Anne L. Peters, MD, CDE; Kathleen M. Dungan, MD


June 28, 2013

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Inpatient Prandial Insulin Management

Anne L. Peters, MD, CDE: Hi. I'm Dr. Anne Peters of the University of Southern California. I am speaking to you from the American Diabetes Association annual meetings in Chicago, Illinois. I am joined by Dr. Kathleen Dungan, Assistant Professor of Medicine in the Division of Endocrinology, Diabetes, and Metabolism at Ohio State University.

Your abstracts are in the field of inpatient diabetes management. Could you tell us what you found?

Kathleen M. Dungan, MD: For the past 5 years, our research has been in this area. The first study[1] that we are reporting is on the use of prandial insulin in hospitals. We did a randomized controlled trial comparing fixed meal dosing with carbohydrate counting in hospitals, and although ultimately we feel that the study was underpowered, we didn't find a difference in glycemic control, with the caveat that all of the dosing was done by the inpatient diabetes team.

Dr. Peters: In your model, who did the carbohydrate counting and how did they determine the doses?

Dr. Dungan: All of our meal trays for the past 6 years have come with a meal ticket that tells exactly how many carbohydrates are in each food item. The nurses would add up the amount of carbohydrates on the meal tray and then calculate the insulin dose and administer it to the patient. This was not new in our hospital, so it allowed us to study it in a rigorous way, and it required minimal training on the part of the nurses who were already accustomed to this type of meal delivery.

Dr. Peters: What was the other way of giving doses?

Dr. Dungan: The comparison was a fixed dose of insulin, regardless of the meal content. That is what is generally recommended and performed throughout the United States.

Dr. Peters: What about correcting? What if a patient's blood glucose was 200 mg/dL vs 100 mg/dL? Would the dose be corrected in both instances?

Dr. Dungan: Yes. In both cases we gave correction dosing. What was unique about our institution was that we can order these carbohydrate-counting doses in a rather straightforward way, as a low dose (1 unit per 20 g of carbohydrate) all the way up to the high dose (1 unit per 5 g of carbohydrate). It takes some of the mystery out of ordering by the inpatient diabetes team. We don't know whether we can we get the same outcomes if we allow general physicians to order the insulin dosing. Then it will get a little harder to do fixed meal dosing.

Dr. Peters: It also requires a team of registered dieticians working with you to figure out the carbohydrate content and allow those kinds of adjustments to be made, because determining the carbohydrate content in a meal is often a stumbling block for patients and for some providers. It's hard to count carbohydrates.

Dr. Dungan: We use this as a way to teach patients how many carbohydrates are in their juice or their bread, and hopefully they carry some of that knowledge home with them.


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