title: Safe and effective dosing of basal-bolus insulin in patients receiving high-dose steroids for hyper-cyclophosphamide, doxorubicin, vincristine, and dexamethasone chemotherapy.
abstract: BACKGROUND
  Hyperglycemia occurs in cancer patients receiving high-dose steroids with cyclophosphamide, doxorubicin, vincristine, and dexamethasone (hyper-CVAD) protocol. The purpose of our study was to determine insulin requirements in patients with hyperglycemia on hyper-CVAD therapy using a systematic algorithm.
  
  
  METHODS
  We did a retrospective chart review of 23 leukemia inpatients with hyperglycemia (two glucose values >250 mg/dL) on hyper-CVAD chemotherapy managed by the Endocrine Diabetes Inpatient Team algorithm. We reviewed demographic and glycemic data, insulin dosages, and use of oral hypoglycemic agents. Using our algorithm, the dose of insulin for each patient was titrated daily and with each subsequent cycle of hyper-CVAD.
  
  
  RESULTS
  Ninety-one percent of patients had known diabetes. The median body mass index was 32.5 (range, 21.6-40.9) kg/m², and median age was 61 (range, 40-80) years. The overall trend in glucose values across cycles showed a statistically significant decrease with each subsequent cycle of hyper-CVAD. Hyperglycemia accounted for 81% of glucose measurements in the first cycle and 60% of glucose values in the last cycle. Patients received 1-1.3 units/kg of insulin per cycle, and insulin requirements were similar across cycles. The distribution of basal versus bolus insulin for each cycle was 63-77% prandial and 23-37% basal. Nine of the 23 patients had at least one glucose value <70 mg/dL, which accounted for 1.3% of all recorded glucose values. None of the patients had severe hypoglycemia.
  
  
  CONCLUSIONS
  Multiple-dose insulin therapy initiated at 1-1.2 units/kg/day, distributed as 25% basal and 75% prandial, reduced hyperglycemia in patients who were receiving high-dose dexamethasone as part of hyper-CVAD.
authors.affiliation: 1 Department of Endocrine Neoplasia & Hormonal Disorders, Division of Internal Medicine, University of Texas-MD Anderson Cancer Center , Houston, Texas.
authors.forename: Veronica
authors.initials: V
authors.lastname: Brady
authors.forename: Sonali
authors.initials: S
authors.lastname: Thosani
authors.forename: Shouhou
authors.initials: S
authors.lastname: Zhou
authors.forename: Roland
authors.initials: R
authors.lastname: Bassett
authors.forename: Naifa Lamki
authors.initials: NL
authors.lastname: Busaidy
authors.forename: Victor
authors.initials: V
authors.lastname: Lavis
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects* / Q000627:therapeutic use; D015992:Body Mass Index; D002173:Cancer Care Facilities; D015331:Cohort Studies; D003520:Cyclophosphamide / Q000009:adverse effects / Q000627:therapeutic use; D003907:Dexamethasone / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D003924:Diabetes Mellitus, Type 2 / Q000150:complications; D004317:Doxorubicin / Q000009:adverse effects / Q000627:therapeutic use; D054796:Drug Dosage Calculations; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000097:blood / Q000139:chemically induced / Q000188:drug therapy*; D007004:Hypoglycemic Agents / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D007328:Insulin / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D008223:Lymphoma / Q000150:complications / Q000188:drug therapy; D008297:Male; D008775:Methylprednisolone / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D008875:Middle Aged; D050177:Overweight / Q000150:complications; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000150:complications / Q000188:drug therapy; D011239:Prednisolone / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use; D012189:Retrospective Studies; D014750:Vincristine / Q000009:adverse effects / Q000627:therapeutic use
chemical_list: D007004:Hypoglycemic Agents; D007328:Insulin; D014750:Vincristine; D003907:Dexamethasone; D004317:Doxorubicin; D003520:Cyclophosphamide; D011239:Prednisolone; D008775:Methylprednisolone