Thursday School 2010 Management of Inpatient Diabetes and Hyperglycemia and Quality Improvement Efforts

Transcription

1 Thursday School 2010 Management of Inpatient Diabetes and Hyperglycemia and Quality Improvement Efforts Kendall Rogers, MD

2 Using subcutaneous insulin to reliably achieve desired glycemic outcomes in non-critically ill hospitalized patients

3 Objectives For This Lecture Appreciate the obstacles to achieving good glycemic control in hospital patients Understand and apply the best practice of inpatient hyperglycemia/diabetes management using subcutaneous insulin, including the use of anticipatory, physiologic insulin dosing in a variety of clinical situations Understand the common deviations from the best practices of insulin management in the hospital Learn how to prevent and manage hyperglycemia and hypoglycemia

4 Case 1 56 year old woman with DM2 admitted with a diabetes-related foot infection which may require surgical debridement in the near future, eating regular meals. - Weight: 100 kg - Home medical regimen: Glipizide 10 mg po qd, Metformin 1000 mg po bid, and 20 units of NPH q HS - Control: A recent HbA1c is 10%, POC glucose in ED 240 mg/dl What are your initial orders?

5 You put the patient on the Insulin Order Set with the reg diet checked, moderate dose scale check marked, and 10 units of glargine written for Write down: When will the CBGs be checked? Exactly what insulin is scheduled and at what times? If the patient is hypoglycemic, what will happen?

6 Managing Diabetes in the Hospital Presents Different Challenges than Managing Diabetes in the Outpatient Arena! The hospital is associated with: - Nutritional and clinical instability - The need for changes from the home diabetes medical regimen - Acute illness, stress-related hyperglycemia - Use of medications that impact glycemic control

7 Why Should We Care? Hyperglycemia occurs frequently in hospital patients, and is associated with poor outcomes Hypoglycemia occurs frequently in hospital patients, and is unpleasant and dangerous Adequate metabolic control is an attainable goal for hospital patients

8 What is the Appropriate Glycemic Control Target for Inpatients? Controversial! ICU Non-ICU, Preprandial Non-ICU, Maximum ACCE/ACE 110 mg/dl 110 mg/dl 180 mg/dl ADA 110 mg/dl mg/dl 180 mg/dl

9 NICE SUGAR March 26, 2009 NEJM Vol 360 (13) Open Label RCT, Multinational 6104 critically ill patients Intensive infusion ( mg/dl) vs Conventional control ( mg/dl) 90 day survival primary end point

10 The NICE-SUGAR Study Blood Glucose Level, According to Treatment Group Probability of Survival RR= 1.14 IIT goal: mg/dl (mean BG 118 mg/dl) CIT goal: <180 mg/dl (mean BG 145 mg/dl) Nice Sugar, NEJM 360; march 26, day mortality: IIT: 829 patients (27.5%), CIT: 751 (24.9%) Absolute mortality difference: 2.6% (95% CI, 0.4 to 4.8); Odds ratio for death with IIT was 1.14 (95% CI, 1.02 to 1.28; P = 0.02).

11 NICE-SUGAR Study Outcomes Outcome Measure Intensive Group Conventional Group Morning BG (mg/dl) Hypoglycemia 206/ /3014 ( 40mg/dL) 28 Day Mortality (p=0.17) 90 Day Mortality (p=0.02) (6.8%) (0.5%) 22.3% 20.8% 27.5% 24.9% 97% infusion 69% infusion The NICE-SUGAR Study Investigators. N Engl J Med. 360: , 2009.

12 RABBIT 2- Surgical ADA Abstract- Umpierrez et al RCT - Gla / Glu basal bolus vs SSI 211 adult (mean age 58) inpatients Hyperglycemic (mean 190, mg/dl) Diabetes 2 diagnosis for 3 months or more Composite outcome hospital complications including postoperative wound infection, pneumonia, respiratory failure, acute renal failure, and bacteremia Mortality Glycemic Control and Hypoglycemia

13 RABBIT 2 SURGICAL Gla / Glu N = 104 SSI N = 107 P value Daily mean glucose <.01 Severe hypoglycemia 3.8% 0%.057 Mortality 1% 1% NS Wound infection 2.9% 10.3%.05 Pneumonia 0 2.8%.24 ARF 3.8% 10.3%.10 ICU transfer 12.5% 19.9%.16 ICU LOS 1.2 days 3.2 days.003 Composite 8.6% 24.3% <.003

14 ? New AACE / ADA Guidelines? BAD GOOD BAD Hypoglycemia Somewhere in the Middle Hyperglycemia < >200

15 How Can Diabetes and Hyperglycemia be Controlled in the Hospital? Oral agents = often inappropriate for hospital patients IV insulin = most often used in the intensive care unit setting (or in other defined populations) Subcutaneous insulin = the drug of choice for controlling hyperglycemia in the majority of non-critically ill patients

16 Recommendations for Managing Patients With Diabetes in the Hospital Setting Antihyperglycemic Therapy Insulin Recommended OADs Not Generally Recommended IV Insulin Critically ill patients in the ICU SC Insulin Non-critically ill patients 1. ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care & Diabetes Care. 2009;31(suppl 1):S1-S110.

17 Oral Agents in the Hospital Oral agents can be continued in stable patients with normal nutritional intake, normal blood glucose levels, and stable renal and cardiac function. However, otherwise not recommended in inpatient setting. Disadvantages of most oral agents: Slow-acting/difficult to titrate Sulfonyureas are a major cause of severe hypoglycemia Metformin is contraindicated in settings of decrease renal blood flow, eg. Use of contrast dye, CHF, dehydration Thiazolidinediones are associated with edema and CHF

18 Diabetes and Hyperglycemia Require Proactive Management Diabetes requires proactive management in all hospital patients. There are no autopilot insulin regimens Insulin is a high alert medication that is frequently associated with medication errors in the hospital, and JCAHO considers insulin to be one of the highest risk medications in the hospital (JCAHO Website, 2006)

19 Current Practice Best Practice Dependence on non-physiologic insulin prescribing (as opposed to insulin that mimics physiologic insulin secretion) Dependence on reactive strategies (e.g. sliding-scale insulin) Overemphasis on simplicity (particularly simplicity from the perspective of the ordering physician) Overemphasis on avoidance of hypoglycemia Lack of standardization of insulin use in the hospital

20 Issues- It is not just about glycemic target Choice of initial regimen in the hospital. Poor glycemic control ignored/accepted. Reliance on sliding scale insulin. Inappropriate follow up of hypoglycemia. Stacking of insulin dosing. Communication between services. Inconsistent approach to insulin ordering Nurse to physician communication.

21 It is not just about glycemic target Hypoglycemia rates high Poor management of hypoglycemia Failure to prevent hypoglycemia Uneven training amongst staff Poor coordination of tray delivery, monitoring, and insulin Inconsistent transitions Patients often confused or angry Obesity and Diabetes increasingly common!

22 What is the Best Practice for Managing Diabetes and Hyperglycemia in the Hospital? The answer is anticipatory, physiologic insulin dosing, prescribed as a basal/bolus insulin regimen This means giving the right type of insulin, in the right amount, at the right time, to meet the insulin needs of the patient Not Sliding Scale Insulin

23 Indications for IV Insulin Therapy Prolonged fasting (>12 h) in type 1 DM Critical illness Before major surgical procedures After organ transplantation DKA Labor and delivery Acute MI Other illnesses requiring prompt glucose control ACE Position statement on inpatient diabetes 2004

24 The Components of a Physiologic Insulin Regimen Basal insulin Nutritional insulin Correctional insulin

25 Glucose (mg/dl) Insulin (µu/ml) Physiologic Insulin Secretion: Basal/Bolus Concept Nutritional (Prandial) Insulin Basal Insulin Breakfast Lunch Supper Nutritional Glucose Basal Glucose A.M. P.M. Time of Day Suppresses Glucose Production Between Meals & Overnight The 50/50 Rule

26 The Components of a Physiologic Insulin Regimen Basal insulin - long-acting insulin required in all Type 1 (and most Type 2) patients to maintain euglycemia by preventing gluconeogenesis Nutritional insulin - scheduled short-acting insulin given just before a meal, in anticipation of the glycemic spike that occurs due to carbohydrate ingestion (this dose is given even when the blood sugar is in the normal range). Correctional insulin - short-acting insulin that is given in addition to scheduled nutritional insulin (or given at other times of the day) as a response to preexisting high blood glucose levels

27 Providing Exogenous Basal Insulin Long-acting, non-peaking insulin is preferred as it provides continuous insulin action, even when the patient is fasting Required in ALL patients with type 1 diabetes Many patients with type 2 diabetes will require basal insulin in the hospital Can be estimated to be about 1/2 of the total daily dose of insulin (TDD)

28 Insulin Effect Which Insulins are Best for Basal Coverage? NPH Detemir (Levemir) Glargine (Lantus) Regular Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) Inhaled insulin Time (hours)

29 Providing Exogenous Nutritional Insulin Usually given as rapid-acting analogue (preferred in most cases) or regular insulin, for those patients who are eating meals Must be matched to the patient s nutrition Should not be given to patients who are not receiving nutrition (e.g. NPO) Can be estimated to be about ½ of the total daily dose of insulin (TDD)

30 Insulin Effect Which Insulins are Best for Basal Coverage? NPH Detemir (Levemir) Glargine (Lantus) Regular Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) Inhaled insulin Time (hours)

31 Providing Exogenous Correctional Insulin Correctional insulin is extra insulin that is given to correct preexisting hyperglycemia Usually rapid-acting or regular insulin (usually the same as the nutritional insulin) Often written in a stepped format that is used in addition to basal and nutritional insulin Customized to the patient using an estimate of the patient s insulin sensitivity If correctional insulin is required consistently, or in high doses, it suggests a need to modify the basal and/or nutritional insulin doses

32 Using Exogenous Insulin to Imitate Physiologic Insulin Secretion: Summary Basal insulin: Use non-peaking, longer acting insulins Glargine or detemir are preferred NPH also possible Nutritional insulin: Depends on the type of nutrition Rapid-acting insulin is preferred when patients are eating meals Regular insulin also possible Correctional insulin: Use rapid-acting (or regular) insulin Usually the same as the nutritional insulin

33 Which Patients Should be Treated with a Physiologic Insulin Regimen? During hospitalization Any patient with blood glucose levels consistently above the target range Immediately at the time of admission All patients with type 1 diabetes Patients with type 2 diabetes if They are known to be insulin-requiring They are known to be poorly controlled despite treatment with significant doses of oral agents They are known to require high doses of oral agents that will be held in the hospital

34 A Stepwise Approach to Physiologic Insulin Dosing in the Hospital 1. Decide if patient is appropriate for the guideline and discontinue oral antidiabetic agents 2. Calculate the estimated total daily dose (TDD) of insulin 3. Determine the distribution of the TDD calculated above based on nutrition regimen. 4. Re-evaluate & adjust the TDD daily based on the glycemic control of the previous 24h

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38 STEP 2: Estimate the Amount of Insulin the Patient Would Need Over One Day, If Getting Adequate Nutrition = Total Daily Dose (TDD) Insulin drip-based estimate For patients already treated with insulin, consider the patient s preadmission subcutaneous regimen and glycemic control on that regimen Weight-based estimate: TDD = 0.4 units x Wt in Kg Adjust down to 0.3 units x Wt in Kg for those with hypoglycemia risk factors, including kidney failure, type 1 diabetes (especially if lean), frail/low body weight/ malnourished elderly, or insulin naïve patients Adjust up to units (or more) x Wt in Kg for those with hyperglycemia risk factors, including obesity and high-dose glucocorticoid treatment

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40 STEP 3: Decide Which Components of Insulin the Patient Will Require, and Which Percentage of the TDD Each Should Represent Basal insulin can generally be estimated to be 1/2 of the TDD Nutritional insulin makes up the remaining 1/2 of the TDD

41 STEP 3: Assess the Patient s Nutritional Situation Eating meals or receiving bolus tube feeds Eating meals but with unpredictable intake Getting continuous tube feeds Getting tube feeds for only part of the day Getting parenteral nutrition NPO

42 STEP 3: Decide Which Components of Insulin the Patient Will Require, and Which Percentage of the TDD Each Should Represent In most cases, basal insulin should be provided In most cases, well-designed corrective insulin regimens should be provided When a patient is not receiving nutrition, nutritional insulin should not be given Nutritional insulin needs must be matched to the actual nutritional intake

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44 STEP 4: Assess Blood Glucoses at Least Daily, Adjusting Insulin Doses as Appropriate Blood glucose targets can only be achieved via continuous management of the insulin program There is no autopilot insulin regimen for a hospitalized patient!

45 Glycemic Control Points Above 180 twice is uncontrolled DM and a change needs to be made in insulin management Use of correction scale is sign of a treatment failure Uncontrolled DM should be on all 3 insulins Avoid clinical inertia, make changes to insulin Check MAR and administration times Use admission HgA1c in transition to home decisions

46 UNM Glycemic Control

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48 Components of a Glycemic Control Program Administrative support Multidisciplinary steering committee to promote the development of initiatives Assessment of current processes, quality of care, and barriers to change Development and implementation of interventions Standardized order sets, protocols, policies. Educational programs, Special teams Metrics for evaluation Inpatient Diabetes and Glycemic Control: A Call to Action Conference. Position Statement. AACE, February Available at: IDGC0207.pdf. Accessed October 24, Garber et al. Endocr Pract. 2006;12(suppl 3):3-13.

49 Primary Improvement Areas IV Insulin (Critical Care) Subcutaneous Insulin (Non-Critical Care) Transition from IV to Subcutaneous Insulin Transition to Home

50 Our current champions: Quality Dept Sharon Perrilliat and Paul Nelson Floor Nursing - Annabelle Baca and Susan Grohman Inpatient Diabetic Educator - Rosa Matonti Outpt DM Ed - Linda Reineke and Barbara McMillan Pharmacy - Nick Crozier IT - Mary Rivera Tricore Lab - Michelle Neal Unit Director - Donna Kindley Finance - Paula Williams Food and Nutrition - Chester "Chet" Kubic

51 History of Project Phase I started in Completed. Development, testing, and implementation of a basal bolus subcutaneous insulin order set and nursing insulin MAR Focus on elimination of sliding scale insulin and insulin myths Extensive education house-wide of nurses and physicians Grassroots and front-line staff leadership and champions Phase II started in Ongoing. Structured quality improvement project currently ongoing with quality department leadership and a multidisciplinary team Focus on identifying and resolving nursing, tech, pharmacy, dietary, and physician practice and process issues About to enter implementation phase of interventions

52 Measures Process Measures MD Process Measures Nursing Process Measures Outcomes Measures Glucose Measurements Patient Sample Means Patient Day Weighted Means Patient Stay Weighted Means

53 Glucose Control Measurement What unit of analysis? Glucose reading Pros: easy to calculate, most statistical power Cons: least clinically relevant, skewed data Patient Stay Pros: most clinically relevant Cons: skewed data by LOS, uneven testing Patient-Day Pros: least biased, good balance of other two Cons: slightly more difficult to calculate and interpret 53

54 Patient Safety Percent patient-days with any value < 40 mg/dl (extreme hypoglycemia) < 70 mg/dl (hypoglycemia) > 300 mg/dl (extreme hyperglycemia) 54

55 55% Reduction 36% Reduction

56 Glycemic Control Outcomes Medicine SAC Floor Patient Day Averages July 2008 July 2009 CBG Median CBG Mean >10% Improvement Percent CBG < Percent CBG > ~50% Reductions

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58 RALS Annual Report 2009 University Hospital

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60 Mean Blood Glucose All Measurements

61 Mean Blood Glucose Non-ICU Measurements

62 Process Measures Insulin Process Measures Excel Sheet

63 Order Set Utilization 100% 90% 80% 70% 60% 50% 40% 86% 74% 71% 72% 73% 70% 50% 86% 67% 95% 58% 76% 79% 54% 87% 60% 75% 72% 74% 69% 70% 72% 67% 63% 82% 89% 90% 60% 74% 71% 88% 65% 83% 74% 72% 55% 100% 91% 89% 86% 91% 58% 57% 53% 82% 57% 80% 63% 90% 88% 85% 83% 61% 63% Order Set Used Insulin Change Made 30% 20% 10% 0% Weeks

64 100% Insulin Type Utilization 90% 80% 70% 60% 50% 40% 71% 57% 67% 63% 44% 57% 57% 58% 57% 54% 53% 38% 38% 43% 42% 67% 52% 50% 48% 45% 44% 42% 72% 74% 70% 59% 56% 62% 60% 58% 55% 53% 48% 44% 42% 39% 70% 65% 64% 64% 62% 60% 59% 53% 48% 53% 55% 50% 40% 35% 61% 58% SS Insulin Only Basal 30% 20% 10% 7% 7% 11% 9% 24% 26% 19% 25% 13% 11% 19% 13% 13% 11% 7% 5% 21% 29% 31% 30% 21% 16% 14% 13% 30% 27% 11% 21% Nutrition 0% Weeks

65 Control of Hyper- and Hypo-glycemia 100% 90% 90% 80% 70% 60% 50% 71% 70% 72% 73% 67% 58% 76% 54% 60% 75% 69% 70% 72% 67% 60% 71% 65% 55% 72% 58% 57% 53% 82% 57% 63% 61% 63% Controlled 40% 30% Hypo Event 20% 10% 0% 23% 22% 16% 17% 10% 13% 14% 11% 13% 13% 11% 10% 9% 7% 6% 7% 7% 6% 5% 3% 4% 7% 3% 0% 0% 0% 0% 0% Weeks

66 30% Treatment Failure Rate 25% 25% 24% 23% 23% 20% 19% 15% 14% 15% 12% 16% 13% 13% 15% 14% 17% 17% 17% Treatment Failure Linear (Treatment Failure) 11% 11% 10% 8% 8% 10% 7% 10% 9% 10% 5% 5% 5% 3% 0%

67 Processes of Care: Other Measures Glucose measured w/in 8h of admission Hgb A1c available w/in 30 days POC glucose testing for all patients w/ diabetes or hyperglycemia Use of diabetes order sets Use of oral diabetic agents (esp. if contraindicated) Coordination of POC glucose testing, insulin administration, and food delivery Patient, physician, and nurse attitudes, education, and satisfaction Reporting of hypoglycemic events, RCA 67

68 Current Initiatives CPOE Insulin Order Set Process Mapped Nursing Processes Insulin Pens Resident MD Education Multi-Disciplinary GC Walk Rounds

69 Primary Issues - Subcutaneous Not recognizing poor control MD Processes Incorrect use of order set on admission Not changing orders when uncontrolled Nursing Processes Delay in insulin administration from CBG timing Incorrect administration Other Processes DM Meal Delivery

70 New Areas Transition to Home Guidelines Transition from IV Insulin Needed order set IV Insulin Coordination with ICU efforts

71 Average glucose mg/dl Run Chart: Outcome Measures Glycemic control 48 hrs post transition with and without protocol. Glucose averages before and after transition from infusion insulin 250 Transition Time Protocol Not Used Insulin Per Protocol No Insulin Per Protocol Insulin Infusion 6HR 5HR 4HR 3HR 2HR 1HR 1-6 HR Day 1 Day HR HR HR HR HR HR HR

72 Step by Step Stable enough for transition? Need SC insulin with transition? Calculate the Total Daily Dose (TDD) Give 40-50% of TDD as basal glargine BEFORE you stop the insulin infusion

73 Transitioning to the Outpatient Arena Deciding on a home regimen HbA1c Anticipating clinical improvement Patient factors: Financial, social, abilities, wishes Patient education Changes made in the hospital Diabetes/insulin survival skills Communication with outpatient physicians

74 Next Steps Continue MultiDisciplinary Rounds Start real time monitoring and interventions Reconvene the full Glycemic Control Team Begin using data to effect process improvement Engage more physician champions

75 Kendall Rogers, MD Pejvak Salehi, MD

76 Case 1 56 year old woman with DM2 admitted with a diabetes-related foot infection which may require surgical debridement in the near future, eating regular meals. - Weight: 100 kg - Home medical regimen: Glipizide 10 mg po qd, Metformin 1000 mg po bid, and 20 units of NPH q HS - Control: A recent HbA1c is 10%, POC glucose in ED 240 mg/dl What are your initial orders?

77 Case 1: Solution Bedside glucose testing AC and HS Discontinue oral agents Total daily dose 100 kg x 0.6 units/kg/day = 60 Basal: Glargine 30 units q HS Nutritional: Rapid-acting analogue 10 units q ac at the first bite of each meal Correction: Rapid-acting analogue per scale q ac and HS (Note: Use correctional insulin with caution at HS, reduce the daytime correction by up to 50% to avoid nocturnal hypoglycemia) How would you alter this if the patient had renal failure?

78 8 AM Noon Supper Bedtime Prior Day Glucose Insulin Total Lispro 18 u 18 u 16 u 8 u 60 u Glargine 30 u 30 u TDD 90 u

79 What is your next step? A. Continue the current regimen B. Increase the Basal insulin by 20 units C. Increase the Nutritional Insulin by 5 units/meal D. Increase the Basal by 15 units and the Nutritional by 15 units (5 with each meal) E. Increase the Basal by 10 units and the Nutritional by 6 units (2 with each meal)

80 8 AM Noon Supper Bedtime Prior Day Glucose Insulin Lispro Mealtime Total 10 u 10 u 10 u 30 u Lispro 8 u 8 u 6 u 8 u 30 u Correctional Glargine 30 u 30 u TDD 90

81 Case 1 Continued The patient is made NPO after midnight for a bone biopsy, but is expected to be able to resume her diet at lunch or dinner the next day. What changes would you make to her management program regarding glucose monitoring and her insulin program?

82 Case 1 continued: Solution Change bedside glucose checks to q 4 hours, as the patient will not be eating meals Continue basal insulin: If using glargine, continue as is. If using NPH, continue in equal twice daily doses with a dose reduction of 1/3-1/2 while NPO. Hold nutritional insulin while NPO Continue appropriate correctional insulin for hyperglycemia

83 Case 2 58 yo M admitted to Vascular surgery team for amputation of RLE for dry gangrene. Medicine consulted on POD #3 for diabetic management. At home he is on max doses of metformin and glyburide and glargine 15 units at bedtime. His HgA1c this admission is 9.2 and there is a question about his compliance in PCP notes. He is on regular SSI and glargine 15 units at bedtime

84 Case 2 Continued POD 1: POD 2 AM CBG: 85 Noon CBG: 248 Dinner CBG: 166 Bedtime CBG: 287 AM CBG: 182 Noon CBG: 255 Dinner CBG: 72 Dinner CBG: 207 SSI given 12 units SSI given 12 units

85 Case 2 Continued What would you do next? A) Divide total daily dose into 50/50 basal and bolus B) Yell at Vascular surgery for using SSI C) Gather more information on meal intake, time of CBG measurements and insulin administration D) Continue with current regimen one more day to gather more data

86 Case 2 Explanation Answer is C Gather more information on meal intake, time of CBG measurements and insulin administration Patient with labile CBGs, but good response to insulin. With history of non-compliance he maybe not eating or snacking in between meals. CBG time and insulin administration may also play an effect. Before dividing CBG 50/50 you need to gather more data. You can make changes to insulin regime after you gather more data.

87 Case 2 Continued His CBGs in POD #1 and 2 are the following POD 1: AM CBG: 85, no insulin given, day prior glargine was given Noon CBG: 248, 4 units Dinner CBG: 166, 2 units Bedtime CBG: 287, 6 units given, glargine held POD 2 AM CBG: 182, 2 units given Noon CBG: 255, 6 units given Dinner CBG: 72, no insulin given Dinner CBG: 207, 4 units insulin and 15 units glargine given

88 Case 3 56 year old woman with type 1 diabetes admitted with a diabetesrelated foot infection. The wound is an infected ulcer on the fifth digit with necrosis. The plan is for amputation first thing in the morning, so the patient will be NPO after midnight. However, she is expected to resume a regular diet at lunch the following day after surgery. - Weight: 70 kg - Home medical regimen: 70/30 insulin 14 units BID - Control: A recent HbA1c is 9%, POC glucose in ED is 240 mg/dl It is now dinner time, and the patient took her last dose of insulin before breakfast. What insulin would you give her now (before dinner) and how would you modify her regimen given the plan for NPO after midnight?

89 Case 3: Solution Bedside glucose testing AC and HS while eating, and q 4 hours when NPO TDD by weight = 70 kg x 0.4 units/kg/day = 28 units Her home TDD is 28, but patient has very poor control on this regimen, so increase (arbitrarily) by 20% = 34 units IV dextrose infusion while NPO (e.g. D5 at cc/hr) Basal: Glargine 17 units q HS Nutritional: Rapid-acting insulin 6 units q ac at the first bite of each meal Correction: Rapid-acting insulin per scale q ac and HS

90 Case 4 77 yo 100kg M with COPD and T2DM is admitted for syncopal episode and pyelonephritis. He reports being clammy and shaky prior to passing. Per EMS CBG was 50. He is from Alabama and uses 70/30 80 units in am and 20 units at bedtime. He takes his meds as prescribed, but has had poor appetite during the past several days. Does not remember his HgA1C. What insulin regimen would you place him on?

91 Case 4 A) Continue home dose of insulin B) Calculate TDD based on weight and place patient on glargine and short acting insulin C) Place on SSI and monitor CBGs for 24 hours D) Call Kendall or Pejvak E) None of the above

92 Case 4 Explanation Answer: none of the above First correct hypoglycemia Once normalized, consider 20u of basal with correction scale, no nutritional until eating well. Then you can place on nutritional and correctional insulin. Basal glargine insulin has much lower incidence of hypoglycemia than NPH

93 Case 5 You are consulted by the neurology service for diabetes management on a 79 y/o M who suffered a large stroke, leaving him with severe dysphagia. He has type 2 diabetes, on maximum doses of metformin, glipizide, and rosiglitazone at home. A PEG was placed and he is up to his goal of 60 cc/hr on continuous tube feeds, but is now hyperglycemic (see next slide). - Weight: 100 kg (BMI 35) - Current medical regimen: High sliding-scale (orals all held) - Control: Glucoses consistently in the mid to high 200 s, a recent HbA1c is 9.6% What insulin regimen will you choose? Does the distinction between basal and nutritional insulin still make sense with continuous feeding?

94 Case 5: Solution TDD = 100 x 0.6 units/kg/day = 60 units Provide this TDD to meet basal and continuous nutritional insulin requirements There is no scientific evidence suggesting one way is better than another Examples: Glargine 60 units daily Glargine 24 units daily (basal) + rapid-acting insulin 6 units q4 hrs (nutritional) Glargine 24 units daily (basal) + regular 9 units q6 hrs (nutritional) 70/30 20 units q8 hrs Regular insulin 15 units q6 hrs Rapid-acting insulin 10 units q 4 hrs Other combinations

95 How would you manipulate this patient s insulin as you initiate tube feeds? Bolus feeds TID Nocturnal Tube Feeds

96 Case 6 62 yo M with COPD is admitted with increased cough, sputum production and green/thick sputum. CXR consistent with pneumonia. He is started on ceftraixone, doxy, duonebs and prednisone 60mg/day. He does not have diabetes, but he reports that during prior hospitalizations and with steroid use he has needed insulin injections. What would you do next?

97 Case 6 Answers A) Calculate TDD insulin and place on Glargine and Aspart B) Place on SSI and monitor CBGs for 24 hours and change to basal/bolus after 24 hours C) Given infection and taper of steroids, monitor CBGs and put on correction insulin D) Do nothing

98 Case 6 Explanation Answer C then maybe B Patient has an acute infection and is on steroids. This combination leads to increased CBGs. However, as infection is treated and steroids tapered, his insulin requirement will decrease. This could lead to unpredictable CBGs and increased risk of hypoglycemia on basal/bolus protocol. Treating increased CBGs shortens hospital stay. If 2 CBGs are above 180 daily, consider using basal/bolus protocol

99 Case 6 Part 2 Patient did well and after 3 days of treatment is ready to be discharged on 14 day taper of steroids. Currently he is on 40mg prednisone and required 4 units of insulin yesterday. Would you discharge this patient in insulin? A) Yes B) No

100 Case 6 Part 2 Explanation Answer is B) NO Patient is not used to using injectable insulin and there is no indication to start him on oral glycemic meds as he has not have a diagnosis of DM. In addition, as mentioned previously, as prednisone is tapers his CBGs will decrease to more normal range and he is at increased risk for hypoglycemia.

101 Case 7 52 yo male, no previous history of dm, admitted for CAP with an O2 requirement, his admission cbg is 210 Wt 60kg What orders would you write? What if the patient had known DM was on 1 oral agent with relatively good control?

102 Case 8 53 yo M with DM, HTN and CAD is admitted for unstable angina to the VAMC. At home he takes NPH 30 units QAM and 30 units QPM, in addition to sliding scale regular insulin. He reports good CBG control at home and uses 7-10units of insulin prior to meals. His last HgA1c is 6.8. He is NPO for possible cardiac cath in the morning. What regimen would you place him on?

103 Case 8 Answers A) Calculate TDD and place on 50/50 basal bolus insulin and correctional insulin B) Decrease NPH by 50% and place on correctional insulin while NPO C) Continue home NPH and correctional insulin D) Convert total home insulin use to glargine and aspart insulin premeal and correctional insulin

104 Case 8 Explanation Answer is B Patient has good control with NPH at home with HgA1c at goal. Due to increased ease of transition from inpatient to outpatient diabetes management, NPH should be continued. However, NPH has increased risk of hypoglycemia if patient is NPO. Dose should be decreased by 1/3 to 1/2 if patient is NPO. Since patient is not eating, his CBGs can be monitored per protocol and treated with correctional insulin while NPO. Once patient is eating, he can be placed on home NPH dose, premeal and correctional insulin

105 Case 9 42 yo on 160 u with HgA1c of 14.3 admitted with pneumonia and current CBG is 260. What are your admit insulin orders?

106 Case yo F with obesity, DM and HTN is admitted to the VAMC with hypertensive urgency. She takes metformin and glyburide with last HGA1c 8.3. He weight is 120kg and BMI 33. She is able to eat. What regime would you place her on at the VA and at the UH respectively.

107 Insulin Order Sets UNM Order Set VA Order Set

108 Summary Understanding these basic principles of physiologic, anticipatory insulin will allow clinicians to formulate rational insulin regimens in virtually any clinical situation!

109 Key Review Articles Inzucchi. Management of Hyperglycemia in the Hospital Setting. N Engl J Med 2006;355: Clement and colleagues. Diabetes Care 2004; 27: American College of Endocrinology Position Statement on Inpatient Diabetes and Metabolic Control. Endocrine Practice 2004; 10: American College of Endocrinology and American Diabetes Association Consensus Statement on Inpatient Diabetes and Glycemic Control. Diabetes Care 2006; 29: