glucose management in non icu med-surg (final) 10-15-16 · archana r. sadhu, md., face director of...
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10/11/2016
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Glucose Management in NONGlucose Management in NONGlucose Management in NONGlucose Management in NON----ICUICUICUICU
Hospitalized PatientsHospitalized PatientsHospitalized PatientsHospitalized Patients
Archana R. Sadhu, MD., FACEArchana R. Sadhu, MD., FACEArchana R. Sadhu, MD., FACEArchana R. Sadhu, MD., FACEDirector of System Diabetes ProgramDirector of System Diabetes ProgramDirector of System Diabetes ProgramDirector of System Diabetes Program
Director of Transplant EndocrinologyDirector of Transplant EndocrinologyDirector of Transplant EndocrinologyDirector of Transplant Endocrinology
Assistant Professor, Weill Cornell Medical CollegeAssistant Professor, Weill Cornell Medical CollegeAssistant Professor, Weill Cornell Medical CollegeAssistant Professor, Weill Cornell Medical College
Adjunct Assistant Professor, Texas A & M Medical SchoolAdjunct Assistant Professor, Texas A & M Medical SchoolAdjunct Assistant Professor, Texas A & M Medical SchoolAdjunct Assistant Professor, Texas A & M Medical School
Houston MethodistHouston MethodistHouston MethodistHouston Methodist
October 15, 2016October 15, 2016October 15, 2016October 15, 2016
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DISCLOSURES
• I do not have any relevant financial disclosures.
3
OBJECTIVES
• Understand the impact of glycemic control on
clinical outcomes for noncritically ill medical
and surgical patients
• Review current guidelines and glycemic targets
for noncritically ill patients
• Review strategies for safe and effective
glycemic control from admission until discharge
• Discuss challenges to glycemic control unique
to the hospital setting
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HYPERGLYCEMIA*: A COMMON
COMORBIDITY IN MEDICAL-SURGICAL
PATIENTS IN A COMMUNITY HOSPITAL
62%
12%
26%
NormoglycemiaKnown history of diabetes
Newly discovered Hyperglycemia
n = 2,020
* Hyperglycemia: Fasting BG ≥≥≥≥ 126 mg/dlor Random BG ≥≥≥≥ 200 mg/dl X 2
Adapted from Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978–982.
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HYPERGLYCEMIA IS AN INDEPENDENT MARKER
OF INPATIENT MORTALITY IN PATIENTS WITH
UNDIAGNOSED DIABETES
1.73
16
0
2
4
6
8
10
12
14
16
18
Adapted from Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978–982.
In-hospital Mortality Rate
(%)
Newly Discovered
Hyperglycemia
Patients With History of Diabetes
Patients With
Normoglycemia
P < 0.01
P < 0.01
THE IMPACT OF HYPERGLYCEMIA IN
NONCRITICALLY ILL PATIENTS
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INPATIENT HYPERGLYCEMIA HAS BEEN
SHOWN TO BE A MARKER OF POOR
OUTCOMES…
�Critical Illness: ICU, cardiothoracic surgery,
acute myocardial infarction
�Surgery: orthopedic, vascular, colorectal,
bariatric, trauma
�Medical: COPD exacerbation, pneumonia
�Neurology: Stroke, Cerebral Aneurysm,
Subarachnoid Hemorrhage
�Obstetrics: Labor and Delivery
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411 diabetics who underwent CABG
Leg and chest wounds, pneumonia, and UTI
Relative Odds of Wound Infections
121-206 –207-229 1.17
230-252 1.86
253-353 1.78
(P < 0.05 for
upward trend)
Golden SH et al. Diabetes Care. 1999;22:1408-1411.*Golden SH et al. Diabetes Care. 1999;22:1408-1411
INCREASED WOUND AND
NOSOCOMIAL INFECTIONSPerioperative Glycemic Control and the Risk of Infectious
Complications in a Cohort of Adults with Diabetes*
Relative risk for “serious” post-op
infections increased to 5.7 when
glucose >220 mg/dL
Early postoperative glucose control predicts nosocomial
infections rate in diabetic patientsǂ
ǂ Pomposelli JJ et al. J Parenteral Ent Nut. 1998;2 2:77-81
9
Thirty-day mortality and in-hospital complication r ates in patients with and without diabetes: blood infection (combined bacteraemia and sepsis); urinary tract infection (UTI), acute
myocardial infarction (AMI), and ARF. *P < 0.001; †NS; ‡P < 0.017.
Frisch, A et al. Dia Care 2010;33:1783-1788
IN-HOSPITAL COMPLICATIONS WITH
AND WITHOUT DIABETES IN
NONCARDIAC SURGERY
N=3,184
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10
• Case controlled study of 2151 patients who underwent elective non-cardiac surgery
• Pre-op random glucose measurements defined as:
- Normal : < 110 mg/dl
- Pre-DM: 110-200 mg/dl
- DM: > 200 mg/dl
• Prediabetes: 1.7 fold 1.7 fold 1.7 fold 1.7 fold increased mortality increased mortality increased mortality increased mortality compared to normal
• Diabetes: 2.1 fold increased 2.1 fold increased 2.1 fold increased 2.1 fold increased mortalitymortalitymortalitymortality
IMMEDIATE PRE-OP
GLUCOSE AND MORTALITY
Noordzij P et al. Eur J Endocr 2007;156:137-142
100 mg/dL
200 mg/dL
Normal Prediabetes Diabetes
11
Frisch, A et al. Dia Care 2010;33:1783-1788
Patients Patients Patients Patients WITHOUTWITHOUTWITHOUTWITHOUT
diabetes had higher odds diabetes had higher odds diabetes had higher odds diabetes had higher odds
ratio of 30 day mortality ratio of 30 day mortality ratio of 30 day mortality ratio of 30 day mortality
with higher mean with higher mean with higher mean with higher mean
glucosesglucosesglucosesglucoses
●●●● All patients■■■■ Patients with Diabetes▴▴▴▴ Patients without Diabetes
ASSOCIATION OF MEAN GLUCOSE
BEFORE AND AFTER NONCARDIAC
SURGERY
No diabetes
No diabetes
Before surgeryBefore surgeryBefore surgeryBefore surgery
After surgeryAfter surgeryAfter surgeryAfter surgery
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PRE-OP GLYCEMIC
CONTROL - ORTHOPEDICS
• 115 patients with Type 2 DM s/p TKA1
�Preoperative HgA1c ≥ 8% was an independent risk
factor of wound complications (OR 6.07)
• Duke Study2: >1 million patients who underwent joint
replacement surgery from 1988-2005
�Uncontrolled diabetes had higher adjusted odds
ratio of:
• Stroke (OR 3.42)Stroke (OR 3.42)Stroke (OR 3.42)Stroke (OR 3.42)
• UTI (OR 1.97)UTI (OR 1.97)UTI (OR 1.97)UTI (OR 1.97)
• Postop hemorrhage (OR 1.99)Postop hemorrhage (OR 1.99)Postop hemorrhage (OR 1.99)Postop hemorrhage (OR 1.99)
• Wound infection (OR 2.28)Wound infection (OR 2.28)Wound infection (OR 2.28)Wound infection (OR 2.28)
• Ileus (OR 1.99)Ileus (OR 1.99)Ileus (OR 1.99)Ileus (OR 1.99)
• Death (OR 3.23)Death (OR 3.23)Death (OR 3.23)Death (OR 3.23)
1. Han H, Kang S. Clinic in Orthopedic Surgery,2013;5:118-123 2. Marchant, MH et al. J Bone Joint Surg 2009; 91:1621-9
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COLORECTAL AND BARIATRIC SURGERY WITH
POSTOPERATIVE GLUCOSE >180 MG/DL
Outcomes stratified by perioperative hyperglycemia (>180 mg/dL at any point on the day of surgery, postoperative day 1, or postoperative day 2) for diabetic patients (A) and nondiabetic patients (B). *P < 0.01; †P< 0.05.
Kwon S, et al. Ann Surg 2013; 257(1):8-14
N=11,633
14Adapted from Vriesendorp. Eur J Vasc Endovasc Surg 2004; 28:520-5
<103 mg/dL 103-117 mg/dL 117-151 mg/dL >151 mg/dL
EARLY (48H) POSTOPERATIVE GLUCOSE EARLY (48H) POSTOPERATIVE GLUCOSE EARLY (48H) POSTOPERATIVE GLUCOSE EARLY (48H) POSTOPERATIVE GLUCOSE
LEVELS AND SSI AFTER VASCULAR LEVELS AND SSI AFTER VASCULAR LEVELS AND SSI AFTER VASCULAR LEVELS AND SSI AFTER VASCULAR
SURGERYSURGERYSURGERYSURGERY
P for trend=0.003; *P=0.006; **P=0.28; ***P=0.69
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A: Predicted probability of in ‐‐‐‐hospital adjusted mortality
Shihab Masrur et al. J Am Heart Assoc 2015;4:e00219 3
HYPERGLYCEMIA AND
STROKE
B: Predicted probability of adjusted symptomatic intracranial
hemorrhage
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GUIDELINES FOR HYPERGLYCEMIA
MANAGEMENT OF NONCRITICALLY
PATIENTS
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MANAGEMENT WITH SLIDING -SCALE
INSULIN IS INADEQUATE
• Reactive therapy � provides supplemental insulin afterafterafterafter hyperglycemia occurs
• No basal (long term) insulin coverage:
� Will cause DKA in patients with Type 1 Will cause DKA in patients with Type 1 Will cause DKA in patients with Type 1 Will cause DKA in patients with Type 1 diabetesdiabetesdiabetesdiabetes
• Does not consider nutritional changes or diurnal insulin requirements
• Non physiologic dosing that results in:
– Increased incidence of hyperglycemic and hypoglycemic episodes1
1Queale WS et al. Arch Intern Med. 1997;157:545-552
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ROLLER COASTER EFFECT
OF SLIDING-SCALE INSULIN
Time
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• 130 insulin naïve patients with Type 2 diabetes
• Discontinued all oral antidiabetic drugs on admission
• Randomized to:
- Basal- Bolus Arm: glargine and glulisine
- Standard Arm : Sliding Scale Insulin alone
• Starting Total Daily Dose (TDD): – 0.4 units/kg/d x BG between 140-200 mg/dL
– 0.5 units/kg/d x BG between 201-400 mg/dL
– Half as glargine and half as glulisine divided daily with meals
RABBITRABBITRABBITRABBIT----2 TRIALS: BASAL / BOLUS 2 TRIALS: BASAL / BOLUS 2 TRIALS: BASAL / BOLUS 2 TRIALS: BASAL / BOLUS
SUBCUTANEOUS INSULIN THERAPY IN SUBCUTANEOUS INSULIN THERAPY IN SUBCUTANEOUS INSULIN THERAPY IN SUBCUTANEOUS INSULIN THERAPY IN
MEDICAL PATIENTSMEDICAL PATIENTSMEDICAL PATIENTSMEDICAL PATIENTS
Umpierrez GE et al. Diabetes Care. 2007;30:2181–2186.
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RABBITRABBITRABBITRABBIT----2 TRIAL: BASAL 2 TRIAL: BASAL 2 TRIAL: BASAL 2 TRIAL: BASAL ---- BOLUS BOLUS BOLUS BOLUS INSULIN INSULIN INSULIN INSULIN
THERAPY HAS BETTER GLYCEMIC THERAPY HAS BETTER GLYCEMIC THERAPY HAS BETTER GLYCEMIC THERAPY HAS BETTER GLYCEMIC CONTROL IN CONTROL IN CONTROL IN CONTROL IN
NON ICU MEDICAL PATIENTSNON ICU MEDICAL PATIENTSNON ICU MEDICAL PATIENTSNON ICU MEDICAL PATIENTS
Sliding scale regular insulin (SSRI): given 4 times daily. Basal-bolus regimen: glargine once daily; glulisine before meals.0.4 U/kg/d x BG between 140-200 mg/dL0.5 U/kg/d x BG between 201-400 mg/dL
Days of Therapy
BG
(m
g/dL
)
100
120
140
160
180
200
220
240
Admit 1
Sliding scale
Basal bolus
*
2 3 4 5 6 7 8 9 10
**
* **
*
* P<0.05.
Umpierrez GE et al. Diabetes Care. 2007;30:2181–2186.
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Days of Therapy
0 1 2 3 4 5 6 7 8 9 10 11 12
Blo
od G
luco
se (
mg/
dL)
100
120
140
160
180
200
220
240
260
280
300
SSRILantus plus Glulisine
Admit 1 2 3 4 1 2 3 4 5 6 7
Failure was defined as 3 consecutive BG values > 240 mg/dL during SSRI
¶
P: NS P: 0.02
¶¶
¶¶
Umpierrez GE et al. Diabetes Care. 2007;30:2181–2186.
Blo
od G
luco
se (
mg/
dL)
BLOOD GLUCOSE LEVELS IN PATIENTS BLOOD GLUCOSE LEVELS IN PATIENTS BLOOD GLUCOSE LEVELS IN PATIENTS BLOOD GLUCOSE LEVELS IN PATIENTS
WHO FAILED WHO FAILED WHO FAILED WHO FAILED SSRISSRISSRISSRI: TRANSITION TO : TRANSITION TO : TRANSITION TO : TRANSITION TO
BASAL BOLUS INSULIN BASAL BOLUS INSULIN BASAL BOLUS INSULIN BASAL BOLUS INSULIN
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• Results: – Daily blood glucose (BG):
Lower mean fasting, lower mean daily glucose more glucose readings < 140 mg/dl
– Reduced composite endpoints of postoperative complications:
- Reduced at 8.6 % vs. 24.3% (P=0.003)
- Wound infection: 2.9 vs. 10.3% (P=0.247)
- Pneumonia: 0 vs. 2.8% (P=0.247)
- Acute renal failure: 3.8 vs. 10.3% (P=0.106)
Umpierrez GE et al. Diabetes Care. 2011; 34:256–261Umpierrez GE et al. Diabetes Care 34:256–261, 2011
RABBITRABBITRABBITRABBIT----2 SURGERY: BASAL2 SURGERY: BASAL2 SURGERY: BASAL2 SURGERY: BASAL----BOLUS BOLUS BOLUS BOLUS
INSULIN THERAPY HAS LOWER INSULIN THERAPY HAS LOWER INSULIN THERAPY HAS LOWER INSULIN THERAPY HAS LOWER
POSTOPERATIVE COMPLICATIONSPOSTOPERATIVE COMPLICATIONSPOSTOPERATIVE COMPLICATIONSPOSTOPERATIVE COMPLICATIONS
23Umpierrez G. E. et al. Diabetes Care 2013;36:3430-3 435
• Randomized, open-label pilot study
of general medical and surgical
patients (n=90)
• T2D on diet, any orals, low dose
insulin (≤ 0.4 units/kg/day)
• 3 Arms: sitagliptin alone, sitagliptin
+ glargine, or basal + bolus insulin
_________________________________
RESULTS
• No difference in mean daily glucose
• No difference in number of target
glucose readings
• No difference in hypoglycemia
• No difference in LOS
• Less total daily insulin dose and
number of injections in the
sitagliptin group
DPP4-INHIBITORS IN THE
HOSPITAL SETTING
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CHALLENGES TO ORAL DIABETES
THERAPIES IN THE HOSPITAL
Many restrictions to use of orals in the hospital:Many restrictions to use of orals in the hospital:Many restrictions to use of orals in the hospital:Many restrictions to use of orals in the hospital:
� Renal or hepatic impairment Renal or hepatic impairment Renal or hepatic impairment Renal or hepatic impairment (e.g. metformin,
sulfonylureas, TZD, SGLT-2)
� Volume overload Volume overload Volume overload Volume overload (TZD)
� Changing nutritional status or malnutrition Changing nutritional status or malnutrition Changing nutritional status or malnutrition Changing nutritional status or malnutrition (insulin
secretagogues)
� Contrast dye Contrast dye Contrast dye Contrast dye for imaging or procedures (metformin)
� Slow pharmacokinetic profiles Slow pharmacokinetic profiles Slow pharmacokinetic profiles Slow pharmacokinetic profiles of oral agents infective
for rapid changes in glucose and insulin requirements
� Risk of hypoglycemia Risk of hypoglycemia Risk of hypoglycemia Risk of hypoglycemia is unclear in the hospital setting
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CURRENT GUIDELINES FOR
GLUCOSE TARGETS
• NonNonNonNon––––ICU Patients:ICU Patients:ICU Patients:ICU Patients:
– Premeal glucose targets <140 mg/dL
– Random blood glucose (BG) <180 mg/dL
– To avoid hypoglycemia, reassess insulin regimen if
BG levels fall below 100 mg/dL
– Some patients may be maintained with a glucose
range below and/or above these cut-points
Hypoglycemia = BG <70 mg/dLSevere hypoglycemia = BG <40 mg/dL
Umpierrez et al, Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline. JCEM , 2012, 97(1):16-38Moghissi ES et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15:353-369. http://www.aace.com/pub/pdf/guidelines/InpatientGlycemicControlConsensusStatement.pdf.
STRATEGIES TO ACHIEVE GLYCEMIC
CONTROL IN CRITICALLY ILL PATIENTS
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ADMISSION #1: HIP
FRACTURE
• 66 year old female with osteoporosis admitted with a hip fracture
• History of T2DM for 12 years, Hypothyroidism, CAD, CKD 3-4
• DM Meds: metformin 1000mg BID, glyburide 5 mg bid, sitagliptin 100 mg QD
• Admission Labs: Glucose 220 mg/dL, Cr= 1.6, A1c = 9.2%
• Underwent ORIF and postoperative glucose is now 330 mg/dl
How should we treat her diabetes?
1. Continue metformin and pioglitazone but increase glyburide dose
2. Discontinue all oral agents and start Sliding Scale insulin therapy Q 4-6 hours
3. Start a basal (intermediate or long acting) + bolus (rapid acting ) insulin regimen
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KEY CONCEPTS OF
EFFECTIVE INSULIN THERAPY
• BasalBasalBasalBasal insulin
– Controls hepatic glucose production
• FoodFoodFoodFood ((((prandialprandialprandialprandial) ) ) ) insulin
– Based on meal carbohydrate content
• CorrectionCorrectionCorrectionCorrection ((((supplementalsupplementalsupplementalsupplemental)))) insulin
– Treats acute elevation in blood glucose
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INITIATING A BASAL BOLUS
INSULIN REGIMEN
No clue where to start???
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WEIGHT BASED INSULIN DOSINGWEIGHT BASED INSULIN DOSINGWEIGHT BASED INSULIN DOSINGWEIGHT BASED INSULIN DOSING
Actual Body Weight (kg): 50 60 70 80 90
A: Basal (Lantus® (insulin glargine) once daily)
Insulin Sensitive (BMI less than 20, ESRD) 5 6 7 8 9
Insulin Average (BMI 20-30, less than 2 agents, admit blood glucose (BG) less than 200mg/dL)
10 12 14 16 18
Insulin Resistant (BMI more than30, on more than 2 agents, admit BG more than 200, on steroid therapy
15 18 21 24 27
Adjust: if fasting BG greater than 140mg/dL and none less than 70mg/dL +2 +2 +3 +4 +5Adjust: if fasting BG less than 70mg/dL -2 -3 -4 -5 -5
B: MealtimeTID--Humalog®(insulin lispro)(Caution if poor appetite; may use different dose each meal)
Insulin Sensitive 2 2 3 3 3
Insulin Average 3 4 5 5 6
Insulin resistant 5 6 7 8 9Adjust: if fasting BG greater than 140mg/dL and none less than 70mg/dL +1 +1 +2 +2 +3
Adjust: if premeal BG less than 70mg/dL -2 -2 -2 -3 -3
C: Corrective—Humalog® (Insulin lispro) : Start algorithm #2 (unless ESRD, then start #1)
Total Daily Dose (TDD) calculations above are based on:Insulin sensitive – 0.2 units/kg/dayInsulin Average – 0.4 units/kg/dayInsulin Resistant – 0.6 units/kg/day
INITIAL DOSING FOR BASAL + BOLUS INSULIN REGIMEN
Choose patients level of insulin resistance(sensitive/average/resistant) and match to patient’s weight in kg to find the dose of Lantus and Lispro with meals.
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WEIGHT BASED INSULIN DOSINGWEIGHT BASED INSULIN DOSINGWEIGHT BASED INSULIN DOSINGWEIGHT BASED INSULIN DOSING
Basal Insulin Dosing
Prandial Insulin Dosing
EHR will auto calculate the basal and prandial insu lin dosing with weight based dosing option
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CORRECTION INSULIN
33
ADMISSION #1 – READY
FOR DISCHARGE
• Patient has been treated with basal bolus
insulin regimen
• Glucose has been between 100-180 mg/dl
• Uncomplicated postop recovery
• Cr is 1.8
What should the discharge regimen be?
Reassess pre-admission regimen:• Outpatient DM Meds: metformin 1000mg bid, glyburide 5mg bid, metformin 1000mg bid, glyburide 5mg bid, metformin 1000mg bid, glyburide 5mg bid, metformin 1000mg bid, glyburide 5mg bid,
sitagliptin 100mg dailysitagliptin 100mg dailysitagliptin 100mg dailysitagliptin 100mg daily
• Labs: Admission glucose 220 mg/dLAdmission glucose 220 mg/dLAdmission glucose 220 mg/dLAdmission glucose 220 mg/dL HgbA1c 9.2%,HgbA1c 9.2%,HgbA1c 9.2%,HgbA1c 9.2%, creatinine 1.6,creatinine 1.6,creatinine 1.6,creatinine 1.6,
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CONSIDERATIONS WITH NON-
INSULIN DIABETES MEDICATIONS
• Renal InsufficiencyRenal InsufficiencyRenal InsufficiencyRenal Insufficiency: � Metformin: Cr > 1.5 (eGFR < 60 cc/min) in men and > 1.4 in
women for metformin
� Sulfonylureas (exception of glipizide)
� Reduce doses for some DPP4 Inhibitors, GLP1-RA agonists and SGLT-2 inhibitors
• Hepatic Insufficiency: Hepatic Insufficiency: Hepatic Insufficiency: Hepatic Insufficiency: � Metformin and TZD: LFT’s >2-3x upper normal
• Volume Overload: Volume Overload: Volume Overload: Volume Overload: � TZDs: Renal failure, liver failure, heart failure
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DISCHARGE REGIMENS
A1c Preadmission Regimen
<7% Continue previous regimen
7-8% Increase doses of previous agents or add additional oral on non-insulin agent.
If already on max dose of ≥ 2 oral agents, consider basal insulin
8-9% Add basal insulin to previous oral or non-insulin regimen or if already on basal
insulin, change to multiple daily injections
>9% Multiple daily injections
What is the A1c?
Other Considerations for Patient Centered Approach:�Financial�Patient cognition, literacy, ability to comply�Risks of hypoglycemia�Weight management�Follow up as outpatient
36
ADMISSION #2: SOB
• 56 year old male admitted to the floor with pneumonia and COPD exacerbation
• History of T2DM for 6 years
• DM Meds: Metformin 1000mg BID, canagliflozin 300mg daily
• Labs: Glucose 190 mg/dL, Cr= 1.0, HgbA1c = 6.7%
• Started on antibiotics and solumedrol 60mg iv daily
How should we treat his diabetes?
1. Continue metformin and canagliflozin
2. Discontinue orals and start sliding scale insulin therapy every 4-6 hours
3. Start basal + bolus insulin therapy
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8 12 6 10
Insulin Requirement High a.m. dose corticosteroids
• Consider NPH with rapid
acting regimens
• Dose basal insulin higher
during the day than
overnight
• Dose prandial insulin
higher towards the end of
the day
• May need a ratio of higher
prandial than basal insulin
(60-70% prandial vs.
30-40% basal)
INSULIN REGIMENS FOR
CORTICOSTEROIDS
38
SUGGESTED INSULIN DOSING
FOR STEROID TAPER
Prednisone Dosage
(mg/day)
Insulin Dosage (U/kg)
≥ 40 0.4
30 0.3
20 0.2
10 0.1
Clore J, Thurby-Hay L. Glucocorticoid-induced hyperglycemia. Endocr Pract. 2009; 15:469-474
Consider other comorbid conditions that would increase or decrease insulin resistance and adjust the ratio
39
ADMISSION # 3:
TRANSFER FROM ICU
• 72 year old female admitted with fever, SOB and
hypotension
• Admitted to medical ICU for urosepsis and SIRS
• No history of Type 2 Diabetes but has HTN ,
Hyperlipidemia, CAD, Gout.
• Labs: Glucose= 225 mg/dL, repeat was 253 mg/dL
HgbA1c = 5.9% Creatinine = 1.8 AST/ALT = normal
• Managed with pressors, corticosteroids, antibiotics and
vent support
• Excellent glycemic control was achieved with
intravenous insulin infusion
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ADMISSION #3–
CONTINUED
• Over the next few days, the patient improves significantly.
• Pressors are weaned off and steroids are reduced. She is
extubated.
• Tube feedings were started and titrated to goal rate
• 24 insulin requirements from insulin infusion while on stable TF
rates are 65 units
• Renal and liver function returning to normal
• Ready for transfer to floor on current TF regimen with plans for
swallow study in a few days.
What should we do with the insulin regimen?
1. D/C insulin infusion and start sliding scale insulin only
2. Transition to a basal + SC insulin regimen with sliding
scale
3. Start metformin 500mg bid and Glyburide 5mg daily
416 10 2 6
Lispro/Apsart Q 4 hours correction -
Glargine/Detemir: ~ 70% of iv requirements
Lispro/Aspart Q 4 hours correction
NPH ~ 70 % of iv requirements divided Q 6-8 hours
Q8 hSample calculation of transition from insulin drip:
Prior 24 hours intravenous insulin = 65 units 70% = 46 unitsNPH 15 units q8 hourswith lispro/aspart correction q4 hours.
Options for Insulin Regimen:
1. Glargine/Detemir daily + Rapid Acting Q4 hours 1
2. NPH Q6-8 hours + Rapid Acting Q 4 hours 2
3. 70/30 Mixed Insulin BID – TID 3
SUBCUTANEOUS INSULIN REGIMENS FOR
NPO, PARENTERAL OR ENTERAL NUTRITION
1. Korytkowski MT, et al. Diabetes Care 2009; 32:594-5962. Cook A, et al. Nutr Clin Pract 2009;24:718-7223. Hsia e, et al. Nutr Clin Pract 2011;26:714-717
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ADMISSION # 3 -
CONTINUED
• Several days later the patient passes the swallow evaluation.
• Hydrocortisone is tapered off
• The TF are discontinued at 10 am
• Last NPH dose was at 8 am as scheduled
• At 1 pm, she has a hypoglycemia to 45 mg/dl45 mg/dl45 mg/dl45 mg/dl
What happened?What happened?What happened?What happened?
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HYPOGLYCEMIA WITH SUDDEN
INTERRUPTION IN CALORIES
• D10% IVF readily available for patients and
start at the same rate as the nutritional rate if
on TPN or tube feeds
• Continue D10% until tube feeds resumed or
effect of long acting insulin is worn off
• ADJUST THE INSULIN THERAPY OR NOTIFY THE ADJUST THE INSULIN THERAPY OR NOTIFY THE ADJUST THE INSULIN THERAPY OR NOTIFY THE ADJUST THE INSULIN THERAPY OR NOTIFY THE
PRIMARY PROVIDERPRIMARY PROVIDERPRIMARY PROVIDERPRIMARY PROVIDER
44
SPECIAL REGIMENS FOR CONTINUOUS
TPN OR TUBE FEEDS
For patients on continuous tube feeds or TPN, recom mend a regimen of NPH Q 8 hours with lispro Q 4 hours
Special nursing instructions: Start Dextrose 10% IV during any interruption in tube feeds or TPN up to a max of 40 cc/hr. HOLD ne xt insulin dose and notify prescriber for further orders.
45
ADMISSION # 3 –
DISCHARGE REGIMEN
• Blood sugars have been normal without
additional insulin on stable oral diet
• Ready for discharge
Does the patient need insulin or oral agents
for discharge?
Reminder: Admission HgbA1c = 5.9%
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HOSPITAL HYPERGLYCEMIA
REQURIES DISCHARGE FOLLOW UP
• In those with previously diagnosed diabetes, In those with previously diagnosed diabetes, In those with previously diagnosed diabetes, In those with previously diagnosed diabetes, newly diagnosed diabetes, or elevated A1cnewly diagnosed diabetes, or elevated A1cnewly diagnosed diabetes, or elevated A1cnewly diagnosed diabetes, or elevated A1c
– Initiate therapy or revise preadmission regimen as required
• In those without previously diagnosed diabetesIn those without previously diagnosed diabetesIn those without previously diagnosed diabetesIn those without previously diagnosed diabetes
– Differentiation between hospital-related hyperglycemia and undiagnosed diabetes requires follow-up testing (FBG, 2h OGTT, A1c) once metabolically stable using established criteria
47
DISCHARGE TRANSITION
• Diabetes Education – Survival Skills
• Nutrition counseling for carbohydrate and
calorie restriction
• Reassessment of admission treatment regimen
• Transition to non insulin therapy, if appropriate
• Outpatient follow-up and referrals for on going
care
• Clear, written medication instructions for
patients
48
ADMISSION #4: HOSPITAL
ACQUIRED CONDITION
• 32 year old male admitted for Left femoral-popliteal bypass
• H/o Type 1 DM for >20 years on an insulin pump at home and on admission. HgbA1c was 6.7% on this regimen
• On admission he was placed NPO after midnight and insulin pump was removed and sliding scale was ordered
• On the morning of surgery, patient was found to be confused, tachypneic with shallow respirations
• Labs: Glucose =426, Potassium = 5.6, pH =7.2 Bicarb=14, anion gap of 16, positive serum ketones
What happened???What happened???What happened???What happened???
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DANGERS OF SLIDING-SCALE
INSULIN REGIMENS
• Sliding Scale Insulin is a reactive therapy �provides supplemental insulin afterafterafterafterhyperglycemia occurs
• No basal (long term) insulin coverage which is critical for patients with Type 1 diabetes
Iatrogenic DKA!Iatrogenic DKA!Iatrogenic DKA!Iatrogenic DKA!
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DIABETES TECHNOLOGY
IN THE HOSPITAL
• Increasing utilization of outpatient technology
will follow patients into the hospital
– Continuous Subcutaneous Insulin Infusion (CSII) or
Insulin Pump therapy
– Continuous Glucose Monitoring (CGM)
• Advantages: less severe glycemic excursions,
programmed to avoid hypoglycemia, patient
satisfaction
• Disadvantages: not well studied or approved in
the hospital, unfamiliarity with non-endocrine
trained staff, not proven to be more efficacious
in inpatient settings
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TYPES OF TECHNOLOGY
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CSII - BASICSPump Feature Description
Basal Rates
Ex: 00:00 0.95 U/h, 06:00 0.5 U/h, 17:00
0.6 U/h
• Rate of continuous infusion of a rapid acting
insulin (lispro, aspart, glulisine, or Regular
U500)
• Set by time of day
• Multiple rates throughout the day
• Can be set to hundredths of a unit per hour
Bolus
Insulin to carbohydrate ratio (ICR) or
Carb Ratio (CR)
Ex: 00:00 10 grams, 08:00 12 grams
• Amount of carbs for a unit of insulin
• Individualized for each patient
• Accurate dosing of insulin for the carbs
Insulin Sensitivity Factor (ISF) or
Correction Factor (CF)
Ex: 00:00 50 mg/dl, 12:00 35 mg/dl
• Amount of decrease in glucose per unit of
insulin
• Individualized for each patient
Target Glucose
Ex: 00:00 90-120 mg/dl; 12:00 100-130
mg/dl
• Glucose level above which a correction dose
is given
Insulin on Board (IOB) or
Active Insulin Time (AIT)
Ex: 4 hours
• Duration of time between successive
correction doses, avoids stacking
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CONTINUOUS SUBCUTANEOUS
INSULIN PUMPS (CSII)
• Some small, single center studies have shown that
continuing CSII is safe in the hospital
• Standardized hospital protocols, order sets and patient
consents are strongly recommended
• Key is to identify that the patient is using their own
supplied insulin pump and has mental capacity to
continue the therapy
• Protocol should include safety parameters that address
the frequency of glucose monitoring, daily pump site
and patient assessment, and hypoglycemia treatment
Noschese et al. Endo Prac 2009; 15(5): 415-424Nassar et al. J Diabetes Sci Techbol. 2010;4(4):863-72
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PERIOPERATIVE
MANAGEMENT OF CSII
• Retrospective review of patients with CSII
preoperatively for elective surgeries
• 49 patients undergoing 57 surgeries
• Protocol in place for CSII management
• Efficacy: 63% had postop CBG of ≤200 mg/dl,
• Safety: No intraoperative or postoperative
hypoglycemia <70 mg/dl
• Lower mean postoperative glucose if surgery was less
than 120 minutes, more patients met this endpoint
• CSSI is safe and efficacious, especially for surgery
<120 min
Sabel et al. Endo Prac 2015, 21(111):1269-1276
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CSII – SURGERIES AND
PROCEDURES
• Plan ahead before elective surgeries
• Can continue CSII during short procedures at
discretion of surgeon and anesthesiologist if
pump site does not interfere with surgical field
• May use short acting SQ insulin if CSII is held
for 1-2 hours.
• If CSII is to be held for > 3 hours, start basal start basal start basal start basal
bolus insulin regimenbolus insulin regimenbolus insulin regimenbolus insulin regimen
• Can reduce basal rates with the “temp basal”
function by a 20-50% of the usual rate
AACE Consensus Panel on Insulin Pump Management Endo Prac 2010 16(5): 746-762
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CONTINUOUS GLUCOSE
MONITORING (CGM)
• Currently not FDA approved in the hospital
setting
• Most studies are in ICU patients or
postoperative patients
• Accuracy is a concern due to interference with
medications (e.g. Tylenol) and physiological
changes during acute illness (pH, volume
overload, etc.)
• No guidelines or protocols available to
incorporate this data into management
• More research is needed in the inpatient
setting
CHALLENGES TO GLYCEMIC CONTROL IN
THE HOSPITAL SETTING
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BARRIERS IN THE
HOSPITAL
• Diabetes/hyperglycemia often overlooked on admission Diabetes/hyperglycemia often overlooked on admission Diabetes/hyperglycemia often overlooked on admission Diabetes/hyperglycemia often overlooked on admission
and throughout the hospitalization if it is not the and throughout the hospitalization if it is not the and throughout the hospitalization if it is not the and throughout the hospitalization if it is not the
primary diagnosisprimary diagnosisprimary diagnosisprimary diagnosis
• Hypoglycemia feared and often overHypoglycemia feared and often overHypoglycemia feared and often overHypoglycemia feared and often over----treated treated treated treated
• Lack of familiarity with the increasing types of diabetes Lack of familiarity with the increasing types of diabetes Lack of familiarity with the increasing types of diabetes Lack of familiarity with the increasing types of diabetes
therapies currently availabletherapies currently availabletherapies currently availabletherapies currently available
• Traditional sliding scale protocols continue to prevail Traditional sliding scale protocols continue to prevail Traditional sliding scale protocols continue to prevail Traditional sliding scale protocols continue to prevail
due to ease and lack of educationdue to ease and lack of educationdue to ease and lack of educationdue to ease and lack of education
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BARRIERS IN THE
HOSPITAL
• Increased workload on nursingIncreased workload on nursingIncreased workload on nursingIncreased workload on nursing
• Timing of insulin with the glucose check and Timing of insulin with the glucose check and Timing of insulin with the glucose check and Timing of insulin with the glucose check and
meals may still be problematicmeals may still be problematicmeals may still be problematicmeals may still be problematic
• Lack of coordination between departments, Lack of coordination between departments, Lack of coordination between departments, Lack of coordination between departments,
e.g., nutrition, radiology, nursing, etc.e.g., nutrition, radiology, nursing, etc.e.g., nutrition, radiology, nursing, etc.e.g., nutrition, radiology, nursing, etc.
• Frequently changing nutritional status, Frequently changing nutritional status, Frequently changing nutritional status, Frequently changing nutritional status,
medications and organ function that affects medications and organ function that affects medications and organ function that affects medications and organ function that affects
glycemic controlglycemic controlglycemic controlglycemic control
• Complexity of individualized dosing + need to Complexity of individualized dosing + need to Complexity of individualized dosing + need to Complexity of individualized dosing + need to
make daily adjustmentsmake daily adjustmentsmake daily adjustmentsmake daily adjustments
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CONDITIONS PREDISPOSING
PATIENTS TO HYPOGLYCEMIA
Advanced ageAdvanced ageAdvanced ageAdvanced age
Sepsis/shockSepsis/shockSepsis/shockSepsis/shock
MalnutritionMalnutritionMalnutritionMalnutrition
BurnsBurnsBurnsBurns
Gastrointestinal malabsorptionGastrointestinal malabsorptionGastrointestinal malabsorptionGastrointestinal malabsorption
Cerebrovascular accidentCerebrovascular accidentCerebrovascular accidentCerebrovascular accident
Hypoglycemia unawarenessHypoglycemia unawarenessHypoglycemia unawarenessHypoglycemia unawareness
Altered Mental StatusAltered Mental StatusAltered Mental StatusAltered Mental StatusGoldberg PA et al. Diabetes Spectrum. 2005;18:28-33.
Congestive heart failureCongestive heart failureCongestive heart failureCongestive heart failure
Renal insufficiencyRenal insufficiencyRenal insufficiencyRenal insufficiency
Adrenal/pituitary Adrenal/pituitary Adrenal/pituitary Adrenal/pituitary
insufficiencyinsufficiencyinsufficiencyinsufficiency
Liver diseaseLiver diseaseLiver diseaseLiver disease
PregnancyPregnancyPregnancyPregnancy
AlcoholismAlcoholismAlcoholismAlcoholism
Polypharmacy (drugPolypharmacy (drugPolypharmacy (drugPolypharmacy (drug
interactions)interactions)interactions)interactions)
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INPATIENT DIABETES
TEAMS
Multidisciplinary experts in diabetes are needed to
form a effective team:
1. Clinician: physician or physician extender
2. Nurse
3. Diabetes Educator
4. Nutritionist
5. Pharmacist
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RESOURCES
http://store.diabetes.org/1980-Managing-Diabetes-and-Hyperglycemia-in-the-Hospital-Setting.aspx
American Association of Clinical EndocrinologyDiabetes Resource Centerhttp://resources.aace.com
THANK YOU FOR YOUR
ATTENTION!
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