Daniela Barros, post graduate student of the Surgical Clinic Program at Ribeirão Preto Medical School, University of São Paulo (FMRP-USP). Ribeirão Preto, SP, Brasil.
A collaborative initiative between researchers from the University of São Paulo (SP, Brazil) and Emory University (Atlanta, USA), resulted in the retrospective study InsulinAPP application protocol for the inpatient management of type 2 diabetes on a hospitalist-managed ward: a retrospective study, published in the Archives of Endocrinology and Metabolism, vol.66 that looked at patients with type 2 diabetes (T2D) admitted from November 2018 to October 2019. The main goal was to assess metrics related to inpatient glycemic control using InsulinAPP, an application available for free in Brazil, on the hospitalist-managed ward of their hospital (TOYOSHIMA, M.T.K., et al.)
InsulinAPP recommends NPH and regular insulins three times a day, in bolus-correction or basal-bolus schemes. Parameters that included BG within range of 70-180 mg/dL, insulin treatment regimen and frequency of hypoglycemia were evaluated (TOYOSHIMA, M.T.K., et al.).
It’s noteworthy to elucidate that the hospitalist-led inpatient diabetes management program is an ideal model in institutional settings with limited endocrinology resources and champions the culture of inpatient glycemic management (DRINCIC, A.T., et al.). The present hospitalist-managed ward is a highly dependency unit that was established in March 2018, an innovative project in this Brazilian hospital, in which the hospitalist team became the main care team for patients with multiple comorbidities and high complexity. The hospitalist-managed ward has a total annual occupancy capacity of 9490 bed-days and an available computerized medical order entry (CPOE) system (TOYOSHIMA, M.T.K., et al.).
This retrospective study included individuals with T2D treated with the InsulinAPP protocol for at least 48 hours. Patients with a known history of T2D or with glycated hemoglobin (HbA1c) greater than 6.5% on admission were included (DRAZNIN, B., et al.). Individuals with type 1 diabetes, pregnancy, age < 18 years, end-of-life or palliative care, and participation in the protocol < 48 hours were excluded. A sequential and convenience sample was chosen, according to the inclusion and exclusion criteria. Clinical and laboratory data of patients were collected from electronic medical records (TOYOSHIMA, M.T.K., et al.).
The InsulinAPP application with this use of human insulins is effective and safe in the management of patients with T2D on the hospitalist-managed ward, with more than 70% BG measurements within the therapeutic range and a low rate of hypoglycemia. A systematic review analyzed other six applications of insulin therapy in hospitalized patients, and these proved to be useful, safe and with improved quality of life for patients, compared to the usual management (JONES, J.M.L., et al.). Many countries continue to use human insulin formulations (NPH/regular) as a standard of care, thus, the InsulinAPP application represents an important clinical tool for the management of patients with T2D (TOYOSHIMA, M.T.K., et al.).
Standardized insulin order sets are important for improving glucometrics and should be practical and easy to use for greater adherence by the medical staff (ALOI, J.A., et al.). InsulinAPP was considered easy to understand and easy to use by physicians from different specialties (JONES, J.M.L., et al.).
The Society of Hospital Medicine and other studies suggested that a simpler insulin therapy regimen than the basal-bolus might be used initially for T2D individuals with good outpatient glycemic control without insulin therapy or with mild inpatient hyperglycemia (MAYNARD, G., et al.; SADHU, A.R., et al.; MIGDAL, A.L., et al.; MIGDAL, A.L., et al).
In the present trial, 47% of the patients did not start insulin therapy with a basal-bolus regimen and around 30% of the total of patients did not need the basal-bolus regimen for glycemic control in the first ten days of hospitalization. Subjects with higher HbA1c and BG on admission started a basal-bolus insulin therapy regimen as foreseen in InsulinAPP protocol. The percentage of BG measurements within the range in the first ten days of the protocol was lower in the basal-bolus group, probably due to the higher BG on admission (TOYOSHIMA, M.T.K., et al.).
This study has some limitations, which include those inherent to a retrospective, single-institution study. About 75% of the patients included in the study were surgical patients. Therefore, the results should not be generalized to other wards with a different profile of inpatients. The study was not designed to show statistical differences between the group that had hypoglycemia and the one that did not. The InsulinAPP protocol was not evaluated after the first ten days of the protocol in this study. Thus, the results of the follow-up evaluations do not necessarily represent the conditions of the analysis throughout the entire hospitalization (TOYOSHIMA, M.T.K., et al.).
In conclusion, the authors agree that InsulinAPP is an effective and safe tool for adjusting human insulins doses in hospitalized patients with type 2 diabetes. Many countries use human insulins as a standard of care and a protocol using such insulins is of great importance. Furthermore, data such as these are important for the maintenance and continuous improvement of the quality of hospital service (TOYOSHIMA, M.T.K., et al.).
JONES, J.M.L. Estudo de validação de aplicativo para insulinização de pacientes com diabetes hospitalizados: InsulinAPP: Escola Bahiana de Medicina e Saúde Pública, Salvador, 2020 [viewed 19 October 2022]. Available from: https://repositorio.bahiana.edu.br:8443/jspui/handle/bahiana/6121
BARROS, D. InsulinAPP application is effective and safe for the management of hyperglycemia on a hospitalist-managed ward [online]. SciELO in Perspective | Press Releases, 2022 [viewed ]. Available from: https://pressreleases.scielo.org/en/2022/10/19/insulinapp-application-is-effective-and-safe-for-the-management-of-hyperglycemia-on-a-hospitalist-managed-ward/
A collaborative initiative between researchers from the University of São Paulo (SP, Brazil) and Emory University (Atlanta, USA), resulted in the retrospective study InsulinAPP application protocol for the inpatient management of type 2 diabetes on a hospitalist-managed ward: a retrospective study, published in the Archives of Endocrinology and Metabolism, vol.66 that looked at patients with type 2 diabetes (T2D) admitted from November 2018 to October 2019. The main goal was to assess metrics related to inpatient glycemic control using InsulinAPP, an application available for free in Brazil, on the hospitalist-managed ward of their hospital (TOYOSHIMA, M.T.K., et al.)
Recent Comments