Inpatient Diabetes 20/01/2015. What should I do? Hyperglycaemia why does it matter? Why are the BSLs unstable? BSL parameters

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1 Hyperglycaemia why does it matter? Inpatient Diabetes Angela Sheu Endocrine Registrar St George Hospital Hyperglycaemia at admission is a predictor of mortality May be part of stress response (eg post op, infection, AMI) Impairs recovery wounds, infection, AMI Symptoms blurred vision, polydipsia, polyuria Potentially life threatening DKA, HHS (hyperglycaemic hyperosmolar state) BSL parameters Why are the BSLs unstable? Diabetes Mellitus Random BSL > 11 Symptoms ~15 Impaired white cell function ~12 Fasting BSL >7 Most inpatients aim <10 Palliative patients <15 Gestational diabetes <7, 2hr post prandial Right medication and dose IR vs MR/XR (gliclazide, metformin) Combinations (glucovance, janumet, galvumet) Insulins (Humalog vs Humalog Mix) Altered metabolism of drug AKI Deranged LFTs Lipohypertrophy Altered glucose physiology Prednisone, infection, stress, decreased exercise Fasting, TPN/NG feeds stopped, decreased intake What should I do? Confirm medications Monitor correctly (pre meals and bedtime) Is there a pattern? Assess baseline control HBGM, BSL monitor, HbA1c, letters Look for precipitating factor Clinical presentation, comorbidities Define parameters BSL targets (usually <10) vs HbA1c (7% vs 8%) Start supplemental insulin Consider Endocrine advice 1

2 SGLT2 inhibitors: reduce renal glucose reabsorption Canagliflozin (Invokana) and Dapagliflozin (Forxiga) SEs: UG infections, diuresis, hypotension Not useful in egfr <60 Class Names Biguanide Metformin Extended Release Safe in renal impairment egfr >30 (lactic acidosis) Good for Everyone Bad for Lactic acidosis Sulfonylureas Glibenclamide Glimepiride Gliclazide Glipizide but more potent High BSLs Elderly* Obese Elderly* DPP-4 inhibitors Sitagliptin Linagliptin Vildagliptin Saxagliptin Alogliptin No same dose* Overweight High BSLs Thiazolidinediones Pioglitazone Rosiglitazone No NASH Heart disease Osteoporosis Peak 1hr, duration 4hrs Peak 2hr, duration 6hrs So no need to check BSLs within 1hr Supplemental insulin Better than sliding scale Pre meals ON TOP of usual insulin Use it to adjust the next day s insulins Novorapid* or actrapid < > < > <12 0 >

3 Insulin regimens and profiles Don t WH long acting insulins if fasting BSLs are good Pre op While NBM: Monitor BSLs q4hrly IV Dextrose 5% ml/hr to keep BSLs 6-10 WH OHAs on day of surgery Consider WH nocte dose beforehand If type 2 Halve dose night before if long acting/premixed WH short acting on day of surgery If type 1 Insulin/Dextrose infusion WH short acting ONLY while NBM NEVER WH long acting insulin Post op Usually can resume pre op treatment Beware Metabolic changes AKI, hypoperfusion Nutritional status NBM, CF, FF, nausea Stress stimulus removed (eg abscess, gastric bypass) Consider temporary insulin until normal parameters Hypoglycaemia Conscious vs unconscious Lemonade + sandwich 50% Dextrose bolus will always work, but then may lead to subsequent hypoglycaemia due to insulin hypersecretion Time to recovery depends on length of action of treatment Long acting sulphonylureas or insulins will last for hours-days IV 5% dextrose at 60-80ml/hr until BSL >8-10 3

4 Other questions The fasting BSL is 4.1 and the patient is allowed to eat and is charted 20units of NovoMix30 do I give it? Is this the usual dose? The bedtime BSL is 6.7 and the patient is not NBM and is charted 20units of Lantus do I give it? Is this the usual dose? It is 20:00 (>2hr post prandial) and the patient s BSL is 15 what do I do? When was the patient last given insulin? It is 20:00 (>2hr post prandial) and the patient s BSL is 25 what do I do? Novorapid 4-8 units DKA Type 1 = absolute insulin deficiency Hyperglycaemia Ketone production Metabolic acidosis Diabetic Emergencies HHS Type 2 = relative insulin deficiency Hyperglycaemia++ Hyperosmolar Fluid deficit Which has the higher mortality? 1. Confirm Dx V/ABG, ketones, UA 2. Find the cause FBC, troponin, septic screen 3. Assess the damage EUC, CMP, LFT, osmolality 4. Baseline HbA1c, antibodies (anti- GAD, islet cells, insulin), insulin, c-peptide 1. Insulin infusion 50u in 500ml NS = 1u/10ml <2.5u/hr = no hypo. No upper limit Overlap IV and SC insulin 2. Hydration correct deficits first (>6L) Total K deficit concurrent K if K<4 Beware Na and pseudohyponatremia Treat other electrolytes (Mg, PO4) 3. Treat the cause 4. Prevent cx actrapid 500ml N/S <6 + IV dextrose IV dextrose >25 Beware ward vs ED/HDU concentrations Rate is ml/hr not u/hr In general, don t stop the insulin infusion (commence IV Dextrose 5% 100ml/hr) I need help! Diabetes Educator #127 Diabetes education Starting insulin Titrating insulin Endocrine team #904 Unstable BSLs Insulin temporarily Perioperatively Enteral nutrition All type 1, GDM, brittle type 2 Getting phone advice is allowed BUT I need the BSLs 4

5 Calling Endocrine Calling Endocrine Type of Diabetes Length of disease (ie new, longstanding) Usual treatment (+/- compliance, control) Current presentation The issue In hospital hyper/hypoglycaemia New diagnosis Poor control with complications Reduced oral intake/nbm/periop/ng feeding I am calling about a 58M with known T2DM, on levemir 15U and metformin 500mg, who is day 1 post left foot amputation for a gangrenous toe. His HbA1c is 9%. His sugars in hospital have all been <10 on no treatment. Do we restart his treatment? Who is he known to? Why is he on this regimen? Is he compliant? What are his other complications? I am calling about an 84M with known T2DM, known to your clinic, who has high BSLs in hospital. He is D10 post NOF# after a fall. He is normally on gliclazide 90mg. He has an egfr of 45. His HbA1c is pending. Can you optimise his treatment? Why is he still in hospital? What is his DC plan? When are the BSLs high? Is this his baseline renal function? Case 1 94M, lives at home alone, presented with syncope, awaiting cardiac investigations. Normally on glicazide MR 60mg, metformin 1g BD and lantus 40u nocte. BSLs in hospital have been consistently >15, despite being treated with sliding scale actrapid. HbA1c = 7%. How does this change your mx? HbA1c = 9%. How does this change your mx? Case 2 72M inferior STEMI, for CABG. Known T2DM, on glicazide MR 60mg BD and metformin 1g BD, but known noncompliance. BSLs is hospital 10-20, on sliding scale actrapid. HbA1c = 9%. How does this change your mx? HbA1c = 18%. How does this change your mx? 5

6 Case 3 45M, NESB, known T2DM, on gliclazide MR 60mg BD and metformin 1g BD. Presents with *something* and now needs prednisone. HbA1c = 7%. How does this change your mx? HbA1c = 9%. How does this change your mx? Key points Chart supplemental insulin, but use it to guide your regular prescription Insulins are like warfarins if charted daily, it should be the day team therefore chart the next 24 hours (including mane doses) If in doubt, monitor more frequently Careful with NG, TPN feeding and perioperatively Don t be afraid to ask for help I would prefer to know earlier rather than later Call about all type 1 patients and don t WH their basal insulin! 6