Intensive insulin Intensive insulin therapy for therapy for

managing diabetic managing diabetic footfoot

Dr. Bipin Kumar SethiDr. Bipin Kumar Sethi

Intensified insulin Intensified insulin therapy ..mythstherapy ..myths

Costly !Costly ! Not for this patient ! Not for this patient ! Not yet ..not so soon !Not yet ..not so soon ! Why this headache?Why this headache? Why another specialist ?Why another specialist ? Patient won’t accept !Patient won’t accept !

Glycemic control is one of the important Glycemic control is one of the important facets of management of diabetic foot & is facets of management of diabetic foot & is complimentary to the general care, complimentary to the general care, antimicrobial therapy and surgeryantimicrobial therapy and surgery

Most hospitalised patients require insulin and Most hospitalised patients require insulin and the regimens depend uponthe regimens depend upon Route of nutritional delivery/sensoriumRoute of nutritional delivery/sensorium Hemodynamic statusHemodynamic status Co-morbid conditions esp. hepatic and renal Co-morbid conditions esp. hepatic and renal

insufficiencyinsufficiency Monitoring facilitiesMonitoring facilities Degree of hyperglycemia/ decompensationDegree of hyperglycemia/ decompensation

Hyperglycemia in a hemodynamically stable Hyperglycemia in a hemodynamically stable patient should not be a deterrent to delivery patient should not be a deterrent to delivery of adequate foot care (debridement, of adequate foot care (debridement, desloughing, amputation)desloughing, amputation)

Why does glycemic control Why does glycemic control worsen ?worsen ?

Never checked before – natural Never checked before – natural coursecourse

RecumbencyRecumbency InfectionInfection DietDiet Drugs- steroidsDrugs- steroids Hospital “schedules/protocols”Hospital “schedules/protocols” StressStress

Benefits of intensified Benefits of intensified insulin regimensinsulin regimens

Quick(er) metabolic controlQuick(er) metabolic control Anabolic effectAnabolic effect Better insulinisationBetter insulinisation

Lesser mismatchLesser mismatch Lesser hyposLesser hypos

OthersOthers

For patients taking For patients taking nutrients orallynutrients orally

MSIMSI R + R + R + Basal (N/L/G/D)R + R + R + Basal (N/L/G/D) S + S + S + Basal (N/L/G/D)S + S + S + Basal (N/L/G/D) Premixed + S/R + PremixedPremixed + S/R + Premixed

International Diabetes CenterInternational Diabetes Center

Re

lati

ve

Ins

ulin

Eff

ec

tR

ela

tiv

e In

su

lin E

ffe

ct

Time (Hours)Time (Hours)

0 2 4 6 8 10 12 14 16

Long (Glargine)Long (Glargine)

18 20

Intermediate (NPH)Intermediate (NPH)

Short (Regular)Short (Regular)

Rapid (Lispro, Aspart)Rapid (Lispro, Aspart)

Insulin Time Action Curves

220220

Blo

od

su

gar

B

loo

d s

ug

ar

(mg

%)

(mg

%)

210210

200200

180180

160160

140140

6 am6 am 12 noon12 noon 6 pm6 pm 12 midnight12 midnight 5 am5 am

BreakfastBreakfast LunchLunch DinnerDinner

INSULIN

Biphasic Rapid insulin Monophasic

Blood sugar :Blood sugar :

Multiple Daily Insulin InjectionsMultiple Daily Insulin Injections

International Diabetes CenterInternational Diabetes Center

RARA

RA

Physiologic Insulin S/R – S/R – S/R– G/D/N

Se

rum

ins

ulin

(m

U/L

)

Hours

S/R S/R S/R G/D/N

Glargine0

10

20

30

40

50

0 2 4 6 8 10 12 14 16 18 20 22 24

For patients not taking For patients not taking nutrients orallynutrients orally

Insulin infusionInsulin infusion GIKGIK Non GIKNon GIK

1.1. Infusion pumpInfusion pump

2.2. NeutralisedNeutralised

3.3. Pediatric dripPediatric drip

Short term NBM requiring Short term NBM requiring procedureprocedure

Insulin + Dextrose infusionInsulin + Dextrose infusion GIKGIK Non GIKNon GIK

AlgorithmsAlgorithms

1.1. Guidelines rather than sacrosanct Guidelines rather than sacrosanct rulesrules

2.2. Go by antecedent responses, Go by antecedent responses, memory and current blood glucose memory and current blood glucose

3.3. Revise if response is suboptimalRevise if response is suboptimal

Target BG 80-110mg/dlMonitoring key to successDon’t leave it to paramedics

Team approachTeam approach

Not just numbers but interacting Not just numbers but interacting dedicated membersdedicated members

Flexibility to change regimensFlexibility to change regimens Monitoring, record keepingMonitoring, record keeping

A chain is as strong as its A chain is as strong as its weakest linkweakest link

AnonymousAnonymous

Case scenarioCase scenario

Mr. MRLS, 55yMr. MRLS, 55y T2DM 10y, Gliclazide + Mixtard 30 & T2DM 10y, Gliclazide + Mixtard 30 &

20 units20 units HTNHTN No CVA, PVDNo CVA, PVD CAD ?CAD ? Cataract bilaterallyCataract bilaterally Neuropathy +, PVD +Neuropathy +, PVD + Admitted on 31.3.04Admitted on 31.3.04

Foot infection on left side for 2 months, Foot infection on left side for 2 months, ulcer is located below the left great toe, ulcer is located below the left great toe, redness, edema and tenderness extending redness, edema and tenderness extending up to forefoot.up to forefoot.

Disarticulation of 2Disarticulation of 2ndnd toe with wide local toe with wide local excision done on 9.4.04excision done on 9.4.04

Continued to be febrile and hyperglycemicContinued to be febrile and hyperglycemic Wound remained unhealthy despite radical Wound remained unhealthy despite radical

excision of all sloughexcision of all slough 15.4.04 endocrinology consultation taken, 15.4.04 endocrinology consultation taken,

started on MSI with A20,20,20; M26unitsstarted on MSI with A20,20,20; M26units

DateDate FPGFPG PPGPPG RapidRapid BasalBasal MixMix

15.4.15.4.0404

293293 364364 20,20,220,20,200

2626

16.4.16.4.0404

160160 28,28,228,28,288

16,3016,30

18.4.18.4.0404

314314 384384 20,20,220,20,244

2626

19.4.19.4.0404

176176 226226 24,24,224,24,244

24,2424,24

20.4.20.4.0404

5454 136136 15,15,115,15,155

1515

21.4.21.4.0404

183183 16,16,116,16,166

1818

25.4.25.4.0404

7878 186186 24,224,244

Mid tarsal amputation done on 17.4.04, as his oral Mid tarsal amputation done on 17.4.04, as his oral intake remained very poor after surgery he was intake remained very poor after surgery he was given infusion of DNS with added insulingiven infusion of DNS with added insulin

He experienced hypoglycemia on 20.4.04He experienced hypoglycemia on 20.4.04 Below knee amputation on 4.5.04Below knee amputation on 4.5.04 Post surgery intake remained poor and had Post surgery intake remained poor and had

vomitingvomiting Surgery team would change to insulin as per Surgery team would change to insulin as per

sliding scale, insulin would be stopped altogether sliding scale, insulin would be stopped altogether whenever hypos occurredwhenever hypos occurred

Parenteral nutrition was also given with no Parenteral nutrition was also given with no provision of insulinprovision of insulin

Altered sensorium with hypotension on 11.5.04Altered sensorium with hypotension on 11.5.04

DateDate FPGFPG PPGPPG RapidRapid BasalBasal CommenCommentsts

5.5.05.5.044

203203 264264 10,10,10,10,1010

1010

7.5.07.5.044

078078 114114 8,8,88,8,8 88

8.5.08.5.044

123123 212212 12,1212,12 Nil Nil orallyorally

9.5.09.5.044

253253 324324 12,12,12,12,1212

1212

10.5.10.5.0404

243243 16,16,16,16,1616

1616

11.5.11.5.0404

65,665,633

9696

DateDate FPGFPG PPGPPG RapidRapid BasalBasal Pre Pre MixeMixedd

15.5.15.5.0404

134134 184184 10,10,10,10,1010

1010

19.5.19.5.0404

111111 161161 15,15,15,15,1515

1515

24.5.24.5.0404

7474 101101 35,235,255

Hyponatremia (Na112),Hypokalemia Hyponatremia (Na112),Hypokalemia (K 2.8) Hypotension 90/50 mmHg, (K 2.8) Hypotension 90/50 mmHg, Pyrexia, Metabolic alkalosisPyrexia, Metabolic alkalosis

Blood culture grew Blood culture grew Klebsiella,Enteococcus speciesKlebsiella,Enteococcus species

Was managed in AMC, received IV Was managed in AMC, received IV insulin infusion insulin infusion

Discharged on 25.5.04 !Discharged on 25.5.04 !

Intensified insulin regimens work but are Intensified insulin regimens work but are introduced rather lateintroduced rather late

Insulin requirements fluctuate but hypos Insulin requirements fluctuate but hypos should not deter from achieving the goalshould not deter from achieving the goal

Shifting from oral to parenteral nutrition does Shifting from oral to parenteral nutrition does occurs and needs closer monitoring and better occurs and needs closer monitoring and better insulinisationinsulinisation

Unplanned procedures often result in Unplanned procedures often result in interruption of insulininterruption of insulin

At all times provide for nutrient/fluid and insulinAt all times provide for nutrient/fluid and insulin

SummarySummary Most patients with diabetic foot ulcers have Most patients with diabetic foot ulcers have

significant hyperglycemia necessitating insulin significant hyperglycemia necessitating insulin therapytherapy

Glycemic control is an important though not the Glycemic control is an important though not the only management tool in the care of diabetic foot only management tool in the care of diabetic foot ulcers ,sadly it is often neglected ulcers ,sadly it is often neglected

Regimens for glycemic control vary among other Regimens for glycemic control vary among other things with the severity of things with the severity of hyperglycemia ,monitoring facilities, co-morbid hyperglycemia ,monitoring facilities, co-morbid conditions but are driven largely by the conditions but are driven largely by the enthusiasm for euglycemia of treating team and enthusiasm for euglycemia of treating team and must ensure continuity of insulin therapymust ensure continuity of insulin therapy

Admission for diabetic foot offers an opportunity Admission for diabetic foot offers an opportunity for salvaging/protecting the individual against for salvaging/protecting the individual against further ravages of micro/macrovascular diseasefurther ravages of micro/macrovascular disease

AcknowledgementAcknowledgement

Thanks…if at Thanks…if at all you could all you could

keep awake!!keep awake!!