Αναγκαιότητα και τρόπος ρύθμισης του διαβήτη στους νοσηλευόμενους ασθενείς

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1 Αναγκαιότητα και τρόπος ρύθμισης του διαβήτη στους νοσηλευόμενους ασθενείς Αναστασία Θανοπούλου Επίκουρη Καθηγήτρια Β Παθολογικής Κλινικής Πανεπιστημίου Αθηνών Διαβητολογικό Κέντρο, Ιπποκράτειο Νοσοκομείο

2 People with diabetes are more likely to be hospitalized and to have longer durations of hospital stay than those without diabetes. Diabetes Care 2009; 32: Ηyperglycemia, even in the diabetic patient, is often overlooked or considered a benign condition and secondary in importance compared to the condition that prompted admission Diabetes Care 2004; 27:

3 Hyperglycemia in hospitalized medical non-icu settings No RCTs on the effect of intensive glycemic control on outcomes Observational studies show a strong association between hyperglycemia and poor clinical outcomes, including prolonged hospital stay, infection, disability after discharge from the hospital, and death. Cohort studies as well as a few early randomized controlled trials (RCTs) have suggested that intensive treatment of hyperglycemia improved hospital outcomes, reduced morbidity and mortality and was cost-effective J Clin Endocrinol Metab 2002;87: Stroke 2001;32: Diabetes Care 2008;31: Diabetes Care 2005; 28: Thorax 2006;61:

4 Lancet 2009; 373:

5 Sliding-scale insulin (SSI) Regular insulin should be avoided for SC postprandial BG correction Should not be used as monotherapy Is not effective for inpatient glycemic control and has been associated with increased inpatient mortality Does not allow for basal or mealtime insulin requirements and grossly underestimates total daily insulin requirements SSI regimens respond to hyperglycemia after it has happened, rather than preventing it, and the sliding scale depends on the inaccurate assumption that insulin sensitivity is uniform among all patients. Diabetes Res Clin Pract 2007;78:

6 Example of a patient on a sliding-scale-only insulin regimen for the first few days of hospitalization with high mean glucose with large glycemic variability. When switched to a basal/bolus insulin regimen, mean glucose gradually decreased, and glycemic variability was significantly less

7 In a randomized, prospective study, the use of a basal/bolus regimen vs SSI regimen in diabetic patients naïve to insulin (on oral agents only) was superior in achieving glycemic control with almost no hypoglycemia (RABBIT-2). Diabetes Care 2007;30: Bad habits die hard; overcoming the popular use of SSI regimens and adjusting nursing habits formed over a career require frequent re-education and support from hospital leaders. Diabetes Educ 2006;32:

8 All patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record (E) All patients with diabetes should have an order for blood glucose monitoring, with results available to all members of the health care team (E) Glucose monitoring should be initiated in any patient not known to be diabetic who receives therapy associated with high risk for hyperglycemia, including high-dose glucocorticoid therapy, initiation of enteral or parenteral nutrition, or other medications such as octreotide or immunosuppressive medications (B) If hyperglycemia is documented and persistent, treatment is necessary. Such patients should be treated to the same glycemic goals as patients with known diabetes (E) Diabetes Care 2012; 35 (Suppl 1): S 1-10

9 Bedside BG monitoring with use of point of-care (POC) glucose meters Is performed: before meals and at bedtime in most inpatients who are eating usual meals from every 30 min to every 2 h, in patients receiving IV insulin infusions until they stabilize and then every 4 6 h Diabetes Care 2012; 35 (Suppl 1): S 1-10 In patients with anemia, polycythemia, hypoperfusion, or use of some medications (manitol, ASA, vit C), caution is needed when interpreting results of point-of-care glucose meters. Endocr Pract. 2009;15:1-15

10 Guideline for Management of Hyperglycemia in Noncritically Ill Hospitalized Patients A consensus guideline from the Endocrine Society, the American Diabetes Association, the American Heart Association, the American Association of Diabetic Educators, the European Society of Endocrinology, and the Society of Hospital Medicine Assess HbA1c in patients with diabetes or hyperglycemia if levels have not been measured within the past 2 to 3 months. The premeal BG target is <140 mg/dl, and the random BG target is <180 mg/dl for most patients. Targets can be modified higher or lower according to clinical status. To avoid hypoglycemia, reassess antidiabetic therapy when BG levels are <100 mg/dl, and modify therapy when levels are <70 mg/dl. J Clin Endocrinol Metab 2012; 97:16 More stringent targets may be appropriate in stable patients with previous tight glycemic control Less stringent targets may be appropriate in those with severe comorbidites Diabetes Care 2012; 35 (Suppl 1): S 1-10

11 Guideline for Management of Hyperglycemia in Non-critically Ill Hospitalized Patients A consensus guideline from the Endocrine Society, the American Diabetes Association, the American Heart Association, the American Association of Diabetic Educators, the European Society of Endocrinology, and the Society of Hospital Medicine Insulin therapy is the preferred method for achieving glycemic control in hospitalized patients. Discontinuation of oral hypoglycemic medications is suggested. J Clin Endocrinol Metab 2012; 97:16

12 The route of insulin administration to a noteating hospitalized patient has traditionally been known in the literature to be the continuous intravenous infusion. Intravenously infused insulin is superior because it can be titrated more quickly and precisely Diabetes Care 2010; 33 (Suppl 1): S 1-10

13 Insulin secretagogues, such as sulfonylureas and glitinides, are associated with an increased risk of hypoglycemia. Metformin should not be used for inpatients because of the increased risk of acute changes in renal function (due to volume shifts, medications, or contrast-induced nephropathy). Pioglitazone can increase circulating plasma volume by 6% to 7%, and therefore should not be used in patients with edema or heart failure. Laboratory Medicine. 2011;42(7):

14 Incretin-based agents Intravenous infusion of a glucagon-like peptide 1 (GLP-1) agonist compared to IV insulin infusions in non-critically ill patients controlled blood sugars with less hypoglycemia. Diabetes Care. 2009;32: Incretins may have a role in the hospital as they affect endogenous insulin secretion in a glucose-dependent mechanism, thereby minimizing the risk of hypoglycemia. have not been frequently studied in the inpatient setting may increase the risk of gastrointestinal adverse effects Laboratory Medicine. 2011;42(7):

15 Initial total daily dose of insulin The initial total daily dose of subcutaneous insulin is calculated using a factor of 0.3 to 0.6 units per kg body a dose of <0.6 units/kg seems to be the threshold to avoid hypoglycemia. A correctional insulin dose provides a final insulin adjustment based on the preprandial glucose value. Diabetes Care 2011; 34:1723

16 Conversion from IV to SC insulin Prospective observational studies The daily subcutaneous insulin requirement from the first day of oral feeding, calculated from the intravenous insulin rate during the final 12 h divided into two: 50% basal and 50% prandial. Diabetes Care 2011; 34: The prandial insulin dose is adjusted accordingly as the patient's appetite improves. The insulin infusion should be continued for 4 hours after the first injection of basal insulin is given (if insulin glargine or detemir; 2 hours if NPH insulin). Laboratory Medicine. 2011;42(7):

17 Insulin analogs are preferred instead of human insulins More predictable absorption and action profile less pharmacokinetic fluctuation in patients with renal insufficiency. human insulins have not only a greater peak effect than lower doses but also result in a longer duration of action. Overlap of insulin doses (known as insulin stacking) increases the risk of a hypoglycemic event. The duration of action of rapid-acting insulin analogs are predictable at low and high doses, thereby decreasing the risk of insulin stacking. Diabetes. 2000;49: Postgrad Med. 1997;101:58 60, 63 65, 70.

18 Αspart/Lispro Actrapid/Regular NPH Glargine

19 Day-to-day decisions concerning treatment of hyperglycemia must be based on clinical judgment and ongoing evaluation of clinical status Endocr Pract. 2009;15:1-15.

20 1000 hypoglycemic events at a large academic medical center 67% were associated with a change in nutritional status Additional factors lack of coordination between feeding and insulin administration (insulin-food dyssynchrony) Change in clinical status or medications (corticosteroids or vasopressors) insufficient frequency of BG testing and glycemic therapy adjustments Poor communication during times of patient transfer to different care teams orders not clearly or uniformly written failure to adjust insulin requirements in patients with advanced age, renal failure, liver disease, or changing clinical status. Severe hypoglycemia in hospitalized patients = Glu <50 mg/dl Am J Physiol 1991;260:E67 E74

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