In-Hospital Management of Diabetes. Dr Benjamin Schiff Assistant Professor McGill University

Transcription

1 In-Hospital Management of Diabetes Dr Benjamin Schiff Assistant Professor McGill University

2 No conflict of interest to declare

3 CLINICAL SCENARIO 62 y/o male with hx of DM 2, COPD, and HT is admitted with 2 days of cough and fever He is taking metformin, glyburide and saxigliptin Home sugars usually in the 8-10 range (well controlled, as per patient) Patient is generally well, though appetite has been a bit diminshed in the past 2-3 days Random glucose on admission is 11.1, Cr is 70, egfr of 80 ml/min Treatment includes antibiotic, bronchodilators and oral steroids How should you manage his diabetes?

4 Outline Goals of therapy Factors affecting glucose Brief review of medications Co-morbid conditions Approach to management Sliding scales Steroids Tips and Pitfalls D/C planning

5 In-Hospital Hyperglycemia is Common Hyperglycemia Approximately 1/3 of inpatients have been found to have hyperglycemia Many have pre-existing diabetes prior to admission

6 Adverse Effects of Hyperglycemia Hyperglycemia Increases risks of postoperative infections and delirium Prolonged hospital stay, resource utilization Increased renal dysfunction and renal allograft rejection in transplant

7 In-Hospital Glycemic Targets Patient Type Glucose Target (mmol/l) Non-critically ill Fasting 5-8 Random <10 Therapy of choice Pre-hospital regimen OR basal-boluscorrection Critically ill 8-10 IV insulin infusion CABG intraop IV insulin infusion Other periop 5-10 As appropriate CABG = coronary artery bypass graft; IV = intravenous; Intraop = intraoperative; periop = perioperative

8 FACTORS INFLUENCING GLYCEMIC CONTROL Diet ( ) Mobility/Exercise Acute illness IV (D5W) Artificial feeding (TPN) Medications Co-morbidities (renal failure, liver failure)

9 Medication Review: Metformin First line in Type 2 Diabetes Lactic Acidosis main concern Liver disease; hold Renal Failure (CrCL<30, or and conditions associated with hypoperfusion/hypoxemia); hold or adjust dose Acute and/or unstable CHF; hold IV contrast: Hold before and 48hr post

10 Class -glucosidase inhibitor (acarbose) Incretin agents: DPP-4 Inhibitors GLP-1R agonists Add another class of agent best suited to the individual (agents listed in alphabetical order): Relative A1C Lowering Hypoglycemia Weight Effect in Cardiovascular Outcome Trial Other therapeutic considerations Rare neutral to Improved postprandial control, GI sideeffects to Rare Rare Neutral to Neutral (alo, saxa, sita) Neutral (lixi) Caution with saxagliptin in heart failure GI side-effects Insulin Yes Neutral (glar) No dose ceiling, flexible regimens $- $$$$ Insulin secretagogue: Meglitinide Sulfonylurea Yes Yes SGLT2 inhibitors to Rare Superiority (empa in T2DM patients with clinical CVD) Less hypoglycemia in context of missed meals but usually requires TID to QID dosing Gliclazide and glimepiride associated with less hypoglycemia than glyburide Genital infections, UTI, hypotension, dose-related changes in LDL-C, caution with renal dysfunction and loop diuretics, dapagliflozin not to be used if bladder cancer, rare diabetic ketoacidosis (may occur with no hyperglycemia) Thiazolidinediones Rare Neutral CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect Weight loss agent (orlistat) None GI side effects $$$ Cost $$ $$$ $$$$ $$ $ $$$ $$ 2016

11 Types of Insulin 2016 Insulin Type (trade name) Onset Peak Duration Bolus (prandial) Insulins Rapid-acting insulin analogues (clear): Insulin aspart (NovoRapid ) Insulin glulisine (Apidra ) Insulin lispro (Humalog ) Insulin lispro U200 (Humalog 200 units/ml) min min min min h h 1-2 h 1-2 h 3-5 h 3-5 h h h Short-acting insulins (clear): Insulin regular (Humulin -R) Insulin regular (Novolin getoronto) 30 min 2-3 h 6.5 h Basal Insulins Intermediate-acting insulins (cloudy): Insulin NPH (Humulin -N) Insulin NPH (Novolin ge NPH) 1-3 h 5-8 h Up to 18 h Long-acting basal insulin analogues (clear) Insulin detemir (Levemir ) Insulin glargine (Lantus ) Insulin glargine U300 (Toujeo ) Insulin glargine (Basaglar TM ) 90 min 90 min Up to 6 h 90 min Not applicable Up to 24 h (detemir h) Up to 24 h (glargine 24 h) Up to 30 h Up to 24 h (glargine 24 h)

12 Types of Insulin (continued) 2016 Premixed Insulins Insulin Type (trade name) Premixed regular insulin NPH (cloudy): 30% insulin regular/ 70% insulin NPH (Humulin 30/70) 30% insulin regular/ 70% insulin NPH (Novolin ge 30/70) 40% insulin regular/ 60% insulin NPH (Novolin ge 40/60) 50% insulin regular/ 50% insulin NPH (Novolin ge 50/50) Time action profile A single vial or cartridge contains a fixed ratio of insulin (% of rapid-acting or short-acting insulin to % of intermediate-acting insulin) Premixed insulin analogues (cloudy): 30% Insulin aspart/70% insulin aspart protamine crystals (NovoMix 30) 25% insulin lispro / 75% insulin lispro protamine (Humalog Mix25 ) 50% insulin lispro / 50% insulin lispro protamine (Humalog Mix50 )

13 Renal Failure Diabetic patients at risk, even if not previously known RF Common complication of acute medical illnesses Increases risk of hypoglycemia Closely monitor renal function, reassess management (diabetes meds, other nephrotoxic medications, etc)

14 Liver Disease Metformin and lactic acidosis Risk of hypoglycemia (hepatic gluconeogenesis) Concomitant pancreatic dysfunction (exocrine and endocrine)

15 Approach to Management Complete Hx, including dietary history, home values (if available), medications, diabetic complications (RF) Labs, including Urea, Cr, K+, and HgB A1C Determine goals of glycemic control ("tight" vs relaxed, short term vs long term) Evaluate and anticipate impact of acute illness(es) on glucose control and choice of medication

16 Management (cont d) Diabetic diet Accuchecks (frequency and duration individualized) Preference is to continue usual medications when possible (including insulin) Reassess management as clinical situation changes Judicious use of sliding scale Above all, avoid hypoglycemia (ensure protocol exists)

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19 Insulin Sliding Scales Indications On home insulin NPO or variable PO intake Artificial feeding (parenteral or enteral) Acutely ill Peri-operative Co-morbities, especially liver disease, renal failure Use of steroids

20 Sliding Scales Short-acting insulin Often QiD, but increased risk of hypoglycemia overnight Alternatively TiD AC meals +/- ½ dose at HS Both CDA and ADA recommend against using sliding scale alone (Reactive rather than proactive) Total daily dosing used to covert to basal/bolus

21 Sliding Scale Insulin Alone Results in Variable Glucose Control BG (mmol/l) What do you do? What do you do? +4 U 0 U 0 U Breakfast Lunch Dinner Bedtime Bolus insulin QID 6.0 What do you do? QID: four times daily; SSI: sliding-scale insulin; BG: blood glucose 16.5 What do you do? +6 U 3.0 Sliding Scale alone BG (mmol/l) Bolus insulin (U) < 4 Call MD > 19.0 Call MD

22 BASAL + BOLUS + CORRECTION Results in Smoother Glycemic Control 6+0 U What do you do? 6.0 Breakfast Lunch Dinner Bedtime 6U 6.0 What do you do? 6+0 U 6U 6+2 U What do you do? 12.0 ROUTINE Bolus insulin 6U What do you do? U Basal insulin Routine Basal Correctional Insulin AC meals BG (mmol/l) Bolus insulin (U) < 4 Call MD > 19.0 Call MD

23 Sliding Scales I begin with basic sliding scale, and review the glycemic readings Adjust the scale according to readings: if glu units units units units units > units Next step(s) depend on anticipated duration of the need for the sliding scale I don t necessarily include call MD

24 Steroids Variable effect on glycemic control Can cause hyperglycemia in non-diabetics Particular risk with Prednisone (effect can begin to wear off after 12 hours) Avoid HS insulin if taking qd steroids Caution when changing from IV to PO Can use qd N in AM

25 Helpful Tips Ensure you know what the patient is actually taking, not just what they were prescribed Review accuchecks early in the day BEFORE long acting insulins Include in your orders fixed time(s) to reassess sliding scales, accuchecks etc as a forced reminder Err on the side of higher glucose values, especially if you anticipate a short term admission (minimize risk of hypoglycemia, improve patient comfort) Unexpectedly high sugars may indicate occult infection

26 Pitfalls Not reviewing the actual glucose readings Continuing accuchecks qid despite being in target range Forgetting about IVs that continue unnecessarily Not reassessing sliding scales if NPO, vomiting etc Using metformin with IV contrast, especially cardiac caths Complications associated with Acute Kidney Injury Giving extra doses of short-acting insulin in between sliding scale

27 Discharge Planning In most situations, resume medications as prescribed at home Dietary counselling/pt education Consider modifying treatment if clear evidence of suboptimal baseline control (ideally in consultation with pt s primary care provider) May need to modify based on sequelae of hospitalization (e.g., new renal failure, new medications) Ensure safe and effective transition to pt s health care provider(s)

28 Key Messages Determine goals of therapy Be aware of co-morbities Safe and effective use of sliding scales

29 References Clinical Practice Guidelines from the Canadian Diabetes Association American Diabetes Association: Standards of Medical care in Diabetes uppl/2015/12/21/39.supplement_1.dc2/20 16-Standards-of-Care.pdf

30 QUESTIONS?

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