The growing number and reliability of insulin pumps and continuous glucose monitors (CGMs) used by inpatients with diabetes pose challenges and opportunities alike for health-system pharmacists.
“These new technologies allow better blood sugar control with less risk of severe hypoglycemia, and they will only get better,” said Michelle Condren, PharmD, BCPPS, a certified diabetes care and education specialist, a professor of pediatrics and the vice chair for research at the University of Oklahoma School of Community Medicine, in Tulsa. “I feel more comfortable than ever before using this technology. It has made so much headway in improving patients’ quality of life.”
For those not familiar with CGMs, these devices use a thin, injected catheter that continuously samples the interstitial fluid directly beneath the skin. They determine not only current glucose level in the interstitial fluid, but display whether the level is rising or falling, and how fast. With some devices, the pump and CGM talk to each other, so that readings from the CGM can cause the pump to increase or lower the basal dose. Real-time readings and alerts can also be shared with others, including nursing staff.
Although most health systems now allow inpatients to keep using their insulin pumps, a show of hands from attendees at the presentation indicated that only about half permit the use of CGMs—a proportion that should be the other way around, Dr. Condren said during a presentation at the ASHP 2022 Midyear Clinical Meeting & Exhibition, in Las Vegas.
“To me, pumps pose much more of a safety issue than CGMs do,” she said. “I don’t see a huge safety issue with CGM. Yet hospitals are more likely to have policies allowing insulin pumps but less likely to allow CGM, simply because they don’t have a written policy.”
Dr. Condren offered an example of a 16-year-old girl who had been using a CGM and an insulin pump, but had to stop because of hospital policy. To cover her overnight needs, she was injected with a long-acting insulin dose equivalent to her pump’s basal rate. Yet twice that night, she developed severely low glucose levels.
“Her sensor-augmented pump had been automatically reducing her basal insulin rates overnight when it detected low sugar levels,” Dr. Condren said. “I can’t tell you how many times we’ve been burned by this. So if you’re uncomfortable with allowing pumps, at least let them keep the CGM on.” During the COVID-19 pandemic, the FDA began allowing in-hospital use of CGM devices from a handful of the manufacturers, to reduce provider-to-patient contact by limiting the need for fingersticks. Since then, Dr. Condren said, health systems have been trying to figure out the circumstances under which they can or cannot be used, and the protocols for ensuring their safety.
Other health-system pharmacists who specialize in diabetes care said pharmacists play an important role in working with these patients.
“We have very few endocrinologists in my area,” said Richard Hess, PharmD, an associate professor of pharmacy practice at the Bill Gatton College of Pharmacy at East Tennessee State University, in Johnson City. “Diabetes is all I see in our clinic. It’s very prevalent around here.”
Dr. Hess, who is also a certified diabetes care and education specialist, said many of his patients with diabetes, including those with type 2, now have CGMs. “CGM is revolutionizing the way diabetes is monitored, much as the blood glucose fingerstick devices revolutionized monitoring back in the day,” he said.
CGMs are especially critical for patients following a kidney transplant, according to Elizabeth Cohen, PharmD, BCPS, a clinical pharmacist in the Solid Organ Transplant Department at Yale New Haven Hospital, in Connecticut. “Insulin is eliminated by the kidney, so when your kidney is not working properly, you don’t need as much insulin,” she said. “Once they have a working kidney after transplantation, they’re going to need more insulin—generally 20% to 30% more. But it’s hard to predict.”
To help patients following kidney transplantation, Dr. Cohen and her colleagues started a pharmacist-managed diabetes clinic. “No one was seeing them after transplantation, but they needed immediate adjustments to their insulin,” she said. “That’s where we pharmacists were able to fill the void.”
According to guidelines released this year by the American Diabetes Association, patients who are comfortable and competent using their own diabetes devices should be given the chance to do so in the inpatient setting (Diabetes Care 2023;46[1]:S111-S127). “Patients who are familiar with treating their own glucose levels can often adjust insulin doses more knowledgably than inpatient staff who do not personally know the patient or their management style,” the association wrote. “However, this should occur based on the hospital’s policies for diabetes management, and there should be supervision to be sure that the individual can adjust their insulin doses in a hospitalized setting.”
The sources reported no relevant financial disclosures.
This article is from the September 2023 print issue.