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Residents; Pharmacist


Abstract: The American Diabetes Association (ADA) recommends intermediate-acting insulin NPH or long-acting insulin glargine for steroid-induced hyperglycemia in patients with diabetes mellitus (DM).1 At Henry Ford Jackson Hospital (HFJH), methylprednisolone is associated with a high incidence of hyperglycemia. HFHS implemented a Steroid-Induced Hyperglycemia Best Practice Alert (BPA) to prompt insulin prescribing (NPH or glargine) in patients with recent hyperglycemia (BG >200 within 24 hours) and a new steroid order. This observational retrospective cohort study included adult patients admitted to HFJH who were initiated on a corticosteroid within 24 hours of having a documented episode of hyperglycemia (blood glucose (BG) > 200 mg/dL). Vulnerable populations and patients with an active insulin order at the time of the BPA were excluded. The primary outcome is the frequency of insulin prescribing in response to the BPA. Secondary outcomes are average time to insulin ordering after the alert, type of insulin regimen prescribed, and the difference in average BG between patients whose prescribers ordered insulin in response to the BPA (responder group) versus patients whose prescribers did not (non-responder group). Safety outcomes include the incidence of steroid-associated adverse drug events and hypoglycemia. Data was analyzed using descriptive statistics. Ninety cases were reviewed. Ten patients met inclusion criteria and 80 were excluded due to having an active insulin order at the time of the BPA. Of the ten patients included, five were in the responder group and five were in the non-responder group. All five patients in the responder group had insulin lispro ordered, and three of the five had insulin glargine ordered in addition. The median time to insulin prescribing post-BPA was four hours. Patients’ average BGs in the responder group was 260 vs. 147 in the non-responder group. No patients in either group experienced adverse drug events or hypoglycemia. Overall, the Steroid-Induced Hyperglycemia BPA order set is not widely used at HFJH. Providers at HFJH were more likely to utilize the “Glycemic Control Protocol” order set, which includes insulin lispro as the default insulin order.

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Insulin Prescribing and Glycemic Control in Response to a Steroid-Induced Hyperglycemia Best Practice Alert