The Transition from Insulin Infusions to Long-Term Diabetes Therapy: The Argument for Insulin Analogs

After cardiac surgery, it is medical mismanagement to place an order for sliding scale insulin at the time of transitioning from intravenous insulin. Use of basal-prandial-correction therapy with insulin analogs constitutes a suitable transitioning regimen for inpatient management of hyperglycemia after heart surgery, to be ordered before interruption of intravenous insulin infusion, in conjunction with a program of blood glucose monitoring before meals, at bedtime, and midsleep. In the ambulatory setting, in comparison to neutral protamine Hagedorn, long-acting insulin analogs reduce hypoglycemia. In comparison to regular insulin, rapid-acting insulin analogs reduce hypoglycemia and improve postprandial control. A standardized approach to order entry for basal-prandial-correction therapy enhances safety and staff familiarity while preserving individualization of patient care. Proposed predictors of successful transition are described. Dose requirements during intravenous insulin infusion can be used to guide initial dose assignments of basal insulin therapy. As the patient approaches discharge, the total daily doses of subcutaneous insulin and basal insulin dose are decreased, and the proportion of prandial insulin approaches or exceeds 50% of the total daily dose as the absolute amount of prandial insulin increases. Before discharge, hyperglycemic patients not known to have diabetes should be advised of the need for outpatient reassessment, and those known to have diabetes but requiring intensification of therapy should participate in decision-making concerning their options for intensified treatment.