Transcript Inpatient Management of the Patient with Diabetes

Stepwise approach to inpatient
diabetes management
Erin Keely
At the Ottawa Hospital:
(From Test Strip Usage)
 On any given day, 250-300 patients
admitted to Ottawa Hospital have
diabetes (25-30%)!
Impact of Diabetes on Length of Stay –
The Ottawa Hospital
Specialty
ALOS No DM
(days)
ALOS DM
(days)
Civic
General
Civic
General
General
Medicine
9
9
13
13
General
Surgery
7
6
23
11
Vascular
Surgery
10
N/A
21
N/A
Orthopedic
Surgery
7
7
18
14
Mean for
Hospital
6
6
15
12
Compiled by S. Brez, APN Endocrinology and Metabolism
Increasing information on diabetes
and cancer
Hyperglycemia in the Hospitalized
Patient: Classification
 Diabetes
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Previously Diagnosed – type 1 or type 2
Previously Undiagnosed
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Confirmed after discharge
Secondary diabetes (glucocorticoids)
 Hospital-related hyperglycemia

Reverts to normal after discharge
Glycemic Targets in Hospitalized Patients
 Medical/surgical floors
 6.1
-10.0 mmol/L
Increase risk of infection if glucose > 12 mmol/l
Glucosuria if >16-18 mmol/l
Potential Benefits of Improving
Glucose Control in the Hospital
 Reduce
mortality
 Reduce morbidity
 Reduce costs of care
Length of stay (LOS)
 Cost of inpatient complications
 Fewer rehospitalizations

Goals of Inpatient Diabetes
Management
 Avoid Hypoglycemia
 Avoid Hyperglycemia
 Assessment of Patient’s diabetes care
 Assessment of Risk Factors
Common Errors in Inpatient
Glucose Management
 Admission orders
 Withdrawal or outpatient treatment regimen
 Failure to modify outpatient regimen
 Overly high glycemic targets
 Lack of therapeutic Adjustments
 Overuse of Sliding Scale!!!!
 Overuse of Sliding Scale!!!!
 Overuse of Sliding Scale!!!!
Classification of oral agents
 Insulin secretagogues

Sulfonylureas
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Diabeta, diamicron (regular and MR)
Amaryl
Meglitinides

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Gluconorm
Starlix
 Insulin sensitizers
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
Metformin
Glitazones

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Actos
Avandia
 Incretins
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DPP-4 inhibitors
GLP-1 analogues
 CHO absorption

acarbose
Principles of InPatient Diabetes
Management
 Type 1 different than type 2
 Be safe
 Be proactive
 Try to continue pre-admission treatment
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Unless NPO or decreased intake
HgbA1c> 8.0 – 10 %
Glucose > 10-12 mmol/L
Frequent hypoglycemia
Types of Insulin
 Two main manufacturers

Novolin, Humulin
 duration of action

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rapid
short
intermediate
Very long
aspart, lyspo, apidra
regular (toronto)
NPH, lente
glargine, detemir
Action Profiles of Bolus & Basal
Insulins
lispro/aspart 4–6 hours
regular 6-10 hours


BOLUS INSULINS
BASAL INSULINS
NPH 12–20 hours
detemir ~ 6-23 hours (dose dependant)
glargine ~ 20-26 hours
Hours
Note: action curves are approximations for illustrative purposes. Actual patient response will vary.
Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491
Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12
Basal-Bolus Approach
therapy addresses:
Basal needs: Glargine, Detemir , NPH
Bolus needs: Lispro, Aspart
Meal
•
•
Meal
Meal
Expected insulin changes during the day
for individuals with a healthy pancreas.
*Insulin effect images are theoretical representations and are not derived from clinical trial data.
Principles of insulin managment
 “Usual” = Proactive
 Basal
 NPH
 Levemir
 Lantus
 Meal-time
 Regular
 Novorapid
 Humalog
 Pre-mixed
 “Corrective” = Reactive
 sliding scale
 Amount depends on
insulin sensitivity
 One size does not fit
all!!
 Use same type of
insulin as meal-time
So What to Do??
Diabetes Pocket Card
1. Is patient on diet/oral agents/insulin
2. Is patient going to eat, be NPO,
tube/parenteral feeds
3. Look at glucose trends and adjust
Patient with Diet controlled diabetes
Order:
 Blood glucose monitoring QID
 Consider doing a HgbA1c
 Consider oral hypoglycemic agent or
insulin if blood sugars in hospital
persistently >11.0 mmol/L
Patient with diabetes on oral
hypoglycemic agents
 Continue oral agents
 Caution if on metformin or actos (pioglitazone)
and renal, cardiac or hepatic dysfunction
 If blood sugars persistently >10.0 mmol in
hospital:
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Step 1: maximize oral agents, add another oral
agent (from a different class)
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Step 2: if not at target, add insulin
Do not use
 Metformin:
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If congestive heart failure
If renal failure
If requiring a test with IV contrast dye
 Thiazolidinediones

If Congestive Heart Failure
How to start Insulin
 Discontinue oral agents except metformin
 Corrective sliding scale alone (if temporary) – if
needs >8-10 units for longer than 48 hrs, consider
starting “usual” insulin
 Start “usual insulin”
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basal – 0.2-0.3 u/kg/day (either NPH split ac breakfast
and supper) or levemir/lantus qhs
Mealtime – 0.1-0.2 u/kg/day (breakfast and supper if
using NPH, all 3 meals if levemir/lantus)
Continue corrective scale
Why don’t sliding scales work?
 Action is Retrospective not Prospective
 Higher risk of Hyper and Hypoglycemia
 Threshold for insulin administration may be too high
 Sliding scales can be useful and effective if used
appropriately (I.e. as supplemental insulin only)
 Same amounts given if eating meal or not
How to Use Sliding Scale Insulin
 Sliding scale insulin can be effective IF used
appropriately
 Never use sliding scale alone (unless for 1 to 2 days
to get idea of insulin requirements)
 Should be used in addition to oral agents or long
acting insulin
 NEVER NEVER NEVER use sliding scale alone in
patient with TYPE 1 DIABETES
Choosing a sliding scale
Correction Insulin
X
X
Total Daily Insulin Dose = Lantus 40 units + Novorapid 5 with meals
= 40 units + 5 units x B, L, D
= 55 units
How do I change the scale?
If patient hyperglycemic and needs more insulin,
choose scale to the RIGHT
If patient hypoglycemic and needs less insulin,
choose scale to the LEFT
Patient on Insulin
 Determine if patient is Type 1 or Type 2!! If unsure
treat as type 1 (i.e. needs insulin all of the time)
 NEVER put a patient with type 1 Diabetes on sliding
scale alone even if not eating
 Insulin requirements may be more or less than as
required as outpatient
 Likely needs long-acting insulin (unless Type 2 and
sugars are excellent without it)
Patient on Insulin
Order
 Blood glucose monitoring QID
 Continue outpatient regimen unless
contraindicated (patient not eating,
Type 1 with DKA, etc..)
Patient on insulin and eating
 If HgbA1c < 8, continue preadmission
 If HgbA1c > 8, or CBG > 10
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Start usual insulin
Use corrective scale
Adjust based on glucose pattern
Dosage Titration Practical Example
1. First adjust insulin that caused the low blood
glucose
2.
day
Breakfast
8u H
Lunch
8u H
Dinner
8u H
Bed
16u N
3.4
8.9
9.4
9.2
Then adjust insulin that caused first high BG of the
Breakfast
8u H
Lunch
8u H
Dinner
8u H
Bed
14u N
5.1
9.2
9.4
9.2
Pre-op
Goal Blood sugar 6-10 mmol
 Start IV D5W at 75 to 100 cc/hour
 Previously on oral agents/diet
 Hold oral agents if not eating
 No basal insulin
 No meal-time insulin
 Corrective scale only
 Previously on insulin
 1/2 – 2/3 usual basal insulin
 No meal-time insulin
 Corrective scale
NPO Patient with Diabetes on Oral Agents
 Hold oral agents:

Humalog or NovoRapid sliding scale may be
added q 4-6 h in case of hyperglycemia:
 Note: 1 unit of humalog usually decreases
blood sugar by 2 to 3 mmol/L
OR
 IV Insulin
NPO Patient with Diabetes on Insulin (2+ shots/day)
Option 1: IV Insulin
OR
 Option 2: Subcutaneous Insulin:
NPO Patient with Diabetes on Insulin (2+
shots/day): SC insulin option
 Order 70-80% of long acting insulin (will need for
basal insulin requirements)
 Add sliding scale to control marked
hyperglycemia
 Remember to order IV D5W to prevent
catabolism
Patient with Diabetes on Feeds
 IF feeds are continuous, no previous insulin:
 Put patient on basal insulin
 0.3-0.4 units/kg/day
 Lanuts qhs or NPH q. 12 h
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Use corrective scale
If feeds stopped suddenly start D5W at 100cc/hr!
 IF feeds are continuous, previous insulin:
 2/3 usual basal insulin
 No meal-time insulin
 Use corrective scale
 If feeds stopped suddenly start D5W at 100cc/hr!
 IF getting bolus feeds:
 Basal- 0.2 u/kg/day or 2/3 usual basal
 Give meal-time insulin before bolus feed (3-4 units
rapid insulin before 250 cc feed)
 If feeds stopped suddenly start D5W at 100cc/hr!
Patient on TPN
 2 options:
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Insulin included in TPN
Subcutaneous insulin if needed
 Start long-acting insulin at time when has
TPN running (i.e. if receives overnight, start
NPH when feeds start and titrate up)
How to control glucose levels on TPN
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Very poorly studied
In the TPN bag or subcutaneous?
If subcutaneous

0.3-0.4 units/kg/day
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NPH q. 12 hr
levemir/lantus q. 12 or 24 hr
regular q. 6 h
rapid q. 4 h
If in TPN bag

0.1 units regular/gm of CHO plus s.c. sliding scale
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3-6 gm/kg/day dextrose = 210-420 gm 50% dextrose = 21-42 units insulin in 24
hr supply
Next day add 80% of insulin given as sliding scale to insulin bag
Assess Blood Glucoses at Daily, Adjusting Insulin Doses
as Appropriate
 Blood glucose targets can only be achieved
via continuous management of the insulin
program
 There is no “autopilot” insulin regimen for
a hospitalized patient!
Pre-Printed
Insulin Orders
Different
Components
• Standing
Hypoglycemia
Orders
• Capillary Blood
Glucose Testing
• Basal and Meal
time Insulins
• Correctional Scale
Standardized Hypoglycemic
Orders
• Standing orders to notify MRP if there is a change to PO intake
• Orders if enteral feeding is stopped
• Standing orders for the treatment of hypoglycemia in patients
who are eating and those who are NPO
Capillary Blood Glucose
Testing
• Frequency and timing of capillary blood
checks
X
X
2
Usual Insulin
• Options for different basal/meal time/mixed insulins and
timing of administration for these
• Example: Lantus 40 units at qhs; NR 3 units ac B, L, D
40
X
3
X
3
3
Correctional Insulin
• Based on Total Daily Insulin Dose
• Example: Lantus 40 units + Novorapid 5 with meals
• Total Daily = 55 units
X
X
X
Consult Diabetes Specialty Team –
RN +/- MD
 Insulin pump
 Severe or frequent hypoglycemia
 Poorly controlled prior to admission (eg.
HbA1c>10%)
 Unrecognized diabetes complications
 IS BEING D/C ON INSULIN AND WAS NOT
ON INSULIN PRIOR TO ADMISSION – and
PLEASE, not on day of d/c!!