This is the first randomized study comparing subcutaneous insulin regimens in non–critically ill inpatients with diabetes receiving ENT. Similar levels of glycemic control were achieved in each group, suggesting that early addition of basal insulin with careful attention to glycemic control is effective and safe in these patients.
The level of glycemic control achieved in this study is similar to that achieved in a prior report where subcutaneous insulin doses were based on an initial dose-finding regimen with intravenous insulin in patients receiving ENT (12
). Although intravenous insulin may offer advantages of rapid attainment of glycemic control during dose-defining periods, many hospitals do not permit this on general nursing units. In addition, the rate and duration of ENT can change frequently, requiring ongoing adjustments in scheduled insulin (13
Concern for hypoglycemia with basal insulin in patients receiving ENT contributes to an overdependence on SSRI regimens (6
). Although SSRI was effective in some patients in this and previous reports, any missed dose can result in hyperglycemia (14
). The subjects who continued SSRI alone in this study had lower glucose levels at randomization and were less likely to have preadmission diabetes. Administration of an SSRI may, thus, be a reasonable initial strategy for selected patients receiving ENT; however, it is important to initiate scheduled insulin once glucose levels exceed 10 mmol/l (7
This study has important implications for clinical practice. More than 50% of study patients had no prior history of diabetes, underscoring the importance of monitoring glucose levels with ENT initiation to allow identification of those requiring insulin (3
). These findings provide a guide for insulin therapy in inpatients who develop hyperglycemia during ENT.
The small number of patients is an important limitation to widespread application of this study. Although the glycemic control achieved was not optimal, frequent changes in the rate and type of ENT were contributing factors. Patients receiving ENT spend the majority of time in a postprandial state, with altering recommendations for glycemic control (4
). Studies that investigate strategies for safely achieving specified glycemic targets during ENT in larger numbers of patients are needed.
In conclusion, we demonstrated that the majority of non–critically ill inpatients will require basal insulin during ENT to achieve and maintain a reasonable degree of glucose control. Although SSRI may be an acceptable initial therapy in the setting of mild hyperglycemia or in patients without prior diabetes, scheduled insulin is required once a consistent insulin requirement is demonstrated.