LAS VEGAS – An outpatient protocol allowed for successful management of acute hyperglycemia in 20 of 27 patients who presented in a primary care setting with blood sugar levels 400 mg/dL or higher.
Inpatient protocols for managing diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) are well defined, with a strong evidence base, yet no such protocols exist for managing acute hyperglycemia in outpatient settings. Some data suggest that type 1 diabetes patients with mild DKA can be managed with subcutaneous rapid-acting insulin analogs in an outpatient setting (Diabetes Care 2004;27:1873-8), but it is currently unknown if symptomatic, mild hyperglycemia in type 2 diabetes patients can be managed adequately in such settings, said certified diabetes educator Becky Armor, PharmD., of the University of Oklahoma, Oklahoma City.
The study enrolled patients who were identified by the physician or nurse as having a fingerstick blood glucose level of 400 mg/dL or above, but who did not have an acute illness, moderate to large ketones, a venous glucose level of 700 mg/dL or higher, or new-onset diabetes. The setting was a freestanding academic family medicine practice that included a full-time diabetes clinic that serves more than 2,500 patients (Diabetes Ther. 2011;2:67-80).
The objective of the study was to determine if the protocol could push blood glucose levels below 300 mg/dL within a 4-hour window, Dr. Armor said.
The hyperglycemia protocol called for patients to be given 0.15 U/kg of rapid-acting insulin, injected subcutaneously into the abdomen (where absorption is fastest). Fingerstick blood glucose testing was done hourly. Lab work included a basic metabolic panel, urinalysis, and blood ketones. Hydration of 1,000 mL or more was given orally or intravenously. Diabetes drug therapy was reestablished. Sick-day management guidelines were reviewed with patients, many of whom had been unaware of them. Patients also were referred for more intensive diabetes management and were given instructions and told to return for follow-up within 72 hours.
Initial fingerstick glucose values could not be assessed in 4 of the 27 patients because the monitor used did not read above 600 mg/dL and simply read as "high." In the other 23 patients, average initial blood glucose was 484 mg/dL. For all 27, the final value achieved was 274 mg/dL, with an average time to achieving less than 300 mg/dL of 2.35 hours.
The protocol was successful in 20 of the 27 patients enrolled (74%). The reasons for lack of success in the other seven patients were not related to clinical issues but rather included transportation and/or communication problems, such as the patient having to leave to catch the last bus and then being unreachable by phone. One patient developed large blood ketones and was referred to the emergency department, Dr. Armor noted.
Predictors of protocol failure, assessed by logistic regression, included age greater than 65 years (both such patients failed the protocol), and "personal stress," such as loss of a job or serious illness of another family member. Indeed, the protocol succeeded in 85% of those without stress, while only 43% of those with personal stress were protocol successes. This is to be expected because the "stress hormones" cortisol and norepinephrine counter the effectiveness of insulin, she said.
Initial venous glucose also predicted success, with a mean of 351 mg/dL in the success group versus 406 mg/dL in the failure group, although the difference was not statistically significant.
"Primary care clinics need improved chronic care models, because keeping patients with diabetes in a system of care allows for resolution of issues leading up to acute hyperglycemic episodes. Managing acute hyperglycemia in the outpatient setting could potentially decrease the frequency of hyperglycemia and diabetes emergencies, and DKA- and HHS-related hospital admissions," Dr. Armor concluded.
The study was funded by the University of Oklahoma College of Pharmacy, Tulsa. Dr. Armor stated that she had no conflicts of interest.