Type 2 diabetes is common among nursing home residents and
often treated with sliding-scale insulin (SSI) therapy, despite current
recommendations that do not support this method. A recent study by Dr. T.S.Dharmarajan and colleagues compared the effectiveness of SSI therapy to
basal-bolus insulin (B-BI) therapy to control blood glucose in older nursing
home residents with type 2 diabetes.
SSI therapy and B-BI therapy share the same
medication—insulin—but differ in the timing of administration in relation to
meals, dosage, and type(s) of insulin given to patients with type 2 diabetes.
SSI regimens administer insulin after demonstrated elevations in blood glucose,
a reactive strategy that is not physiological. B-BI therapy takes a more
personalized approach, using both a longer acting form of insulin to provide
steady regulation of blood sugar (even between meals) and separate injections
of shorter-acting insulin throughout the day along with meals. B-BI therapy
roughly simulates a non-diabetic body’s delivery of insulin. The B-BI approach
is more physiological and mimics pancreatic release of insulin to provide a
steady-state regulation, essentially a proactive approach.
T.S. Dharmajan, MD, MBBSDr. Dharmarajan's study, sponsored by the AMDA Foundation
and scheduled to appear in the March 2016 print issue of the Journal of the
American Medical Directors Association (published online in September 2015), measured levels of fasting blood
glucose (FBG) in 64 nursing home residents from 14 long-term care sites
randomly assigned to SSI or B-BI therapies over a 21-day clinical intervention
trial. Participants treated with B-BI had significantly lower 3-day average FBG
levels compared to the SSI participants. The study concluded that switching
long-term care patients with type 2 diabetes to B-BI therapy is feasible, safe,
and effective.
"As physicians who care for patients with diabetes, our primary goal is to achieve a level of glycemic control that mimics that of nondiabetic patients, and B-BI therapy appears to be a more effective way to do that," Dr. Dharmarajan said. "It is time for us to shift from a reactive to a physiologically proactive approach."
Dr. Dharmarajan is Vice Chairman of the Department of
Medicine, Clinical Director of the Division of Geriatrics, and Program Director
of the Geriatric Medicine Fellowship Program at Montefiore Medical Center
(Wakefield Campus). He was instrumental in developing the Wakefield Campus's
large inpatient geriatric medicine program, with recognized clinical, academic
and research components, including a fully accredited geriatrics fellowship
program. His research interests focus primarily in the areas of geriatrics,
nutrition, anemia and anticoagulation. A prominent local, national and
international speaker and recipient of numerous teaching and mentoring awards,
he has been featured on the cover of AgingWell magazine as one of the country's
noteworthy geriatricians.
Published February 21, 2016