Abstract
BackgroundHyperglycaemia can influence 18F-fluorodeoxyglucose (FDG) uptake due to competition for glucose transport and phosphorylation by hexokinase. Major international nuclear medicine societies recommend blood glucose level (BGL) < 11.1 mmol/L (200 mg/dL) prior to performing FDG positron emission tomography/computed tomography (PET/CT). However, there is no consensus approach and complications of previously proposed insulin guidelines included significant hypoglycaemia, inconvenience and skeletal muscle uptake. This study aims to establish the safety and efficacy of a personalised insulin calculator protocol to estimate the dose of intravenous insulin injection for correction of hyperglycaemia prior to FDG PET/CT.ResultsThis is a retrospective audit of all patients treated with insulin for hyperglycaemia (BGL > 10 mmol/L) prior to FDG PET/CT at the Peter MacCallum Cancer Centre over a 2-year period. Cohort 1 comprised a 12-month period (April 1, 2014–March 31, 2015) using the department’s established empiric-dose insulin protocol, and Cohort 2 the 12 months (April 1, 2015–March 31, 2016) following introduction of a personalised insulin calculator protocol. Variables including body mass index, insulin-dose calculated and/or administered, BGL at baseline and nadir, and time to FDG injection were analysed. There were 115 and 136 patients treated with insulin in Cohorts 1 and 2 respectively, with similar baseline variables including mean BGL (14.5 vs 14.4 mmol/L) and range (10.5–22.7 vs 10.4–24.3 mmol/L). Use of the new personalised insulin calculator resulted in significantly fewer hypoglycaemic events (0.7% vs 5.2%; P < 0.03), shorter median time from insulin to FDG injections (108 min vs 136 min; P < 0.001) and greater individualised range in insulin prescription (3–32 IU vs 4–20 IU). The majority of patients (88.3%) receiving the personalised insulin calculator prescribed dose achieved BGL < 10.0 mmol/L. All scans obtained were of diagnostic quality.ConclusionsThe use of our personalised insulin calculator protocol effectively lowered BGL to the target range, resulted in significantly fewer hypoglycaemic events and reduced median time between insulin and FDG injection compared to a pre-existing empiric protocol whilst achieving diagnostic scans.
Highlights
Imaging of glucose analogue 18F-fluorodeoxyglucose (FDG) metabolism using positron emission tomography/ computed tomography (PET/CT) has an important role in the diagnosis, staging and response assessment of many common malignancies, in addition to a growing number of non-oncologic indications
There were 184 patients in Cohort 1, of whom 65 (35.3%) patients proceeded with FDG positron emission tomography/computed tomography (PET/CT) despite uncorrected hyperglycaemia, 3 patients had insufficient data recorded, 1 patient presenting with severe hyperglycaemia (31.2 mmol/L) received insulin in our department prior to referral for acute medical assessment and the remaining 115/184 (63.0%) patients received insulin according to the empiric protocol
Of 167 patients in Cohort 2, 30 (18.0%) patients proceeded with FDG PET/ CT despite uncorrected hyperglycaemia and 1 patient that presented with severe hyperglycaemia (20.4 mmol/L) was referred for diabetes stabilisation and rescheduled
Summary
Imaging of glucose analogue 18F-fluorodeoxyglucose (FDG) metabolism using positron emission tomography/ computed tomography (PET/CT) has an important role in the diagnosis, staging and response assessment of many common malignancies, in addition to a growing number of non-oncologic indications. There is concern that hyperglycaemia can influence FDG uptake due to competition for glucose transport and phosphorylation by hexokinase. Numerous studies have demonstrated reduction in maximum standardised uptake value (SUVmax) and/or sensitivity for detection of malignancies in the pancreas [5, 6], lung [7], and head and neck [8] associated with hyperglycaemia. Hyperglycaemia can influence 18F-fluorodeoxyglucose (FDG) uptake due to competition for glucose transport and phosphorylation by hexokinase. This study aims to establish the safety and efficacy of a personalised insulin calculator protocol to estimate the dose of intravenous insulin injection for correction of hyperglycaemia prior to FDG PET/CT
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