What is the best way to manage type 1 diabetes in a medical-surgical (medsurg) setting?

From the Guidelines

The best way to manage Type 1 diabetes in a medical-surgical setting is to implement a comprehensive basal-bolus insulin regimen with careful monitoring, as recommended by the most recent guidelines 1. This approach involves administering long-acting insulin for basal coverage and rapid-acting insulin before meals, with blood glucose monitoring before meals and at bedtime, and targeting ranges of 100-180 mg/dL.

• Key considerations include:
  • Holding metformin on the day of surgery and discontinuing SGLT2 inhibitors 3-4 days before surgery 1.
  • Reducing basal insulin doses by 25% the evening before surgery to minimize hypoglycemia risk 1.
  • Using basal-bolus insulin coverage, which has been associated with improved glycemic outcomes and lower rates of perioperative complications compared to reactive, correction-only insulin coverage 1.
• It is essential to individualize the insulin regimen based on the patient's type of diabetes, clinical judgment, and glucose monitoring results, as well as to have protocols in place for managing hyperglycemia and hypoglycemia, such as administering correction insulin and treating hypoglycemia with fast-acting carbohydrates 1.
• Continuous glucose monitoring may also be beneficial for some patients, and sliding scale insulin alone is inadequate for Type 1 diabetes management, as insulin must never be discontinued in these patients due to the risk of diabetic ketoacidosis 1.

From the FDA Drug Label

Individualize the dosage of MERILOG based on the patient's metabolic needs, blood glucose monitoring results and glycemic control goal. Dosage adjustments may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), changes in renal or hepatic function or during acute illness During changes to a patient's insulin regimen, increase the frequency of blood glucose monitoring

The best way to manage type 1 diabetes in a medsurg setting is to:

• Individualize the patient's insulin dosage based on their metabolic needs and blood glucose monitoring results
• Monitor blood glucose levels frequently, especially during changes to the patient's insulin regimen or physical activity
• Adjust the insulin dosage as needed to achieve the patient's glycemic control goal
• Be aware of the risk of hypoglycemia and take steps to mitigate it, such as educating patients and caregivers to recognize and manage hypoglycemia 2

From the Research

Management of Type 1 Diabetes in Medsurg Setting

The management of type 1 diabetes in a medical-surgical (medsurg) setting involves the use of insulin therapy to control blood glucose levels. Several studies have compared the efficacy and safety of different insulin regimens in patients with type 1 diabetes.

• Insulin Detemir vs. Insulin Glargine: A 52-week, multinational, randomized, open-label, parallel-group, treat-to-target noninferiority trial compared the efficacy and safety of insulin detemir and insulin glargine in patients with type 1 diabetes 3. The results showed that insulin detemir was noninferior to insulin glargine in terms of glycemic control, with similar reductions in HbA1c levels.
• Insulin Detemir: A Review: A review of insulin detemir found that it is a useful option for basal insulin therapy in patients with type 1 or 2 diabetes, with a beneficial effect on glycemic control and less within-patient variability in blood glucose levels compared to NPH insulin 4.
• Comparison of Insulin Glargine, Detemir, and Lispro Protamine: A study using continuous glucose monitoring (CGM) compared the effect of insulin glargine, detemir, and lispro protamine on glycemic variability in patients with type 1 diabetes 5. The results showed that insulin lispro protamine and glargine were more effective than detemir in reducing glycemic variability and improving glycemic control.
• Rapid-Acting Insulin Analogues: A study compared the efficacy and safety of rapid-acting insulin analogues, including glulisine, lispro, and aspart, in patients with type 1 diabetes 6. The results showed that glulisine had comparable glucose control to lispro and aspart, with similar rates of hypoglycemia and diabetic ketoacidosis.
• Fast-Acting Insulin Aspart: A 26-week, multicenter, active-controlled, treat-to-target, randomized, parallel-group trial evaluated the efficacy and safety of fast-acting insulin aspart versus conventional insulin aspart in adults with type 1 diabetes 7. The results showed that fast-acting insulin aspart improved glycemic control, with a statistically significant reduction in HbA1c levels compared to conventional insulin aspart.

Key Findings

• Insulin detemir is a useful option for basal insulin therapy in patients with type 1 diabetes, with a beneficial effect on glycemic control and less within-patient variability in blood glucose levels.
• Insulin glargine and lispro protamine may be more effective than detemir in reducing glycemic variability and improving glycemic control.
• Rapid-acting insulin analogues, including glulisine, lispro, and aspart, have comparable glucose control and safety profiles.
• Fast-acting insulin aspart improves glycemic control, with a statistically significant reduction in HbA1c levels compared to conventional insulin aspart.