Updating beers criteria
Successful implementation of these practices can reduce the burden diabetes places on the healthcare system while improving the patient’s quality of life. Coggins, Pharm D, CGP, FASCP, is a director of pharmacy services for more than 300 skilled nursing centers operated by Golden Living and a director on the board of the American Society of Consultant Pharmacists. He was recognized by the Commission for Certification in Geriatric Pharmacy with the 2010 Excellence in Geriatric Pharmacy Practice Award.. Insulin administered in response to current blood glucose alone can compound a prior dosing error, which can lead to significant fluctuations in high and low blood glucose levels.The risk of hypoglycemia is of significant concern since administering insulin doses without regard to meal intake and other factors can result in excessive doses of insulin being administered.5 Another common sliding-scale insulin scenario occurs when a patient does not receive insulin when his or her glucose level is normal.Issues related to hypoglycemia, when severe and left untreated, can lead to unconsciousness, seizures, coma, or even death.1 Continued Widespread Sliding-Scale Insulin Use Glycemic control in many hospitalized diabetic patients who are not critically ill remains suboptimal in part due to the continued use of sliding-scale insulin regimens despite more than 40 years’ worth of studies questioning the practice’s effectiveness and numerous diabetic best practice treatment guidelines recommending its discontinuation.3 One of the largest cohort studies done to date found that 76% of general medical inpatients received sliding-scale insulin, with these regimens not only failing to control hyperglycemia but also resulting in more episodes of hypoglycemia and longer hospital stays.Additionally, patients on these regimens experienced blood glucose levels greater than 300 mg/d L at a rate three times that of patients on other insulin regimens that were more intensive and physiological based.4 Clinicians’ failure to adjust sliding-scale insulin to improve glycemic control once these regimens have been implemented is an issue in both hospitals and nursing homes.Regular insulin isn’t recommended for the nutritional component because its longer duration doesn’t mimic normal physiologic insulin production.
A multidisciplinary effort is necessary to push back against the continued use of sliding-scale insulin, and the healthcare team must design and implement adequate policies to promote the use of these newer insulin regimens.
A retrospective observational study conducted at a large medical center observed 84% of patients on sliding-scale insulin experienced hyperglycemia, with dosage adjustments occurring in only 18% of these patients.5 A longitudinal study reviewed 9,804 diabetic patients aged 65 and older who had resided in a nursing home for at least one month.
Fifty-four percent of the patients were started on sliding-scale insulin during their stay, and 22% of all insulin orders in the facilities involved a sliding-scale regimen.
The nutritional dose is then added to the correctional dose to obtain the total rapid-acting insulin dose required for that meal.
Additional considerations to further individualize insulin therapy are weight-based correction insulin regimens. Golightly LK, Jones MA, Hamamura DH, Stolpman NM, Mc Dermott MT.