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Petite et al
hypoglycemia.18 Due to the known risks of hyperglycemia
in the inpatient setting, empiric dose reductions past 50%
should be avoided for patients on home basal insulin during a short (<24 hour) NPO period.3
A multivariable logistic regression was conducted to minimize confounders impacting the primary study outcome.
The use of dextrose-containing fluids decreased the risk of
hypoglycemia in this study cohort. This study finding is supported by the recommendation to utilize these maintenance
fluids during the NPO period.1,11 Alternatively, a prolonged
NPO period was independently associated with hypoglycemia. The median NPO duration was approximately 1 day.
Utilization of dextrose-containing maintenance fluids or
more frequent BG readings should be considered for patients
requiring a longer NPO period.
Strengths of this study include the large sample size and
statistical analysis to minimize confounding. This study had
a similar patient population size to other trials evaluating
inpatient diabetes management. The multivariable analysis
controlled for identified variables imbalanced between
groups, including admission reason of infection or admission
reason of surgical procedure. A power analysis was also conducted a priori to confirm a sufficient patient population
needed to detect a difference.
Limitations to this study include the retrospective
nature, particularly related to accuracy of documentation.
Prior to admission insulin doses were obtained through the
institution's electronic medical record utilizing the admission medication reconciliation. No uniform medication
reconciliation process was in place at the study institution
during the study period, leading to possible differences in
the accuracies of medication histories obtained depending
on the individual completing them. Determination of an
NPO order was made through the electronic ordering system. The study institution does not require providers to
indicate the reason for NPO status and this was unable to
be determined for included patients. The NPO duration
was approximately 1 day; therefore, these results cannot be
extrapolated to longer NPO durations. The target BG goal
set by each medical team was unable to be determined due
to the retrospective nature of the study. Inaccuracies in
documentation are possible due to the study design; however, all data were collected in a uniform manner to avoid
any additional bias.
Determination of patient groups was based on previous
expert opinion and typical clinical practice.14,15 Further
exploration of insulin dose reductions (ex. 25 and 75%) was
not performed in this study but may help further define the
role of basal insulin dose reductions. Severe hypoglycemia
occurred infrequently in this patient population, and the
study was not powered to detect differences in this outcome.
Therefore, the true impact of empiric insulin dose reductions
on severe hypoglycemia cannot be determined. There is also
a potential for unaccounted variables impacting the study

results, such as patients on hemodialysis; however, the CCI
score was similar between patient groups.
In conclusion, this study did not detect a difference in the
rate of hypoglycemia observed in hospitalized, non-ICU
patients with T2DM while NPO receiving ≤50% and >50%
of their home basal insulin. In non-ICU hospitalized patients
with T2DM and anticipated short NPO durations (<24
hours), empiric dose reductions past 50% of home basal
insulin should not be utilized. Future studies should evaluate
multiple empiric dose reductions beyond these two groups
studied to determine the ideal basal insulin dose to give
patients while NPO.
Acknowledgments
The authors thank Jeremy Patton for assistance with data collection
and John Macko for assistance with data extraction.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Hospital Pharmacy - August 2020

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