Thursday, November 20, 2008

Discharge planning after glycemic control in hospitalized patients

So you’ve done a good job controlling your critically ill patient’s blood sugar with an insulin drip. The patient has recovered and discharge is approaching. Now what? This CME approved Medscape article provides some tips for the transition to out patient care.

A while back, after an exchange with Dr. Daniel Carlat, author of the Carlat Psychiatry Blog (really more of a pharma-critical site than a psychiatry blog) I vowed to asses all Medscape CME offerings I post for bias, imbalance and non-evidence based content. This has gotten to be a competition between collections of anecdotes (which, mind you, do not equal evidence).

The activity in question is based entirely on an article from the Medscape Journal of Medicine. Editorial assistance for the article was provided by the makers of Lantus. (Does that mean it is one of those dreaded ghost written articles?). The author received no financial support from industry. The CME activity itself is non-industry supported.

Ghost written or not, the article can easily be critically appraised by examination of primary sources of evidence. The only thing I found that was non-evidence based and unbalanced was the discussion of glycemic control via insulin drips in the initial phase of critical illness and acute coronary syndrome. Specifically, the article selectively cites evidence in favor of tight glycemic targets while tending to ignore negative studies and the prevailing controversy surrounding in patient glucose control.

The principal focus of the article is on the transitions from insulin drip to sub q insulin to discharge. Those sections contain helpful tables and text on basal bolus regimens. Although they mention the pharmacokinetic advantages of the newer insulins none are mentioned by brand name and no clear recommendation for one over others is made.

My final take? The only unbalanced portion of this presentation was the promotion of plain old regular insulin and had nothing to do with the company which was in a position to influence content.

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