Deepika Reddy MD Department of Endocrinology

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1 Deepika Reddy MD Department of Endocrinology

2 Management of hyperglycemic crisis Review need for inpatient glycemic control Brief overview of relevant trials Case based review of diabetes management strategies/review guidelines

4 Protocol for the management of adult patients with DKA. *DKA diagnostic criteria: serum glucose >250 mg/dl, arterial ph <7.3, serum bicarbonate <18 meq/l, and moderate ketonuria or ketonemia. Kitabchi A E et al. Dia Care 2006;29: Copyright 2011 American Diabetes Association, Inc.

5 Protocol for the management of adult patients with HHS. HHS diagnostic criteria: serum glucose >600 mg/dl, arterial ph >7.3, serum bicarbonate >15 meq/l, and minimal ketonuria and ketonemia. Kitabchi A E et al. Dia Care 2006;29: Copyright 2011 American Diabetes Association, Inc.

6 Patients with known diabetes Patients with undiagnosed diabetes Stress hyperglycemia

7 Has an effect on Morbidity (including infection rates) Mortality Length of stay

2030 consecutive adult patients admitted between July and October 1998 Previous History DM Normoglycemic New hyperglycemia 38% had hyperglycemia*

8 2030 consecutive adult patients admitted between July and October 1998 Previous History DM Normoglycemic New hyperglycemia 38% had hyperglycemia* *Hyperglycemia defined as admission or FPG 126 mg/dl or random BG 200 mg/dl Umpierrez et al. J Clin Endocrinol Metab. 2002;87: slide from desantis ACPONLINE

35 Total Inpatient Mortality ICU Mortality 35 30 *P<0.01 30 P<0.01 31% 25 n=1886 25 n=243 20 20 15 10 16% * 15 10 10% 11% 5 5 0 1.

9 35 Total Inpatient Mortality ICU Mortality *P< P< % 25 n= n= % * % 11% % 3% Normoglycemia Known Diabetes New hyperglycemia 0 Normoglycemia Known Diabetes New hyperglycemia Umpierrez et al. J Clin Endocrinol Metab. 2002;87: slide from desantis ACPONLINE.

10 Rates of deep sternal wound infection in 4864 patients with diabetes who underwent an open-heart surgical procedure Rate of infection, % P=0.001 Note inflection point < >250 3-day average postoperative blood glucose, mg/ dl Furnary et al. Endocr Pract. 2004;10(suppl 2):21-33.

10 8 CII Mortality (%) 6 4 Patients with diabetes Patients without DM diabetes 2 0 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 Year Reprinted

11 10 8 CII Mortality (%) 6 4 Patients with diabetes Patients without DM diabetes Year Reprinted from Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;125: with permission from American Association for Thoracic Surgery. Purple: No DM

HYPERGLYCEMIA Index of disease severity 15 14.5% Mortality % 10 5 0.9% 1.3% 2.3% 4.1% 6.

12 HYPERGLYCEMIA Index of disease severity % Mortality % % 1.3% 2.3% 4.1% 6.0% Cardiac Non-Cardiac 0 < Average post-op glucose >250 Furnary et al J Thorac Cardiovasc Surg 2003;125:

13 Intensive therapy to achieve blood glucose levels of mg/dl reduced mortality ( 34%), sepsis ( 46%), dialysis ( 41%), blood transfusion ( 50%), and polyneuropathy ( 44%) N = 1, Blood Mortality Sepsis Dialysis Transfusion Polyneuropathy Reduction (%) % 46% 41% 50% 44% van den Berghe G, et al. N Engl J Med. 2001;345:

14 NEJM 2001;345:

15 VISEP Trial Mean Blood Glucose (mg/dl) Blood Glucose Conventional therapy Intensive therapy Days Probability of Survival (%) Overall Survival Conventional therapy (n=290) Intensive therapy (n=247) Days Data from 537 patients: 247 received IIT goal: mg/dl: mean BG 112 mg/dl 290 received CIT goal: mg/dl: mean BG 151 mg/dl IIT, intensive insulin therapy; CIT, conventional insulin therapy. Brunkhorst FM et al. N Engl J Med. 2008;358:

16 VISEP Trial IIT (n=247) CIT (n=290) P Mortality rate, % 28 days days % of Patients with glucose 40 mg/dl 17.0% 4.1% <0.001 SOFA* score (mean) 95% CI *SOFA sequental organ failure assessment Brunkhorst FM et al. N Engl J Med. 2008;358:

17 NICE SUGAR NEJM2009;360:

18 Hypoglycemic events Favors IIT Favors Control Griesdale et al., CMAJ 2009;180:821

19 A 60 year old gentleman with a history of smoking is admitted to the hospital with pneumonia. He is started on antibiotics and nebuliser treatments. He has a blood sugar on initial evaluation of 150

20 Would you start point of care blood sugar monitoring in this patient? If blood sugars remain elevated would you get a HbA1c?

21 Test Normal Prediabetes Diabetes Hemoglobin A1C <5.7% % >6.5 %

22 The patient continues to have blood sugars in the 180 to 200 range. What would you do? What are blood sugar goals in the hospital setting? What treatment would you use for blood sugar control in the hospital? If using insulin what regimen would you use?

23 The endocrine society guidelines recommend: Pre meal blood gluose <140 mg/ dl.random blood glucose <180 mg/ dl In other words desired, in some situations acceptable. Blood sugars outside of these ranges ( <110 or >180 ) not acceptable

24 ADA/AACE Target Glucose Levels ICU setting: in ICU Patients Insulin infusion should be used to control hyperglycemia Starting threshold of no higher than 180 mg/dl Once IV insulin is started, the glucose level should be maintained between 140 and 180 mg/dl Lower glucose targets ( mg/dl) may be appropriate in selected patients Targets <110 mg/dl are not recommended Not recommended < 110 Acceptable Recommended Not recommended >180 ADA/AACE Inpatient Task Force Endocrine Practice 2009;15;1-17 ADA/AACE Inpatient Task Force Endocrine Practice 2009;15;1-17

25 ADA/AACE Target Glucose Levels in non ICU Patients Non-ICU setting: Pre-meal glucose targets <140 mg/dl Random BG <180 mg/dl To avoid hypoglycemia, reassess insulin regimen if BG levels fall below 100 mg/dl Occasional patients may be maintained with a glucose range below or above these cutpoints Hypoglycemia= BG < 70 mg/dl Severe hypoglycemia= BG < 40 mg/dl ADA/AACE Inpatient Task Force Endocrine Practice 2009;15:1-17

26 What would you use to treat the patient? Stop Orals Use Basal Insulin

27 Medication Sulfonylurea Metformin TZD Alpha glucosidase inhibitors Incretin Primary complication Hypoglycemia Lactic acidosis, careful peri op, if getting dye CHF, CAD, Bladder CA Diarrhea Only helpful when eating, GI side effects

28 Stop orals Treat with Insulin Use basal (either with supplemental scale or bolus) 0.4 or 0.5 unit/kg/day in normal patients.50% of this would be basal needs. 0.3 units/kg/ day in elderly and renal failure 0.2 or 0.25 units/kg a day if NPO

29 Hyperglycemia is unfavorable, but hypoglycemia is also associated with adverse outcomes To avoid hypoglycemia, the insulin regimen should be reassessed if blood glucose levels fall below 100 mg/ DL

30 Patient on tube feeds or parenteral nutrition Started on meds that cause hyperglycemia

31 Patient on tube feeds or parenteral nutrition Started on meds that cause hyperglycemia

32 What regimen should the patient use at home? What other aspects of care should be addressed?

34 Multidisciplinary Team Extends Beyond Caregivers Performance Improvement/ QI staff P&T Committee Unit clerks/ Surgery, Trauma, secretaries Orthopedics, Anesthesiology leaders Patient Safety Committee Patient Representatives Biomedical, medical records, CPOE expertise GLYCEMIC CONTROL COMMITTEE Pharmacists Chief residents/ residency program directors Hospitalists Endocrinologists Lab Departmental committees Critical Care physicians OR or Perioperative Committees Other internists Nursing groups Nutritionists/ Dietitians Hospital Informatics Maynard et al. SHM Glycemic Control Workgroup. Available at: : Section=Quality_Improvement_Resource_Rooms1&Template=/CM/HTMLDisplay.cfm&ContentID=4337. Forms Committee

Inpatient Management of Diabetes Mellitus. Jessica Garza, Pharm.D. PGY-1 Pharmacotherapy Resident TTUHSC School of Pharmacy

Inpatient Management of Diabetes Mellitus Jessica Garza, Pharm.D. PGY-1 Pharmacotherapy Resident TTUHSC School of Pharmacy 2 Disclosure Jessica Garza does not have any actual or potential conflicts of