Expert Discusses Considerations for Inpatient Use of Diabetes Technology

In an interview with Pharmacy Times, Michelle Condren, PharmD, AE-C, BCPPS, CDCES, FPPA, Professor and Vice Chair for Research at the University of Oklahoma School of Community Medicine, discussed pharmacists' roles in inpatient diabetes management. Condren also discussed this topic in a presentation at the American Society of Health-System Pharmacists (ASHP) 2022 Midyear Clinical Meeting.

Q: What are the benefits of inpatient use of diabetes technology?

Michelle Condren, PharmD, AE-C, BCPPS, CDCES, FPPA: When talking about diabetes technology, there's 2 main things we're talking about, so continuous glucose monitors (CGM) and insulin pump therapy. From a continuous glucose monitor perspective, there's less hypoglycemia. Generally, CGMs will give alerts and let people know that blood sugars might be trending down, so that they can maybe be caught before it's a true low blood sugar. There's also less high blood sugar that occurs when someone's on CGM. The other advantage is you just get a lot more information. So, more information for making adjustments because it's testing blood sugar every 5 minutes. So, you can have a full day's worth of blood sugars from the insulin pump perspective. And it seems, you know, if you think about insulin pump therapy, especially if you pair insulin pumps with continuous glucose monitors, it's almost like that patient has gone from a manual transmission car to an automatic, where it's making a lot of adjustments for them. Yes, they have to put in some input, but they don't have to worry nearly as much. And so, it very much personalizes the insulin dosing to that patient and you can't do that with a standard basal bolus regimen, if you take somebody off their insulin pump. And so, blood sugar control would be often compromised in the first few days of that and there's a lot of stress for the patient and family when you take away their normal method of controlling their blood sugar.

Q: What are some potential pitfalls of personal diabetes management technologies in the inpatient setting?

Michelle Condren, PharmD, AE-C, BCPPS, CDCES, FPPA: The majority of pitfalls are going to come with insulin pump therapy. We've had several people who will come into the hospital and report what their insulin doses are, but then when you actually look in the pump, it's actually not what they're getting. And so, if personnel aren't trained on the importance of verifying doses in that pump, then we may have inaccurate information from the beginning. Additionally, that pump is available to that patient. It's like having a home met at the bedside, they could give insulin at any point in time. And so, if someone isn't trained to be looking at that pump regularly and documenting what's been happening, then there's the potential for either low or high blood sugars just by not knowing what's been happening.

From a continuous glucose monitor perspective, you know, continuous glucose monitors aren't perfect. If the blood sugar is changing rapidly, you have to check it with a fingerstick blood glucose. And so, staff need to recognize that you don't just treat a blood sugar under 70 based on a CGM until you've done a finger stick. So, it's really a lot of staff education, to understand how to properly use and how to document what's happening, which has been a challenge for a lot of places trying to figure out how to get all this information into their electronic record.

Q: How can inpatient pharmacies implement the use of diabetes technology for patients?

Michelle Condren, PharmD, AE-C, BCPPS, CDCES, FPPA: This one's going to be very institution dependent. There have been some institutions, especially during COVID, where the pharmacy department in conjunction with endocrinology actually implemented continuous glucose monitoring in the hospital for people who previously weren't on it. That allows less contact with nurses so infection control is better, less contact with that patient. So, if a facility decides to go that direction, the pharmacy is going to be integral in making sure they have the supplies needed. And you can't really implement, most people don't implement insulin pump technology new. And so, I think it's more about what the pharmacist can do and what their role can be. If the decision is to continue to use patients’ inpatient or outpatient technology, their pharmacy is going to be critical in policy development. It could be, should be one of the key players at the table to develop policies around how diabetes technology is going to be used in the hospital.

Q: What safety considerations should pharmacists be aware of for the use of current diabetes technologies?

Michelle Condren, PharmD, AE-C, BCPPS, CDCES, FPPA: From a CGM perspective, I don't worry about safety too much. Yes, they have to be replaced every once in a while, but a CGM itself isn't going to cause a safety concern. But an insulin pump could. As I said earlier, basically that patient has full access to their insulin at any given time. The other [thing] is that insulin pump therapy requires changing the insulin and the infusion set every 3 days. And so, somebody needs to remember that. And so, making sure that happens, because if not, you can compromise blood sugar control or even increase infection risk.

The other one that has come up a little more lately is there are times when people use more concentrated insulins in the pump than what the pump is designed for. So, U100 is our standard. Somebody may be using U200, U500, and so what's programmed in the pump isn't actually their insulin doses, and so that can that requires a lot of math and a lot of thinking through how to do that safely in the hospital, especially if you have to stop that pump. Those are the 2 primary things I can think of. But the other is just that insulin is available at any given point in time. And there's just some patients that it’s not a good candidate for. If somebody comes in and they're on suicide watch, you don't want them to have full access to insulin doses all the time. But for the most part, if supervised appropriately, it's safer to just continue someone's home device than to try to manage it another way.

Q: What is the role of the pharmacist in inpatient diabetes care?

Michelle Condren, PharmD, AE-C, BCPPS, CDCES, FPPA: And again, that's going to depend on the institution and kind of how well supported they are by certified diabetes educators, endocrinologists, and all that. But me as a pharmacist, I feel like we can play an integral role starting with when they first come in, making sure we know what kind of insulin they're putting in their pump, and also making sure those doses are correct. S,o it's almost like doing a different kind of metric. Someone needs to look at that pump and actually write down what the settings are. And so being trained to be able to do that, because the accuracy of everything you do after that depends on that. And so, I think pharmacists, like that's almost part of a metric to get those insulin doses correct. And I think that pharmacists can definitely be in a key role to be looking at trends in blood sugars over and over. And if something's not going well to be able to help the team, determine the best solution to that. And then again, just making sure people are changing their sites when they need to for their pumps, because that insulin won't be good for very long. They're wearing it right next to their body, it's hot. And so, making sure that they recognize that they're going to need new insulin every 3 days.

Q: Do you have any closing thoughts?

Michelle Condren, PharmD, AE-C, BCPPS, CDCES, FPPA: I think the biggest thing is that diabetes technology is changing month by month, and all of that, all of those changes have made diabetes management safer, more effective, and are improving quality of life for these patients. And so, our challenge as health care providers and facilities is to keep up with that. And I think we're going to have to figure out a way to make sure our people and our infrastructure is set up in such a way that people can continue doing what is in the majority of scenarios going to be better for them in the long run.