Clinical observations of insulin-glucose therapy for their heart disease

From experiments on the experiencing hearts of warm-blooded animals, it became known that, along with a number of inorganic salts, sugar is a necessary component of the irrigation nutrient fluid.

High Prevalence of Insulin Resistance in Asymptomatic Patients with Acute Intermittent Porphyria and Liver-Targeted Insulin as a Novel Therapeutic Approach

Acute porphyria attacks are associated with the strong up-regulation of hepatic heme synthesis and over-production of neurotoxic heme precursors. First-line therapy is based on carbohydrate loading. However, altered glucose homeostasis could affect its efficacy. Our first aim was to investigate the prevalence of insulin resistance (IR) in an observational case-control study including 44 Spanish patients with acute intermittent porphyria (AIP) and 55 age-, gender- and BMI-matched control volunteers. Eight patients (18.2%) and one control (2.3%, p = 0.01) showed a high HOMA-IR index (cut-off ≥ 3.4). Patients with IR and hyperinsulinemia showed clinically stable disease. Thus, the second aim was to evaluate the effect of the co-administration of glucose and a fast-acting or new liver-targeted insulin (the fusion protein of insulin and apolipoprotein A-I, Ins-ApoAI) in AIP mice. The combination of glucose and the Ins-ApoAI promoted partial but sustained protection against hepatic heme synthesis up-regulation compared with glucose alone or co-injected with fast-acting insulin. In a prevention study, Ins-ApoAI improved symptoms associated with a phenobarbital-induced attack but maintained high porphyrin precursor excretion, probably due to the induction of hepatic mitochondrial biogenesis mediated by apolipoprotein A-I. In conclusion, a high prevalence of IR and hyperinsulinemia was observed in patients with AIP. The experimental data provide proof-of-concept for liver-targeted insulin as a way of enhancing glucose therapy for AIP.

Impact of insulin adsorption in various container during hyperkalemia treatment

Background The insulin-glucose therapy in hyperkalemia treatment had a narrow therapeutic index for a safe and efficient use. We assess the variability of the effective delivered insulin under conditions used in the setting of hyperkalemia treatment. Methods A range of simulated insulin infusions was studied using different containers (bag or syringes) according of the different hyperkalemia treatment procedures of our institution. Insulin concentration was assayed using a chromatographic method on an automatic high-performance liquid chromatography. We calculated the effective delivered insulin and compared the time-average of percentage delivered insulin (TAdi) between all the procedures. Results The TAdi is significantly decreased to 63.3% of the expected insulin delivery in the polyurethane (PE) bag compared to allover container. The procedure duration and the insulin concentration influenced the variability of the insulin delivery in the PE and glass (G) bag. The polyvinyl chloride (PVC) bag have the highest TAdi at 93.8% without significant variation during the time. TAdi reach around 90% of the expected insulin with all the syringe procedure without variation according the solute used to dilute insulin. Conclusions Clinically significant variations in intravenous insulin delivery occur in the setting of hyperkalemia treatment according to the container. The use of propylene syringe limits the insulin delivery variation. In the future, clinical studies on hyperkalemia treatment by insulin-glucose therapy should detailed the procedure precisely.

The Effects of Glucose Therapy Agents—Apple Juice, Orange Juice, and Cola—on Enteral Tube Flow and Patency

To develop evidence-based hypoglycemia treatment protocols in patients receiving total enteral nutrition, this study determined the effect on enteral tube flow of glucose therapy agents: apple juice, orange juice, and cola, and it also examined the effects of tube type and feed type with these glucose therapy agents. For this study, 12 gastrostomy tubes (6 polyethylene and 6 silicone) were set at 50 mL/h. Each feeding set was filled with Isosource HN with fibre or Novasource Renal. Each tube was irrigated with 1 glucose therapy agent, providing approximately 20 g of carbohydrate every 4 h. Flow-rate measurements were collected at 2 h intervals. The results showed that the glucose therapy agent choice affected flow rates: apple juice and cola had higher average flow rates than orange juice (P = 0.01). A significant difference was found between tube type and enteral formula: polyethylene tubes had higher average flow rates than silicone tubes (P < 0.0001), and Isosource HN with fibre had higher flow rates than Novasource Renal (P = 0.01). We concluded that apple juice and cola have less tube clogging potential than orange juice, and thus may be considered as primary treatment options for hypoglycemia in enterally fed patients. Polyethylene tubes and Isosource HN with fibre were less likely to clog than silicone tubes and Novasource Renal.

β-Blocker and Calcium Channel Blocker Poisoning: High-Dose Insulin/Glucose Therapy

Overdoses of β-blockers and calcium channel blockers can produce significant morbidity and mortality, and conventional therapies often do not work as treatments for these poisonings. High-dose insulin/glucose therapy has been successful in reversing the cardiotoxic effects of these drugs in cases where the standard therapies have failed, and it appears to be relatively safe. Many successes have been well documented, but the clinical experience consists of case reports, the mechanisms of action are not completely understood, and guidelines for use of the therapy are empirically derived and not standardized. Regardless of these limitations, high-dose insulin/glucose therapy can be effective, it is often recommended by clinical toxicologists and poison control centers, and critical care nurses should be familiar with when and how the therapy is used.

Abstract P161: Relationship Between Clinical Availability of Hemoglobin A1c and Glucose Therapy Intensification in Patients With Diabetes Hospitalized for Acute Myocardial Infarction

BACKGROUND Hemoglobin A 1c (A1C) assessment is recommended for hospitalized patients (pts) with diabetes (DM). Whether in-hospital A1C levels are associated with glucose therapy intensification (GTI) after MI is unknown. METHODS TRIUMPH is a multicenter MI registry which enrolled 1343 pts with established DM between 2005-08. Of 1149 pts with DM and measured A1C, 886 (77%) were assessed as part of clinical care, and an additional 263 (23%) had A1C assessed in the research core laboratory (results unavailable to clinicians). GTI was defined as new or increased doses of antihyperglycemic agents, or increased daily insulin dose by ≥20% at discharge. Pts were divided into those with vs. without clinically available A1C and stratified by A1C subgroup (<7, 7-9, >9). Poisson regression models evaluated if clinically available A1C was independently associated with GTI. RESULTS Overall, 420 of 1149 pts (36%) with measured A1C had levels <7, 423 (37%) were between 7-9, and 306 (27%) were >9. GTI was prescribed in 367 pts (32%). Clinically available A1C was associated with more frequent GTI in pts with suboptimal (A1C 7-9) and poor (A1C >9) glycemic control, but not in those with adequate control (A1C <7; Figure ). After multivariable adjustment (including blood glucose), clinically available A1C was an independent predictor of GTI (RR 1.27, 95% CI 1.08-1.51). CONCLUSION Nearly two-thirds of pts with DM have suboptimal or poor long-term glucose control at the time of acute MI, and fewer than 50% of these pts are prescribed GTI at hospital discharge. Availability of A1C levels to clinicians may facilitate intensification of glucose therapy after MI in pts with inadequate long-term DM control.