Continuous enteral nutrition (EN) with tube feeds is a common strategy for nutritional support for patients not meeting their nutritional needs in the hospital critical care setting. However, EN is characterized by a high incidence of hyperglycemia in patients with or without diabetes,1,2 and EN-related hyperglycemia has been linked to increased morbidity and mortality.3 One prior randomized clinical trial and other retrospective studies have demonstrated varying degrees of glycemic control using intermediate-acting (IA) insulin (neutral protamine Hagedorn [NPH] or biphasic NPH 70/30) and long-acting (LA) insulin (as part of basal-bolus) insulin regimens in patients receiving EN4, 5, 6, 7, 8, 9, 10, but there is no consensus on best practices.11, 12, 13 The small sample sizes in published studies are a critical limitation to generalizability of the findings in clinical practice.

Given the continuous postprandial state of continuous EN, there is a general consensus of target glucose range of 140 to 180 mg/dL, which is the same target recommended by investigators in the Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial to minimize hypoglycemia-related complications and mortality.14,15 However, the risk and fear of hypoglycemia remain significant in patients on EN treated with insulin. This is due to frequent tube feed interruptions that occur in the inpatient setting caused by scheduled (ie, procedures and imaging studies) and unscheduled events (ie, feeding tube dislodgement or clogging), which were noted to occur in 49% of the hospitalized EN cohort.1 Theoretically, IA NPH with its shorter half-life can limit the risk of hypoglycemia because split dosing of IA or biphasic insulin results in the use of a smaller dose more frequently, posing a lower risk of hypoglycemia than that with a larger once-daily dose.16 This retrospective study adds to the existing literature by comparing the effectiveness (achieving glucose levels within the target range and minimizing hyperglycemia) and safety (minimizing hypoglycemia) of IA insulin (NPH 70/30 3 times daily), LA insulin, and rapid-acting (RA) insulin only regimens for those who received 24-hour continuous EN while hospitalized in the critical care setting.