Diabetes Technology Update: Use of Insulin Pumps and Continuous Glucose Monitoring in the Hospital

Guillermo E Umpierrez, David C Klonoff, Guillermo E Umpierrez, David C Klonoff

Abstract

The use of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) systems has gained wide acceptance in diabetes care. These devices have been demonstrated to be clinically valuable, improving glycemic control and reducing risks of hypoglycemia in ambulatory patients with type 1 diabetes and type 2 diabetes. Approximately 30-40% of patients with type 1 diabetes and an increasing number of insulin-requiring patients with type 2 diabetes are using pump and sensor technology. As the popularity of these devices increases, it becomes very likely that hospital health care providers will face the need to manage the inpatient care of patients under insulin pump therapy and CGM. The American Diabetes Association advocates allowing patients who are physically and mentally able to continue to use their pumps when hospitalized. Health care institutions must have clear policies and procedures to allow the patient to continue to receive CSII treatment to maximize safety and to comply with existing regulations related to self-management of medication. Randomized controlled trials are needed to determine whether CSII therapy and CGM systems in the hospital are associated with improved clinical outcomes compared with intermittent monitoring and conventional insulin treatment or with a favorable cost-benefit ratio.

© 2018 by the American Diabetes Association.

Figures

Figure 1
Figure 1
Recommendations on the course of action for hospitalized patient with T1D wearing an insulin pump (18). IV, intravenous; EGD, esophagogastroduodenoscopy.

References

    1. Centers for Disease Control and Prevention National Diabetes Statistics Report, 2017. Atlanta, GA, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2017
    1. Donnan PT, Leese GP, Morris AD; Diabetes Audit and Research in Tayside, Scotland/Medicine Monitoring Unit Collaboration . Hospitalizations for people with type 1 and type 2 diabetes compared with the nondiabetic population of Tayside, Scotland: a retrospective cohort study of resource use. Diabetes Care 2000;23:1774–1779
    1. American Diabetes Association Economic costs of diabetes in the U.S. in 2012 [published correction appears in Diabetes Care 2013;36:1797]. Diabetes Care 2013;36:1033–1046
    1. Moghissi ES, Korytkowski MT, DiNardo M, et al. .; American Association of Clinical Endocrinologists; American Diabetes Association . American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract 2009;15:353–369
    1. Umpierrez GE, Hellman R, Korytkowski MT, et al. .; Endocrine Society . Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2012;97:16–38
    1. Murad MH, Coburn JA, Coto-Yglesias F, et al. . Glycemic control in non-critically ill hospitalized patients: a systematic review and meta-analysis. J Clin Endocrinol Metab 2012;97:49–58
    1. Umpierrez GE, Smiley D, Jacobs S, et al. . 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;34:256–261
    1. Wexler DJ, Meigs JB, Cagliero E, Nathan DM, Grant RW. Prevalence of hyper- and hypoglycemia among inpatients with diabetes: a national survey of 44 U.S. hospitals. Diabetes Care 2007;30:367–369
    1. Umpierrez GE. Basal versus sliding-scale regular insulin in hospitalized patients with hyperglycemia during enteral nutrition therapy. Diabetes Care 2009;32:751–753
    1. Umpierrez GE, Smiley D, Hermayer K, et al. . 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;36:2169–2174
    1. Finfer S, Liu B, Chittock DR, et al. .; NICE-SUGAR Study Investigators . Hypoglycemia and risk of death in critically ill patients. N Engl J Med 2012;367:1108–1118
    1. Gamble JM, Eurich DT, Marrie TJ, Majumdar SR. Admission hypoglycemia and increased mortality in patients hospitalized with pneumonia. Am J Med 2010;123:556.e11–556.e16
    1. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 2002;87:978–982
    1. Chiang JL, Kirkman MS, Laffel LM, Peters AL; Type 1 Diabetes Sourcebook Authors . Type 1 diabetes through the life span: a position statement of the American Diabetes Association. Diabetes Care 2014;37:2034–2054
    1. Maahs DM, West NA, Lawrence JM, Mayer-Davis EJ. Epidemiology of type 1 diabetes. Endocrinol Metab Clin North Am 2010;39:481–497
    1. American Diabetes Association Statistics about diabetes: overall numbers, diabetes and prediabetes [Internet]. Available from . Accessed 22 March 2018
    1. Sayers A, Thayer D, Harvey JN, et al. . Evidence for a persistent, major excess in all cause admissions to hospital in children with type-1 diabetes: results from a large Welsh national matched community cohort study. BMJ Open 2015;5:e005644
    1. Mendez CE, Umpierrez GE. Management of type 1 diabetes in the hospital setting. Curr Diab Rep 2017;17:98.
    1. Icks A, Rosenbauer J, Holl RW, Grabert M, Rathmann W, Giani G; German Working Group for Pediatric Diabetology . Hospitalization among diabetic children and adolescents and the general population in Germany. Diabetes Care 2001;24:435–440
    1. Tomlin AM, Tilyard MW, Dovey SM, Dawson AG. Hospital admissions in diabetic and non-diabetic patients: a case-control study. Diabetes Res Clin Pract 2006;73:260–267
    1. Viens NA, Hug KT, Marchant MH, Cook C, Vail TP, Bolognesi MP. Role of diabetes type in perioperative outcomes after hip and knee arthroplasty in the United States. J Surg Orthop Adv 2012;21:253–260
    1. Robertshaw HJ, Hall GM. Diabetes mellitus: anaesthetic management. Anaesthesia 2006;61:1187–1190
    1. Cryer PE. Hypoglycemia in type 1 diabetes mellitus. Endocrinol Metab Clin North Am 2010;39:641–654
    1. Heinemann L, Fleming GA, Petrie JR, Holl RW, Bergenstal RM, Peters AL. Insulin pump risks and benefits: a clinical appraisal of pump safety standards, adverse event reporting, and research needs: a joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care 2015;38:716–722
    1. Lansang MC, Modic MB, Sauvey R, et al. . Approach to the adult hospitalized patient on an insulin pump. J Hosp Med 2013;8:721–727
    1. Beck RW, Tamborlane WV, Bergenstal RM, Miller KM, DuBose SN, Hall CA; T1D Exchange Clinic Network . The T1D Exchange clinic registry. J Clin Endocrinol Metab 2012;97:4383–4389
    1. Blackman SM, Raghinaru D, Adi S, et al. . Insulin pump use in young children in the T1D Exchange clinic registry is associated with lower hemoglobin A1c levels than injection therapy. Pediatr Diabetes 2014;15:564–572
    1. Orchard TJ, Nathan DM, Zinman B, et al. .; Writing Group for the DCCT/EDIC Research Group . Association between 7 years of intensive treatment of type 1 diabetes and long-term mortality. JAMA 2015;313:45–53
    1. Cook CB, McNaughton DA, Braddy CM, et al. . Management of inpatient hyperglycemia: assessing perceptions and barriers to care among resident physicians. Endocr Pract 2007;13:117–124
    1. Houlden RL, Moore S. In-hospital management of adults using insulin pump therapy. Can J Diabetes 2014;38:126–133
    1. Noschese ML, DiNardo MM, Donihi AC, et al. . Patient outcomes after implementation of a protocol for inpatient insulin pump therapy. Endocr Pract 2009;15:415–424
    1. Cook CB, Beer KA, Seifert KM, Boyle ME, Mackey PA, Castro JC. Transitioning insulin pump therapy from the outpatient to the inpatient setting: a review of 6 years’ experience with 253 cases. J Diabetes Sci Technol 2012;6:995–1002
    1. Kannan S, Satra A, Calogeras E, Lock P, Lansang MC. Insulin pump patient characteristics and glucose control in the hospitalized setting. J Diabetes Sci Technol 2014;8:473–478
    1. Bailon RM, Partlow BJ, Miller-Cage V, et al. . Continuous subcutaneous insulin infusion (insulin pump) therapy can be safely used in the hospital in select patients. Endocr Pract 2009;15:24–29
    1. American Diabetes Association 14. Diabetes care in the hospital: Standards of Medical Care in Diabetes—2018. Diabetes Care 2018;41(Suppl. 1):S144–S151
    1. Funnell MM, Brown TL, Childs BP, et al. . National Standards for Diabetes Self-Management Education. Diabetes Care 2011;34(Suppl. 1):S89–S96
    1. Grunberger G, Bailey TS, Cohen AJ, et al. .; AACE Insulin Pump Management Task Force . Statement by the American Association of Clinical Endocrinologists Consensus Panel on insulin pump management. Endocr Pract 2010;16:746–762
    1. Yogi-Morren D, Lansang MC. Management of patients with type 1 diabetes in the hospital. Curr Diab Rep 2014;14:458.
    1. Moghissi ES, Korytkowski MT, DiNardo M, et al. .; American Association of Clinical Endocrinologists; American Diabetes Association . American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care 2009;32:1119–1131
    1. Bode BW. Use of rapid-acting insulin analogues in the treatment of patients with type 1 and type 2 diabetes mellitus: insulin pump therapy versus multiple daily injections. Clin Ther 2007;29(Suppl. D):S135–S144
    1. Klonoff DC, Freckmann G, Heinemann L. Insulin pump occlusions: for patients who have been around the (infusion) block. J Diabetes Sci Technol 2017;11:451–454
    1. Sobel SI, Augustine M, Donihi AC, Reider J, Forte P, Korytkowski M. Safety and efficacy of a peri-operative protocol for patients with diabetes treated with continuous subcutaneous insulin infusion who are admitted for same-day surgery. Endocr Pract 2015;21:1269–1276
    1. Corney SM, Dukatz T, Rosenblatt S, et al. . Comparison of insulin pump therapy (continuous subcutaneous insulin infusion) to alternative methods for perioperative glycemic management in patients with planned postoperative admissions. J Diabetes Sci Technol 2012;6:1003–1015
    1. García-Patterson A, Gich I, Amini SB, Catalano PM, de Leiva A, Corcoy R. Insulin requirements throughout pregnancy in women with type 1 diabetes mellitus: three changes of direction. Diabetologia 2010;53:446–451
    1. Roeder HA, Moore TR, Ramos GA. Insulin pump dosing across gestation in women with well-controlled type 1 diabetes mellitus. Am J Obstet Gynecol 2012;207:324.e1–324.e5
    1. Farrar D, Tuffnell DJ, West J, West HM. Continuous subcutaneous insulin infusion versus multiple daily injections of insulin for pregnant women with diabetes. Cochrane Database Syst Rev 2016;(6):CD005542.
    1. Bruttomesso D, Bonomo M, Costa S, et al. .; Italian Group for Continuous Subcutaneous Insulin Infusion in Pregnancy . Type 1 diabetes control and pregnancy outcomes in women treated with continuous subcutaneous insulin infusion (CSII) or with insulin glargine and multiple daily injections of rapid-acting insulin analogues (glargine-MDI). Diabetes Metab 2011;37:426–431
    1. Wender-Ozegowska E, Zawiejska A, Ozegowska K, et al. . Multiple daily injections of insulin versus continuous subcutaneous insulin infusion for pregnant women with type 1 diabetes. Aust N Z J Obstet Gynaecol 2013;53:130–135
    1. Feldman AZ, Brown FM. Management of type 1 diabetes in pregnancy. Curr Diab Rep 2016;16:76.
    1. Clarke SF, Foster JR. A history of blood glucose meters and their role in self-monitoring of diabetes mellitus. Br J Biomed Sci 2012;69:83–93
    1. Skyler JS. CGM—a technology in evolution. Diabetes Technol Ther 2009;11:63–64
    1. Adamson TL, Eusebio FA, Cook CB, LaBelle JT. The promise of electrochemical impedance spectroscopy as novel technology for the management of patients with diabetes mellitus. Analyst (Lond) 2012;137:4179–4187
    1. Wallia A, Umpierrez GE, Rushakoff RJ, et al. .; DTS Continuous Glucose Monitoring in the Hospital Panel . Consensus statement on inpatient use of continuous glucose monitoring. J Diabetes Sci Technol 2017;11:1036–1044
    1. Clinical and Laboratory and Standards Institute (CLSI) Performance Metrics for Continuous Interstitial Glucose Monitoring: Approved Guideline. Wayne, PA, Clinical and Laboratory Standards Institute, 2008. (CLSI document POCT05-A)
    1. Krinsley JS, Chase JG, Gunst J, et al. . Continuous glucose monitoring in the ICU: clinical considerations and consensus. Crit Care 2017;21:197.
    1. Klonoff DC, Buckingham B, Christiansen JS, et al. .; Endocrine Society . Continuous glucose monitoring: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011;96:2968–2979
    1. Goldberg PA, Siegel MD, Russell RR, et al. . Experience with the continuous glucose monitoring system in a medical intensive care unit. Diabetes Technol Ther 2004;6:339–347
    1. Corstjens AM, Ligtenberg JJ, van der Horst IC, et al. . Accuracy and feasibility of point-of-care and continuous blood glucose analysis in critically ill ICU patients. Crit Care 2006;10:R135.
    1. De Block C, Manuel-Y-Keenoy B, Van Gaal L, Rogiers P. Intensive insulin therapy in the intensive care unit: assessment by continuous glucose monitoring. Diabetes Care 2006;29:1750–1756
    1. Yamashita K, Okabayashi T, Yokoyama T, et al. . Accuracy and reliability of continuous blood glucose monitor in post-surgical patients. Acta Anaesthesiol Scand 2009;53:66–71
    1. Holzinger U, Warszawska J, Kitzberger R, Herkner H, Metnitz PG, Madl C. Impact of shock requiring norepinephrine on the accuracy and reliability of subcutaneous continuous glucose monitoring. Intensive Care Med 2009;35:1383–1389
    1. Logtenberg SJ, Kleefstra N, Snellen FT, et al. . Pre- and postoperative accuracy and safety of a real-time continuous glucose monitoring system in cardiac surgical patients: a randomized pilot study. Diabetes Technol Ther 2009;11:31–37
    1. Rabiee A, Andreasik V, Abu-Hamdah R, et al. . Numerical and clinical accuracy of a continuous glucose monitoring system during intravenous insulin therapy in the surgical and burn intensive care units. J Diabetes Sci Technol 2009;3:951–959
    1. Holzinger U, Warszawska J, Kitzberger R, et al. . Real-time continuous glucose monitoring in critically ill patients: a prospective randomized trial. Diabetes Care 2010;33:467–472
    1. Jacobs B, Phan K, Bertheau L, Dogbey G, Schwartz F, Shubrook J. Continuous glucose monitoring system in a rural intensive care unit: a pilot study evaluating accuracy and acceptance. J Diabetes Sci Technol 2010;4:636–644
    1. Brunner R, Kitzberger R, Miehsler W, Herkner H, Madl C, Holzinger U. Accuracy and reliability of a subcutaneous continuous glucose-monitoring system in critically ill patients. Crit Care Med 2011;39:659–664
    1. Lorencio C, Leal Y, Bonet A, et al. . Real-time continuous glucose monitoring in an intensive care unit: better accuracy in patients with septic shock. Diabetes Technol Ther 2012;14:568–575
    1. Kopecký P, Mráz M, Bláha J, et al. . The use of continuous glucose monitoring combined with computer-based eMPC algorithm for tight glucose control in cardiosurgical ICU. BioMed Res Int 2013;2013:186439.
    1. Rodríguez-Quintanilla KA, Lavalle-González FJ, Mancillas-Adame LG, Zapata-Garrido AJ, Villarreal-Pérez JZ, Tamez-Pérez HE. Continuous glucose monitoring in acute coronary syndrome. Arch Cardiol Mex 2013;83:237–243
    1. Ballesteros D, Martínez Ó, Blancas Gómez-Casero R, et al. . Continuous tissue glucose monitoring correlates with measurement of intermittent capillary glucose in patients with distributive shock. Med Intensiva 2015;39:405–411
    1. Boom DT, Sechterberger MK, Rijkenberg S, et al. . Insulin treatment guided by subcutaneous continuous glucose monitoring compared to frequent point-of-care measurement in critically ill patients: a randomized controlled trial. Crit Care 2014;18:453.
    1. Kosiborod M, Gottlieb RK, Sekella JA, et al. . Performance of the Medtronic Sentrino continuous glucose management (CGM) system in the cardiac intensive care unit. BMJ Open Diabetes Res Care 2014;2:e000037
    1. Leelarathna L, English SW, Thabit H, et al. . Accuracy of subcutaneous continuous glucose monitoring in critically ill adults: improved sensor performance with enhanced calibrations. Diabetes Technol Ther 2014;16:97–101
    1. De Block CE, Gios J, Verheyen N, et al. . Randomized evaluation of glycemic control in the medical intensive care unit using real-time continuous glucose monitoring (REGIMEN trial). Diabetes Technol Ther 2015;17:889–898
    1. Punke MA, Decker C, Wodack K, Reuter DA, Kluge S. Continuous glucose monitoring on the ICU using a subcutaneous sensor. Med Klin Intensivmed Notf Med 2015;110:360–363
    1. van Hooijdonk RT, Leopold JH, Winters T, et al. . Point accuracy and reliability of an interstitial continuous glucose-monitoring device in critically ill patients: a prospective study. Crit Care 2015;19:34.
    1. Gottschalk A, Welp HA, Leser L, Lanckohr C, Wempe C, Ellger B. Continuous glucose monitoring in patients undergoing extracorporeal ventricular assist therapy. PLoS One 2016;11:e0148778.
    1. Umbrello M, Salice V, Spanu P, et al. . Performance assessment of a glucose control protocol in septic patients with an automated intermittent plasma glucose monitoring device. Clin Nutr 2014;33:867–871
    1. Sechterberger MK, van der Voort PH, Strasma PJ, DeVries JH. Accuracy of intra-arterial and subcutaneous continuous glucose monitoring in postoperative cardiac surgery patients in the ICU. J Diabetes Sci Technol 2015;9:663–667
    1. Nohra E, Buckman S, Bochicchio K, et al. . Results of a near continuous glucose monitoring technology in surgical intensive care and trauma. Contemp Clin Trials 2016;50:1–4
    1. Righy Shinotsuka C, Brasseur A, Fagnoul D, So T, Vincent JL, Preiser JC. Manual versus Automated moNitoring Accuracy of GlucosE II (MANAGE II). Crit Care 2016;20:380.
    1. Wollersheim T, Engelhardt LJ, Pachulla J, et al. . Accuracy, reliability, feasibility and nurse acceptance of a subcutaneous continuous glucose management system in critically ill patients: a prospective clinical trial. Ann Intensive Care 2016;6:70.
    1. Bochicchio GV, Nasraway S, Moore L, Furnary A, Nohra E, Bochicchio K. Results of a multicenter prospective pivotal trial of the first inline continuous glucose monitor in critically ill patients. J Trauma Acute Care Surg 2017;82:1049–1054
    1. Rijkenberg S, van Steen SC, DeVries JH, van der Voort PHJ. Accuracy and reliability of a subcutaneous continuous glucose monitoring device in critically ill patients. J Clin Monit Comput. 7 December 2017 [Epub ahead of print]. DOI: 10.1007/s10877-017-0086-z
    1. Schierenbeck F, Franco-Cereceda A, Liska J. Accuracy of 2 different continuous glucose monitoring systems in patients undergoing cardiac surgery. J Diabetes Sci Technol 2017;11:108–116
    1. Burt MG, Roberts GW, Aguilar-Loza NR, Stranks SN. Brief report: comparison of continuous glucose monitoring and finger-prick blood glucose levels in hospitalized patients administered basal-bolus insulin. Diabetes Technol Ther 2013;15:241–245
    1. Schaupp L, Donsa K, Neubauer KM, et al. . Taking a closer look—continuous glucose monitoring in non-critically ill hospitalized patients with type 2 diabetes mellitus under basal-bolus insulin therapy. Diabetes Technol Ther 2015;17:611–618
    1. Gómez AM, Umpierrez GE, Muñoz OM, et al. . Continuous glucose monitoring versus capillary point-of-care testing for inpatient glycemic control in type 2 diabetes patients hospitalized in the general ward and treated with a basal bolus insulin regimen. J Diabetes Sci Technol 2015;10:325–329
    1. Gu W, Liu Y, Chen Y, et al. . Multicentre randomized controlled trial with sensor-augmented pump vs multiple daily injections in hospitalized patients with type 2 diabetes in China: time to reach target glucose. Diabetes Metab 2017;43:359–363
    1. OptiScan Biomedical Corporation OptiScan Biomedical’s OptiScanner® 5000 receives 510(k) clearance from US Food and Drug Administration for the first inline continuous glucose monitor in the SICU [article online]. PR Newswire, 18 October 2017. Available from . Accessed 17 October 2017
    1. Wallia A, Umpierrez GE, Nasraway SA, Klonoff DC; PRIDE Investigators . Round table discussion on inpatient use of continuous glucose monitoring at the International Hospital Diabetes Meeting. J Diabetes Sci Technol 2016;10:1174–1181
    1. Gomez AM, Umpierrez GE. Continuous glucose monitoring in insulin-treated patients in non-ICU settings. J Diabetes Sci Technol 2014;8:930–936
    1. Levitt DL, Silver KD, Spanakis EK. Inpatient continuous glucose monitoring and glycemic outcomes. J Diabetes Sci Technol 2017;11:1028–1035
    1. Spanakis EK, Levitt DL, Siddiqui T, et al. . The effect of continuous glucose monitoring in preventing inpatient hypoglycemia in general wards: the glucose telemetry system. J Diabetes Sci Technol 2018;12:20–25
    1. Peyser T, Dassau E, Breton M, Skyler JS. The artificial pancreas: current status and future prospects in the management of diabetes. Ann N Y Acad Sci 2014;1311:102–123
    1. Hanazaki K, Munekage M, Kitagawa H, et al. . Current topics in glycemic control by wearable artificial pancreas or bedside artificial pancreas with closed-loop system. J Artif Organs 2016;19:209–218
    1. Mibu K, Yatabe T, Hanazaki K. Blood glucose control using an artificial pancreas reduces the workload of ICU nurses. J Artif Organs 2012;15:71–76
    1. Okabayashi T, Shima Y, Sumiyoshi T, et al. . Intensive versus intermediate glucose control in surgical intensive care unit patients. Diabetes Care 2014;37:1516–1524
    1. Namikawa T, Munekage M, Kitagawa H, et al. . Comparison between a novel and conventional artificial pancreas for perioperative glycemic control using a closed-loop system. J Artif Organs 2017;20:84–90
    1. Thabit H, Hovorka R. Bridging technology and clinical practice: innovating inpatient hyperglycaemia management in non-critical care settings. Diabet Med 2018;35:460–471
    1. Peters AL, Ahmann AJ, Battelino T, et al. . Diabetes technology—continuous subcutaneous insulin infusion therapy and continuous glucose monitoring in adults: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2016;101:3922–3937
    1. Handelsman Y, Bloomgarden ZT, Grunberger G, et al. . American Association of Clinical Endocrinologists and American College of Endocrinology – clinical practice guidelines for developing a diabetes mellitus comprehensive care plan – 2015. Endocr Pract 2015;21(Suppl. 1):1–87
    1. Rodbard D. Continuous glucose monitoring: a review of recent studies demonstrating improved glycemic outcomes. Diabetes Technol Ther 2017;19:S25–S37
    1. DeJournett L, DeJournett J. In silico testing of an artificial-intelligence-based artificial pancreas designed for use in the intensive care unit setting. J Diabetes Sci Technol 2016;10:1360–1371

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir