by Timothy Gieseke MD, CMD

In 2015, the AGS updated the Beers list to include SSI as a PIM (Potentially Inappropriate Medication) noting that the literature clearly documents associated increased risk of serious hypoglycemia and poor long-term glycemic control.  This PIM is focused on the common practice of relying on SSI at meal times to not only catch up on insulin deficits (pre-meal hyperglycemia), but also to cover the meal to be eaten.  The tolerance for this risky care plan by facilities and clinicians may have been exacerbated by the many recent recommendations to raise the A1C goal for older adults to 7.5% or higher.  In addition, we are now receiving many patients with diabetes as short stay residents, who were begun on SSI while unstable in the acute hospital, and come to us still on SSI.

I appreciate the AMDA CPG (Clinical Practice Guidelines) on Diabetes Care which addresses this PIM in a very constructive way.  If a person has Type 2 IDDM, they recommend about 40-50% of the insulin consist of long acting insulin for basal coverage and that the other 50-60% come from meal time administration of short acting insulin.  This approach works quite well in our facilities where our standard controlled carbohydrate diet spreads the carbohydrates out in fairly equal quantities throughout the meals of the day and are consistent throughout the week.

I commonly receive new short- or long-stay residents who are becoming medically stable but still on basal insulin combined with a short acting SSI regimen a.c. meals tid.  Following the AMDA guidelines, I will begin them on scheduled short acting insulin a.c. tid at a fixed dose that’s lower than the current total daily dose of SSI, while continuing the SSI scale.  In addition, I commonly stop SSI at bedtime, since the risk of serious nocturnal hypoglycemia is usually too high.  Within days to weeks, the glycemic control usually improves allowing further adjustments to the fixed doses of meal insulin and eventual cessation of SSI.  As the glycemic control improves, insulin resistance from the high glucose improves so the net dose of insulin commonly declines.

The key safety feature necessary for fixed dose insulin regimens is to specify in your orders when to hold the insulin and notify the clinician.  For short-acting insulin, I commonly request this for FS Glc < 90 and long-acting if < 100.  This usually properly balances patient safety with the burden of excessive notifications.  To reduce the burden of this care plan on my on-call team, I generally try to order the basal insulin for the daytime hours when I’m likely to be available.   

Having done this for many years, I’m amazed at how many patients I previously considered “brittle diabetics” are now well-controlled persons with DM who remain well controlled with minor adjustments to their insulin regimen. I believe nurses in facilities also appreciate this approach since it is much less complicated than the former basal insulin with SSI meal coverage plans.

For more detailed guidance, purchase the AMDA CPG at:   http://www.paltc.org/product-store/diabetes-management-cpg  

In addition, the education committee of CALTCM is planning a half-day workshop for next April’s annual meeting on improving care of diabetes.

Stay tuned!