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.

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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

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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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• 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

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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

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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

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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

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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

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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

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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.

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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

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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

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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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