiley D, Jacobs S, Peng L, Temponi A, Mulligan P, Umpierrez D, Newton C, Olson D, Rizzo M. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery (RABBIT 2 surgery). Diabetes Care. 2011 Feb;34(2):256-61. doi: 10.2337/dc10-1407. Epub 2011 Jan 12. PMID 21228246
• Umpierrez GE, Smiley D, Hermayer K, Khan A, Olson DE, Newton C, Jacobs S, Rizzo M, Peng L, Reyes D, Pinzon I, Fereira ME, Hunt V, Gore A, Toyoshima MT, Fonseca VA. Randomized study comparing a Basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013 Aug;36(8):2169-74. doi: 10.2337/dc12-1988. Epub 2013 Feb 22. PMID 23435159
• Christensen MB, Gotfredsen A, Norgaard K. Efficacy of basal-bolus insulin regimens in the inpatient management of non-critically ill patients with type 2 diabetes: A systematic review and meta-analysis. Diabetes Metab Res Rev. 2017 Jul;33(5). doi: 10.1002/dmrr.2885. Epub 2017 Feb 23. PMID 28067472

• Study Protocol, Statistical Analysis Plan, and Informed Consent Form (PDF, 2019-08-02)

• Jose A Alvarez, PhD, Principal investigator, Universidad de Guanajuato