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Insulin glargine in enteric tube feeding
Diabetes Research and Clinical Practice 78 (2007) 298–299 www.elsevier.com/locate/diabres
Correspondence Insulin glargine in enteric tube feeding Insulin glargine, a long-acting insulin analogue, was introduced to provide effective basal insulin replacement with once-daily dosing. An insulin regimen with insulin glargine allows optimal glucose control with a lower risk of hypoglycaemia compared with neutral protaminated hagedorn insulin in Type 2 diabetes [1,2]. Recently, insulin glargine has been proposed for patients on continuous enteral artificial nutrition [3,4]. We report an 18-month follow-up of a patient treated with basal insulin glargine during continuous enteral nutrition and thereafter during intermittent enteral nutrition without evidence of hypoglycaemic events. The patient, a 75-year-old woman with Alzheimer’s disease and Type 2 diabetes, was admitted to our department in June 2005 after a suspected ischaemic brain event, and with severe hyperglycaemia and dehydration. She developed progressive cognitive impairment at the age of 58 years, and in the last 7 years she had developed progressive impairment of personal autonomy. She was diagnosed with Type 2 diabetes 5 years ago and, before this admission, had been managed with diet intervention; her weight was 59 kg and her metabolic control was reported as fair. On admission, the patient was semiconscious and appeared drowsy and lethargic. Laboratory assessment revealed blood chemistry as follows: blood glucose 28.1 mmol/L (505 mg/dL), sodium 163 mEq/L, chloride 116 mEq/L and creatinine 1.23 mg/dL. Oropharyngeal candidiasis was present and she required intensive intravenous therapy and peripheral parenteral nutrition for 17 days. Insulin (60–70 U) was initiated to stabilize blood glucose levels. The patients remained severely anorexic, so a percutaneous endoscopic gastrostomy tube was introduced to allow enteral feeding with a diabetes-specific, low-carbohydrate formula (approximately 1900 kcal/ day), following which her insulin requirement decreased. Good metabolic control was achieved with
15 U insulin glargine/day. She was discharged on total enteral nutrition. Although the patient was unable to take responsibility for her own healthcare management, including enteral feeding, insulin administration and blood glucose monitoring, her family decided to look after her at home, where, with the help of another elderly person, they could personally take care of her. The patient resides in an outlying urban area with limited medical facilities nearby. Home clinical monitoring was carried out via telephone counselling; blood glucose was determined at 12-h intervals and maintained within an acceptable range (5.5–10 mmol/L [100–180 mg/ dL]) with glargine (15 U/day). HbA1c was 6.7% 2 months after discharge. After 6 months, the patient’s health status improved: she gained 6 kg body weight and could consume some food orally; enteral feeding was reduced and limited to overnight. Even during this period, blood glucose levels were between 8.9–10 mmol/L (160–180 mg/dL) in the morning and 4.4–5.5 mmol/L (80–100 mg/dL) in the evening. There were no episodes of symptomatic hypoglycaemia (<3.3 mmol/L [60 mg/dL]) or hyperglycaemia (>11.1 mmol/L [200 mg/dL]) and the patient maintained a constant body weight during the 18-month follow-up. Considering the age of the patient and the difficulties in obtaining an intensive clinical monitoring, we decided not to strive for optimal glycaemic control. Currently, the patient has been living at home for 18 months and she has had no additional clinical problems or required further hospitalization. Once-daily insulin glargine, to substitute basal insulin requirements, was shown to be safe and effective in keeping the patient asymptomatic with a good quality of life whilst living with her family. When enteral nutrition was suspended during the day, no episodes of hypoglycaemia were reported. Despite the serious
0168-8227/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2007.03.011
Correspondence / Diabetes Research and Clinical Practice 78 (2007) 298–299
hyperglycaemic state of the patient when she arrived at the hospital, the patient had been suffering from Type 2 diabetes for a relatively brief time (5 years), and most likely had residual insulin production, which is supported by her requirement for a low dose of insulin glargine. We hypothesize that administration of a small dose of basal insulin prevented excessive increase of blood glucose and allowed some endogenous insulin production, which contributed to her glycaemic control. Our observation is consistent with data by Schreiber and Haak reporting a low-insulin requirement in early stage of Type 2 diabetes [2]. This case study supports the use of once-daily insulin glargine as a safe and effective treatment option for an elderly patient with significant neurological disabilities and limited medical and nursing assistance. The patient remained asymptomatic and with a quality of life consistent with living at home with her family, without experiencing troublesome and dangerous hypoglycaemic episodes. References [1] J. Rosenstock, G. Daily, M. Massi-Benedetti, A. Fritsche, Z. Lin, A. Salzman, Reduced hypoglycemia risk with insulin glargine: a meta-analysis comparing insulin glargine with human NPH insulin in type 2 diabetes, Diabetes Care 28 (2005) 950–955.
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[2] S.A. Schreiber, T. Haak, Insulin glargine benefits with type 2 diabetes inadequately controlled on oral antidiabetic treatment: an observational study of everyday practice in 12,216 patients, Diabetes Obes. Metab. 9 (2007) 31–38. [3] D. Putz, U.M. Kabadi, Insulin glargine in continuous enteric tube feeding, Diabetes Care 25 (2002) 1889–1890. [4] G. Fatati, E. Mirri, S. Del Tosto, M. Palazzi, A.M. Vendetti, R. Mattei, et al., Use of insulin glargine in patients with hyperglycaemia receiving artificial nutrition, Acta Diabetol. 42 (2005) 182–186.
Gloria Marchetti Manfredi Tesauro Nicola Di Daniele Maria Rosa Bollea Renato Lauro Aldo Bertoli* Department of Internal Medicine, Universita` di Roma Tor Vergata, Via Montpellier, 1-00133 Roma, Italy *Corresponding author. Tel.: +39 06 2090 3618; fax: +39 06 2090 2679 E-mail address: [email protected] (A. Bertoli) 9 February 2007 Available online 3 May 2007
Correspondence Insulin glargine in enteric tube feeding Insulin glargine, a long-acting insulin analogue, was introduced to provide effective basal insulin replacement with once-daily dosing. An insulin regimen with insulin glargine allows optimal glucose control with a lower risk of hypoglycaemia compared with neutral protaminated hagedorn insulin in Type 2 diabetes [1,2]. Recently, insulin glargine has been proposed for patients on continuous enteral artificial nutrition [3,4]. We report an 18-month follow-up of a patient treated with basal insulin glargine during continuous enteral nutrition and thereafter during intermittent enteral nutrition without evidence of hypoglycaemic events. The patient, a 75-year-old woman with Alzheimer’s disease and Type 2 diabetes, was admitted to our department in June 2005 after a suspected ischaemic brain event, and with severe hyperglycaemia and dehydration. She developed progressive cognitive impairment at the age of 58 years, and in the last 7 years she had developed progressive impairment of personal autonomy. She was diagnosed with Type 2 diabetes 5 years ago and, before this admission, had been managed with diet intervention; her weight was 59 kg and her metabolic control was reported as fair. On admission, the patient was semiconscious and appeared drowsy and lethargic. Laboratory assessment revealed blood chemistry as follows: blood glucose 28.1 mmol/L (505 mg/dL), sodium 163 mEq/L, chloride 116 mEq/L and creatinine 1.23 mg/dL. Oropharyngeal candidiasis was present and she required intensive intravenous therapy and peripheral parenteral nutrition for 17 days. Insulin (60–70 U) was initiated to stabilize blood glucose levels. The patients remained severely anorexic, so a percutaneous endoscopic gastrostomy tube was introduced to allow enteral feeding with a diabetes-specific, low-carbohydrate formula (approximately 1900 kcal/ day), following which her insulin requirement decreased. Good metabolic control was achieved with
15 U insulin glargine/day. She was discharged on total enteral nutrition. Although the patient was unable to take responsibility for her own healthcare management, including enteral feeding, insulin administration and blood glucose monitoring, her family decided to look after her at home, where, with the help of another elderly person, they could personally take care of her. The patient resides in an outlying urban area with limited medical facilities nearby. Home clinical monitoring was carried out via telephone counselling; blood glucose was determined at 12-h intervals and maintained within an acceptable range (5.5–10 mmol/L [100–180 mg/ dL]) with glargine (15 U/day). HbA1c was 6.7% 2 months after discharge. After 6 months, the patient’s health status improved: she gained 6 kg body weight and could consume some food orally; enteral feeding was reduced and limited to overnight. Even during this period, blood glucose levels were between 8.9–10 mmol/L (160–180 mg/dL) in the morning and 4.4–5.5 mmol/L (80–100 mg/dL) in the evening. There were no episodes of symptomatic hypoglycaemia (<3.3 mmol/L [60 mg/dL]) or hyperglycaemia (>11.1 mmol/L [200 mg/dL]) and the patient maintained a constant body weight during the 18-month follow-up. Considering the age of the patient and the difficulties in obtaining an intensive clinical monitoring, we decided not to strive for optimal glycaemic control. Currently, the patient has been living at home for 18 months and she has had no additional clinical problems or required further hospitalization. Once-daily insulin glargine, to substitute basal insulin requirements, was shown to be safe and effective in keeping the patient asymptomatic with a good quality of life whilst living with her family. When enteral nutrition was suspended during the day, no episodes of hypoglycaemia were reported. Despite the serious
0168-8227/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2007.03.011
Correspondence / Diabetes Research and Clinical Practice 78 (2007) 298–299
hyperglycaemic state of the patient when she arrived at the hospital, the patient had been suffering from Type 2 diabetes for a relatively brief time (5 years), and most likely had residual insulin production, which is supported by her requirement for a low dose of insulin glargine. We hypothesize that administration of a small dose of basal insulin prevented excessive increase of blood glucose and allowed some endogenous insulin production, which contributed to her glycaemic control. Our observation is consistent with data by Schreiber and Haak reporting a low-insulin requirement in early stage of Type 2 diabetes [2]. This case study supports the use of once-daily insulin glargine as a safe and effective treatment option for an elderly patient with significant neurological disabilities and limited medical and nursing assistance. The patient remained asymptomatic and with a quality of life consistent with living at home with her family, without experiencing troublesome and dangerous hypoglycaemic episodes. References [1] J. Rosenstock, G. Daily, M. Massi-Benedetti, A. Fritsche, Z. Lin, A. Salzman, Reduced hypoglycemia risk with insulin glargine: a meta-analysis comparing insulin glargine with human NPH insulin in type 2 diabetes, Diabetes Care 28 (2005) 950–955.
299
[2] S.A. Schreiber, T. Haak, Insulin glargine benefits with type 2 diabetes inadequately controlled on oral antidiabetic treatment: an observational study of everyday practice in 12,216 patients, Diabetes Obes. Metab. 9 (2007) 31–38. [3] D. Putz, U.M. Kabadi, Insulin glargine in continuous enteric tube feeding, Diabetes Care 25 (2002) 1889–1890. [4] G. Fatati, E. Mirri, S. Del Tosto, M. Palazzi, A.M. Vendetti, R. Mattei, et al., Use of insulin glargine in patients with hyperglycaemia receiving artificial nutrition, Acta Diabetol. 42 (2005) 182–186.
Gloria Marchetti Manfredi Tesauro Nicola Di Daniele Maria Rosa Bollea Renato Lauro Aldo Bertoli* Department of Internal Medicine, Universita` di Roma Tor Vergata, Via Montpellier, 1-00133 Roma, Italy *Corresponding author. Tel.: +39 06 2090 3618; fax: +39 06 2090 2679 E-mail address: [email protected] (A. Bertoli) 9 February 2007 Available online 3 May 2007