Sliding Scale Insulin Regimens Demonstrate No Added Benefit For Patients with Type 2 Diabetes Mellitus

Contact:
Angela Lower
(800) 274-2237 ext. 5224
alower@aafp.org

LEAWOOD, Kan. - Debunking the common belief that sliding scale insulin (SSI) regimens are better able to maintain tight glycemic control and prevent glycemic events, a new study in the May/June 2003 issue of Annals of Family Medicine shows that the practice provides no benefit in glucose control or in the length of hospitalization for patients with type 2 diabetes mellitus (DM) who are hospitalized for other conditions.

"Our findings demonstrate that the addition of the SSI regimen or the use of routine diabetes medications alone are equally acceptable treatment strategies for managing diabetes in patients hospitalized for other illnesses," explained the study's lead author, Lori M. Dickerson, PharmD., B.C.P.S., from the Medical University of South Carolina. "Physicians should consider patient preferences in their treatment selection and consider the cost implications and additional nursing time demands before routinely ordering SSI coverage for their patients."

The SSI regimen consists of short-acting insulin four to six times a day based on regularly obtained capillary blood glucose measurements. The regimen is commonly used in belief that it is better able to maintain tight glycemic control and avoid glycemic events.

According to background information provided in the study, the SSI regimen has become a popular method of glucose control despite numerous problems associated with the practice, including an increase in the number of insulin injections, disruption of patients' sleep for monitoring and insulin therapy, and an increased risk of hyper- and hypoglycemia. Moreover, while tight glycemic control with insulin and glucose infusions have been shown to reduce mortality in patients with acute myocardial infarction and reduce morbidity and mortality in critically ill patients in the intensive care setting, there is no known benefit from tight glycemic control during hospitalization for many other illnesses.

Given the increased scrutiny of the SSI regimen, Dickerson and colleagues conducted a randomized clinical trial of 153 patients hospitalized between June 2000 and October 2001 to evaluate the effect of the SSI regimens on glycemic events and length of stay in patients with type 2 DM hospitalized for other co-morbid illnesses. The researchers measured the frequency of hyper- and hypoglycemic events as well as the length of hospitalization for all subjects.

The researchers found "no differences between the addition of an SSI regimen to routine medications and the use of routine medications alone with respect to the frequency of glycemic events or the length of hospitalization. Patients experienced a similar rate of hyperglycemia and hypoglycemia and length of stay regardless of treatment assigned."

Secondary findings by the researchers included three risk factors associated with glycemic events. They write, "Patients who were using intermediate acting insulin at the time of admission were nearly three times as likely to have glycemic events during their hospitalization. In addition, patients receiving corticosteroids and those with elevated blood glucose values greater than 250 mg/dL on admission were also six to nine times more likely to have glycemic events, regardless of the treatment assigned." The researchers suggest that the presence of these risk factors should prompt physicians to more closely monitor these patients.

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Editor's Note: This work was supported by a grant from the American Academy of Family Physicians Foundation and the American Academy of Family Physicians.

Annals of Family Medicine is a peer-reviewed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care discipline. Launched in May 2003, the journal is sponsored by six family medical organizations, including the American Academy of Family Physicians (AAFP), the American Board of Family Practice (ABFP), the Society of Teachers of Family Medicine (STFM), the Association of Departments of Family Medicine (ADFM), the Association of Family Practice Residency Directors (AFPRD) and the North American Primary Care Research Group (NAPCRG). The journal is published six times per year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. A board of directors with representatives from each of the sponsoring organizations oversees the Annals. Complete editorial content and interactive discussion groups can be accessed free of charge on the journal's Web site, www.annfammed.org.