ADA 2018: Dr. Archana Sadhu on Challenges of Basal-Bolus Insulin Therapy

Dr. Archana Sadhu presented “Basal-Bolus Insulin Therapy May Not Be the Optimal Strategy in a ‘Real-World’ Hospital Setting for Inpatient Hyperglycemia Management” at the 78th Scientific Sessions for the American Diabetes Association(June 22–26) in Orlando, FL.

Doximity discussed the research with Dr. Sadhu at ADA 2018. Below is a transcript of the video interview.

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Doximity: Why is basal bolus (BB) insulin therapy considered too complex for real-world hospital settings?

Sadhu: Basal bolus for endocrinologists is the mainstay of how we use insulin therapy. It tries to replicate what the pancreas normally does for glycemic control.

Unfortunately, it does take quite a bit of coordination and frequent adjustments based on what's happening to the patient, whether it be their medication effects, their nutritional status or their underlying illness. In the hospital all of these factors are changing very frequently. In order to use basal bolus, as it's intended to be very effective, you have to account for many, many factors in the hospitalized patients.

In the hospital, endocrinologists do not take care of the majority of diabetes—it's usually a primary care doctor or a hospitalist or maybe another sub specialist. I don't think that it is trained adequately in those other areas [that] endocrinologist get trained to use this therapy to its best ability.

Because of that complicated nature, we could actually potentially cause more dysglycemia, or more ups and downs, if we can't implement the basal bolus appropriately.

Doximity: What is the most meaningful implication of this study for clinicians?

Sadhu: It doesn't require a complicated basal bolus regimen to get better glycemic control than our traditional old way of doing things, which is called sliding scale.

Actually, it seems from our findings, that all you need to do is add on a basal insulin to get more smooth and steady state control, and that actually benefits the patients even more so than basal bolus therapy and definitely more than sliding scale. We got the best results in reducing hyperglycemia and maintaining euglycemia, and with a lower glucose average with basal only.

This is important because it's much easier to add on a basal insulin, which is a steady-state insulin at a steady dose, than to add on too complicated insulins of basal as well as prandial or rapid acting insulin.

I'm hoping that with these findings that we can simplify this practice as well as preserve the safety and efficacy for patients glucose control in the hospital.

Doximity: If not BB insulin therapy, what do you recommend as a more optimal scalable strategy for inpatient hyperglycemia management?

Sadhu: Going back to our findings, I think the best strategy for now universally—[with the exception of] subpopulations that definitely need BB, [like] type 1 diabetes for instance—when we looked at a universal group of patients in the hospital with multiple different comorbidities and we accounted for all these comorbidities, patient factors, as well as prescriber factors, we found that those that receive the basal only had better glycemic control than correction scale or sliding scale and basal bolus.

So, I would advocate that we should train our physicians, non endocrinologists, on the majority practice, which is add basal insulin. This is still steps ahead in terms of better quality [compared to] using correction scale or sliding scale. It simplifies it as well as preserves the patient's glycemic control and to improve outcomes.

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