Diabetes Update 2018: Challenging Transitions. Patricia A. Daly, MD, FACP, FACE Medical Director for Diabetes Valley Health System

Diabetes Update 2018: Challenging Transitions Patricia A. Daly, MD, FACP, FACE Medical Director for Diabetes Valley Health System 1

Patricia A. Daly, MD, FACP, FACE Medical Director for Diabetes Valley Health System Disclosures: None 2

Diabetes Update 2018: Challenging Transitions Hyperglycemia in the hospital setting Common Costly Associated with poor clinical outcomes Glycemic targets have been modified 140-180 mg/dl Insulin is the treatment of choice to manage hyperglycemia in hospital setting Hyperglycemia management requires multidisciplinary collaboration 3

Diabetes Update 2018: Challenging Transitions Hyperglycemia management in hospital setting is challenging, especially in specific situations. Changes in patient location Admission Transfer between units Discharge Changes in oral intake Stress of illness, surgery Changes in renal or liver function Interaction between hospital events and medications and the patient s outpatient medication regimen

Diabetes Update 2018: Challenging Transitions Review appropriate management of patients with hyperglycemia in hospital setting Discuss how transitions in care impact blood sugar control Understand how noninsulin diabetic medications work and how they may interact; review specific issues with their use in hospital setting Provide overview of upcoming new VHS hypoglycemia and hyperglycemia policies and how these may help improve diabetes management in the hospital 5

Factors Affecting Blood Glucose Levels in the Hospital Setting Increased counter-regulatory ( stress ) hormones Changing IV glucose rates TPN and enteral feedings Lack of physical activity Unusual or inappropriate timing of insulin injections Use of glucocorticoids Unpredictable or inconsistent food intake Fear of hypoglycemia Cultural acceptance of hyperglycemia TPN, total parenteral nutrition. Carter L. Oklahoma Nutrition Manual, 12 th ed. Owasso, OK: Oklahoma Dietetic Association; 2006. 6

Glucose Control Deteriorates During Hospitalization Hyperglycemic Influences Stress hyperglycemia Concomitant therapy Decreased physical activity Medication omissions Medication errors Fear of hypoglycemia Hypoglycemic Influences Decreased caloric intake Gastrointestinal illness Monitored compliance Medication errors Altered cognition Residual effects of home medications Decline in kidney or liver function Metchick LN, et al. Am J Med. 2002;113:317-323. 7

Patient AL 65yo man admitted with possible recurrent stroke New onset DM with admission glucose 682. A1c > 14 8

AL 65yo man admitted with possible recurrent stroke. New onset DM with admission glucose 682. A1c > 14. How should his diabetes be managed in the hospital? What discharge planning will he require? What should his discharge diabetic medication regimen be? 9

Glycemic Management Strategies in Hospitalized Patients (Non-critically ill) Insulin therapy preferred regardless of type of diabetes Discontinue noninsulin agents at hospital admission of most patients with type 2 diabetes with acute illness Use scheduled SC insulin with basal, nutritional, and correction components Modify insulin dose in patients treated with insulin before admission to reduce risk for hypoglycemia and hyperglycemia Avoid prolonged therapy with sliding scale insulin alone Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 10

Glycemic Targets in Noncritical Care Setting Insulin therapy should be initiated for treatment of persistent hyperglycemia starting at a threshold 180 mg/dl (10.0 mmol/l). Once insulin therapy is started, a target glucose range of 140 180 mg/dl is recommended for the majority of patients. More stringent goals, such as 110 140 mg/dl, may be appropriate for selected patients, if this can be achieved without significant hypoglycemia. Less stringent targets may be appropriate in terminally ill patients or in patients with severe comorbidities ADA 2018 Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 11

What about noninsulin diabetic medications in the hospital? 12

Insulin vs Noninsulin Medications, how to decide? Does the patient have type 1 or type 2 diabetes? Noninsulin medications only indicate for type 2 If diagnosis is uncertain, screen patient for autoantibodies that are present in type 1 Thin patient with poor response to initial therapy with noninsulin diabetic medications Personal or family history of autoimmune disease Overweight or obese children/adolescents with apparent type 2 who may actually have early type 1 ADA 2018 Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 13

Insulin vs Noninsulin Medications, how to decide? If patient has new type 2 diabetes and A1c is 9% or above, initial therapy should include insulin, and may also include other agents if appropriate ADA and AACE guidelines ADA 2018 Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 14

Pathophysiology of DM2 Pancreas Muscle Increase glucose uptake Decreased insulin secretion from -cells Liver Increased endogenous glucose production Adipose (fat) Increased FFA production The Ominous Octet Digestive tract Decreased incretin effect Brain Neurotransmitter dysfunction DeFronzo RA. Diabetes. 2009;58:773-795 Increased glucagon secretion from -cells Pancreas Kidney Increased glucose reabsorption

Noninsulin Agents Available for T2D Class Primary Mechanism of Action Agent(s) Available as -Glucosidase inhibitors Delay carbohydrate absorption from intestine Acarbose Miglitol Precose or generic Glyset Amylin analogue Biguanide Bile acid sequestrant DPP-4 inhibitors Decrease glucagon secretion Slow gastric emptying Increase satiety Decrease HGP Increase glucose uptake in muscle Decrease HGP? Increase incretin levels? Increase glucose-dependent insulin secretion Decrease glucagon secretion Pramlintide Metformin Colesevelam Alogliptin Linagliptin Saxagliptin Sitagliptin Symlin Glucophage or generic WelChol Nesina Tradjenta Onglyza Januvia Dopamine-2 agonist Activates dopaminergic receptors Bromocriptine Cycloset Glinides Increase insulin secretion Nateglinide Repaglinide Starlix or generic Prandin DPP-4, dipeptidyl peptidase; HGP, hepatic glucose production. Garber AJ, et al. Endocr Pract. 2016;22:84-113. Inzucchi SE, et al. Diabetes Care. 2015;38:140-149. 16 Continued on next slide

Noninsulin Agents Available for T2D Class Primary Mechanism of Action Agent(s) Available as GLP-1 receptor agonists Increase glucose-dependent insulin secretion Decrease glucagon secretion Slow gastric emptying Increase satiety Albiglutide Dulaglutide Exenatide Exenatide XR Liraglutide Tanzeum Trulicity Byetta Bydureon Victoza SGLT2 inhibitors Increase urinary excretion of glucose Sulfonylureas Increase insulin secretion Increase glucose uptake in muscle Thiazolidinediones and fat Decrease HGP Canagliflozin Dapagliflozin Empagliflozin Glimepiride Glipizide Glyburide Pioglitazone Rosiglitazone Invokana Farxiga Jardiance Amaryl or generic Glucotrol or generic Dia eta, Glynase, Micronase, or generic Actos Avandia GLP-1, glucagon-like peptide; HGP, hepatic glucose production; SGLT2, sodium glucose cotransporter 2. Garber AJ, et al. Endocr Pract. 2016;22:84-113. Inzucchi SE, et al. Diabetes Care. 2015;38:140-149. 17 Continued from previous slide

Mechanism of Action of Antihyperglycemic Agents Muscle Increase glucose uptake Metformin, TZD Adipose (fat) Increased FFA production TZD Pancreas Decreased insulin secretion from -cells GLP1 RA, DPP4i, SU, GLN The Ominous Octet GLP1 RA, DPP4i Liver Increased endogenous glucose production Metformin, TZD, GLP1 RA, DPP4i Digestive tract Decreased incretin effect GLP1 RA, AGis, Colesevelam Brain Neurotransmitter dysfunction DeFronzo RA. Diabetes. 2009;58:773-795 GLP1 RA Bromocriptine Increased glucagon secretion from -cells Pancreas Kidney Increased glucose reabsorption SGLT2i

21 Fixed-Dose Oral Combination Agents for Type 2 Diabetes Class Added Agent Available as DPP4 inhibitor + SGLT-2 inhibitor Linagliptin + empagliflozin Glyxambi Saxagliptin + dapagliflozin Qtern Alogliptin Kazano Metformin + DPP4 inhibitor Linagliptin Jentadueto Sitagliptin Janumet Metformin + glinide Repaglinide Prandimet Metformin + SGLT2 inhibitor Canagliflozin Invokamet Dapagliflozin Xigduo XR Metformin + sulfonylurea Glipizide Metaglip and generic Glyburide Glucovance and generic Metformin + thiazolidinedione Pioglitazone ACTOplus Met Rosiglitazone* Avandamet Thiazolidinedione + DPP4 inhibitor Pioglitazone + alogliptin Oseni Thiazolidinedione + sulfonylurea Pioglitazone Duetact Rosiglitazone Avandaryl

Effects of Agents Available for T2D Met GLP1RA SGLT2I DPP4I TZD AGI Coles BCR-QR SU/ Glinide Insulin Pram FPG lowering Mod Mild to mod* Mod Mild Mod Neutral Mild Neutral SU: mod Glinide: mild Mod to marked (basal insulin or premixed) Mild PPG lowering Mild Mod to marked Mild Mod Mild Mod Mild Mild Mod Mod to marked (short/ rapidacting insulin or premixed) Mod to marked AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibitors; FPG = fasting plasma glucose; GLP1RA = glucagon-like peptide 1 receptor agonists; Met = metformin; Mod = moderate; PPG = postprandial glucose; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU = sulfonylureas; TZD = thiazolidinediones. *Mild: albiglutide and exenatide; moderate: dulaglutide, exenatide extended release, and liraglutide. Handelsman YH, et al. Endocr Pract. 2015;21(suppl 1):1-87. 22 Continued on next slide

Effects of Agents Available for T2D Met GLP1RA SGLT2I DPP4I TZD AGI Coles BCR-QR SU/ Glinide Insulin Pram NAFLD benefit Mild Mild Neutral Neutral Mod Neutral Neutral Neutral Neutral Neutral Neutral Hypoglycemia Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral SU: mod to severe Glinide: mild to mod Mod to severe* Neutral Weight Slight loss Loss Loss Neutral Gain Neutral Neutral Neutral Gain Gain Loss AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibitors; GLP1RA = glucagon-like peptide 1 receptor agonists; Met = metformin; Mod = moderate; NAFLD, nonalcoholic fatty liver disease; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU = sulfonylureas; TZD = thiazolidinediones. *Especially with short/ rapid-acting or premixed. Handelsman YH, et al. Endocr Pract. 2015;21(suppl 1):1-87. 23 Continued from previous slide

Effects of Agents Available for T2D Met GLP1RA SGLT2I DPP4I TZD AGI Coles BCR-QR SU/ Glinide Insulin Pram Renal impairment/ GU Contraindicated egfr <30 Caution if 30-45 Exenatide contraindicated CrCl <30 mg/ml GU infection risk Dose adjustment (except linagliptin) May worsen fluid retention Neutral Neutral Neutral Increased hypoglycemia risk Increased risks of hypoglycemia and fluid retention Neutral GI adverse effects Mod Mod* Neutral Neutral* Neutral Mod Mild Mod Neutral Neutral Mod CHF Neutral Neutral Neutral Neutral Mod Neutral Neutral Neutral Neutral Neutral Neutral CVD Possible benefit Neutral Neutral Neutral Neutral Neutral Neutral Safe? Neutral Neutral Bone Neutral Neutral Bone loss Neutral Mod bone loss Neutral Neutral Neutral Neutral Neutral Neutral AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; CHF = congestive heart failure; CVD = cardiovascular disease; DPP4I = dipeptidyl peptidase 4 inhibitors; GI = gastrointestinal; GLP1RA = glucagon-like peptide 1 receptor agonists; GU = genitourinary; Met = metformin; Mod = moderate; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU = sulfonylureas; TZD = thiazolidinediones. *Caution in labeling about pancreatitis. DKA Risk Caution: possibly increased CHF hospitalization risk seen in CV safety trial. Handelsman YH, et al. Endocr Pract. 2015;21(suppl 1):1-87. 24 Continued from previous slide

Invokana (canagliflozin) Jardiance (empagliflozin) Farxiga (dapagliflozin)

Metformin: Updated FDA guidelines Prior recommendations for metformin: Hold if creatinine above 1.5 in men, 1.4 in women or abnormal creatinine clearance and hold for 48h after IV contrast. New guidelines from April 2016 use egfr If egfr is < 30, drug is contraindicated. For egfr 30-45 weigh risks and benefits of continuing, consider cutting the dose in 1/2, and do not START metformin in this range. For 45-60, safe to use Discontinue metformin at the time of or before an iodinated contrast imaging procedure in patients with an egfr between 30 and 60 ml/minute/1.73 m 2 ; in patients with a history of liver disease, alcoholism, or heart failure; or in patients who will be administered intraarterial iodinated contrast. Re-evaluate egfr 48 hours after the imaging procedure; restart metformin if renal function is stable. If egfr is 60 or higher (and not intra-arterial contrast), no need to discontinue. 27

Noninsulin Therapies in the Hospital Time-action profiles of oral agents can result in delayed achievement of target glucose ranges in hospitalized patients Sulfonylureas are a major cause of prolonged hypoglycemia Metformin is contraindicated in patients with decreased renal function, use of iodinated contrast dye (sometimes), and any state associated with poor tissue perfusion (CHF, sepsis) Thiazolidinediones are associated with edema and CHF α-glucosidase inhibitors are weak glucose-lowering agents Pramlintide and GLP-1 receptor agonists can cause nausea and exert a greater effect on postprandial glucose SGLT2 inhibitors may cause atypical DKA in setting of stress DPP4 inhibitors may provide safe and effective blood glucose control when used alone or in combination with basal insulin (caution with aloglipitin and saxagliptin re: CHF risk) 28 Insulin therapy is the preferred approach

Glycemic Management Strategies in Noncritically Ill Patients Insulin therapy preferred regardless of type of diabetes Discontinue noninsulin agents at hospital admission of most patients with type 2 diabetes with acute illness Use scheduled SC insulin with basal, nutritional, and correction components Modify insulin dose in patients treated with insulin before admission to reduce risk for hypoglycemia and hyperglycemia Avoid prolonged therapy with sliding scale insulin alone Consider resumption of noninsulin medications 1-2 days prior to discharge. Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 29

Pharmacokinetics of Insulin Products Rapid (lispro, aspart, glulisine) Insulin Level Short (regular) Intermediate (NPH) Long (glargine) Long (detemir) 0 2 4 6 8 10 12 14 16 18 20 22 24 Hours Adapted 30 from Hirsch I. N Engl J Med. 2005;352:174 183.

Subcutaneous Insulin Options Basal insulin Nutritional (prandial) insulin Correction insulin Controls blood glucose in the fasting state Detemir (Levemir), glargine (Lantus), NPH Blunts the rise in blood glucose following nutritional intake (meals, IV dextrose, enteral/parenteral nutrition) Rapid-acting: aspart (NovoLog), glulisine (Apidra), lispro (Humalog) Short-acting: regular (Humulin, Novolin) Corrects hyperglycemia due to mismatch of nutritional intake and/or illness-related factors and scheduled insulin administration 31

AL. 65 yo man admitted with possible recurrent stroke. New onset DM with admission glucose 682. A1c > 14. Per ADA and AACE guidelines, for new type 2 diabetic with A1c 10 or higher, insulin is preferred starting medication Either basal bolus regimen or basal plus GLP1 agonist* *remember GLP1 agonist not recommended for use in hospital due to nausea and slowed gastric empyting 32

AL. 65 yo man admitted with possible recurrent stroke. New onset DM with admission glucose 682. A1c > 14. Patient initially started on glipizide 10mg bid and correctional insulin. Blood sugars on 2 nd hospital day: 33

AL. 65 yo man admitted with possible recurrent stroke. New onset DM with admission glucose 682. A1c > 14. On evening of hospital day 2, sitagliptin (Januvia) added 34

AL. 65 yo man admitted with possible recurrent stroke. New onset DM with admission glucose 682. A1c > 14. On hospital day 3, metformin added and Januvia increased to 50mg bid, and bedtime basal insulin added 35

AL. 65 yo man admitted with possible recurrent stroke. New onset DM with admission glucose 682. A1c > 14. Basal/bolus and correction insulin A better solution! 36

AL. 65 yo man admitted with possible recurrent stroke. New onset DM with admission glucose 682. A1c > 14. Basal/bolus and correction insulin, a better solution! BUT how do we decide on the dose? 37

Initiating Insulin Therapy in the Hospital Total Daily Dose Choose an appropriate total units/kg/day estimation after reviewing the patient's factors below. 0.3 units/kg/day - malnourished, no history of DM, cognitive impairment, elderly, renal or liver disease, pancreatectomy. 0.4 units/kg/day - lean (BMI = 18-24.9) Type 2 DM, steroid-induced hyperglycemia (without underlying DM), or Type 1 DM. 0.5 units/kg/day - overweight (BMI 25-30) type 2 DM. 0.6 units/kg/day - obese (BMI greater than 30) Type 2 DM or Type 2 DM receiving steroids. 38

AL. 65 yo man admitted with possible recurrent stroke. New onset DM with admission glucose 682. A1c > 14. Weight 90 kg Not on steroids egfr 68 Normal liver function 39

Initiating Insulin Therapy in the Hospital Patient AL Obtain patient weight in kg: 90kg Calculate total daily dose (TDD) 0.5 units per kg/day 45 units/day 40% of total to be given as basal insulin: 18 units of Lantus once daily 40

Initiating Insulin Therapy in the Hospital Patient AL TDD 45 units, 40% basal 60% to be given as nutritional insulin = 27 units 27/3 = 9 units per meal Use medium dose correction insulin based on total daily dose of 41-80 units daily Adjust according to results of bedside glucose monitoring Adjust dose for NPO status or changes in clinical status 41

AL. 65 yo man admitted with possible recurrent stroke. New onset DM with admission glucose 682. A1c > 14. Patient discharged on hospital day 4, on basal bolus insulin Discharge regimen: Lantus, premeal insulin with correction 42

AL. 65 yo man admitted with possible recurrent stroke. New onset DM with admission glucose 682. A1c > 14. Patient discharged on hospital day 4 Discharge regimen: Lantus, premeal correction, BID glipizide, metformin, and Januvia 43

Patients Newly Diagnosed With Diabetes During Hospitalization Develop a diabetes education plan prior to hospital discharge that addresses the following: Understanding of the diagnosis of diabetes SMBG and explanation of home blood glucose goals Definition, recognition, treatment, and prevention of hyperglycemia and hypoglycemia Identification of healthcare provider who will provide diabetes care after discharge Information on consistent eating patterns When and how to take medication, including proper disposal of needles and syringes Sick-day management *Susan Zontine, NP to review diabetes survival skills during the next talk! ADA. Diabetes Care. 2013;36(suppl 1):S11-S66. Handelsman 44 Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.

AL 65 yo man admitted with possible recurrent stroke. New onset DM with admission glucose 682. A1c > 14. Discharge Planning What medications should he go home on? If regimen includes insulin, who will give it? Can he afford the medication regimen prescribed? Has he and/or family members been taught Diabetes survival skills? Who will follow him post-discharge to adjust the regimen? 45

AL 65 yo man admitted with possible recurrent stroke. New onset DM with admission glucose 682. A1c > 14. Discharge Planning Can he afford his medication? How do you find out? Case managers and pharmacists can be helpful resources. At WMC, contact the Valley Pharmacy Discharge Program, 540-536-0598 At WMH, contact Kari Gordon, Clinical Pharmacist 540-635- 0926, Kris Jett, Nurse Case Manager 540-636-0319 or Tara Reber, Social Worker 540-636-0264 At other facilities, contact the Nurse Case Manager or Clinical Pharmacist. 46

Stretch Break! 47

Diabetes and the Bedside Nurse Every day dilemmas 48

Case Study RG 61 yo man POD 3 from CABG on basal Lantus, nutritional Novolog and correction Novolog. Complains of feeling shaky and sweaty at 11:00 AM. What should you do? 49

Case Study RG 61 yo man POD 3 from CABG on basal/bolus, shaky and sweaty at 11:00 AM. What should you do? Give him a large glass of juice Feed him lunch Call rapid response team Hold his lunchtime insulin All of the above 50

Case Study RG 61 yo man POD 3 from CABG on basal/bolus, shaky and sweaty at 11:00 AM. What should you do? Check POCT Glucose! 51

Case Study RG 61 yo man POD 3 from CABG on basal/bolus, shaky and sweaty with POCT glucose 62 at 11:00 AM. What should you do? Give him a large glass of juice Feed him lunch Call rapid response team Hold his lunch time insulin All of the above 52

The 15-15 Rule Give 15 grams of fastacting carbohydrate and wait 15 minutes Recheck blood glucose and then give another 15 grams of fast-acting carbohydrate, if necessary 53

Strategies for Reducing Risk for Hypoglycemia in Noncritical Care Settings Avoidance of sliding-scale insulin alone Use caution in prescribing oral antihyperglycemic agents Modify outpatient insulin doses in patients treated with insulin prior to admission Braithwaite SS, et al. Endocr Pract. 2004;10(suppl 2):89-99. 56

Case Study RG 61 yo man POD 3 from CABG on basal Lantus, nutritional Novolog and correction Novolog. Presupper blood sugar is 336. On further questioning, patient reports that family brought him a small sub from Subway for mid afternoon snack. What should you do? 57

Case Study RG 61 yo man POD 3 from CABG on basal/bolus, 336 before supper after Subway snack. What should you do? Give him correction dose of insulin Give him meal insulin Call rapid response team Cancel his dinner meal Forbid family from bringing him anything else to eat All of the above 58

Case Study RG 61 yo man POD 3 from CABG on basal/bolus, 336 before supper after Subway snack. Patient indicates he is still hungry and planning to eat his dinner, so you should: Give correction insulin only Give correction and nutritional insulin Give nutritional insulin only Encourage him to drink extra fluids and give correction and nutritional insulin 60

Case Study RG 61 yo man POD 4 from CABG on basal Lantus, nutritional Novolog and correction Novolog. The next morning, you are on the way to give him his prebreakfast insulin when your other patient next door has acute respiratory distress requiring RRT. 90 minutes later you are finally able to give RG his breakfast insulin, but he finished eating his breakfast 85 minutes ago. CNA has just rechecked blood sugar and it is 227. What should you do? 61

Case Study RG 61 yo man POD 4 from CABG on basal/bolus, 227 1.5h after breakfast. What should you do? Give him correction dose of insulin only Give him meal insulin only Give him both meal and correction dose of insulin Give him no insulin at all, it s too late now. Call the provider for further orders. All of the above 62

Case Study RG From new hyperglycemia policy, Recommendations for safe administration of NUTRITIONAL and CORRECTION Novolog If greater than 60 minutes after meal, and AC scheduled NUTRITIONAL and CORRECTION Novolog were not given, 1. Perform a blood glucose POCT and administer the AC CORRECTION Novolog, per MAR. 2. DO NOT give scheduled NUTRITIONAL Novolog. Contact provider for an order to HOLD the scheduled NUTRITIONAL Novolog. 63

Case Study RG 61 yo man POD 5 from CABG on basal Lantus, nutritional Novolog and correction Novolog. He is now ready for discharge, 5 days after CABG. What regimen should he be discharged on? 64

Case Study RG 61 yo man POD 5 from CABG on basal/bolus, ready for discharge. What regimen should he go home on? The basal bolus insulin regimen he is currently getting The insulin regimen he was on before admission but not the other diabetic medications The insulin and other diabetic medications he was on before admission All of the above Whatever the provider orders It depends 65

Discharging Patients With Previously Diagnosed Diabetes Resume preadmission diabetes regimen at time of discharge for patients with acceptable preadmission glycemic control, no contraindication to prior therapy, and no significant health changes during hospitalization. When possible, resume this 24h prior to discharge to verify well tolerated. Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 66

Discharging Patients With Previously Diagnosed Diabetes Modify preadmission therapy for Patients found to have been in poor control prior to admission Patients who have had significant change in weight, oral intake or other factors that may affect glycemic control. Patients for whom preadmission medication(s) is now contra-indicated based on change in health status. Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 67

Discharging Patients With Previously Diagnosed Diabetes Provide patient and family members/caregivers with written and oral instructions regarding glycemic management regimen at time of hospital discharge Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 68

Ensuring Good Glycemic Control in Patients Being Discharged Ensure patient has survival skills ie, diabetes self-management education (DSME) Use of personal glucose monitor Rudiments of meal plan (effect of CHO) Medications How and when to administer Side effects Symptoms and treatment of hypo- and hyperglycemia When and whom to contact with problems Be sure patient has a name and phone number Additional education/resources 69

Connecting Inpatient Care to Outpatient Support: Circle of Care Appropriate inpatient/outpatient referrals and consultations Intake and identification Discharge summary and documentation of met needs Multidisciplinary involvement and coordination is required Admission database Focused bedside teaching/interventions Multidisciplinary team referrals Focused clinical assessment Pollom RK, Pollom RD. Crit Care Nurse Q. 2004;27:185-188. 70

Diabetes Update 2018: Challenging Transitions To effectively manage diabetes and nutrition in the hospital setting, a multidisciplinary team approach is key Collaboration among physicians, nurses, CNAs, pharmacists, laboratory staff, social workers, and dietary staff can optimize patient care and support favorable metabolic control and successful transitions in care 71

Diabetes Update 2018: Challenging Transitions Summary Reviewed appropriate management of abnormal blood sugars in hospital setting Reviewed impact of transitions in care on glycemic control Overview of upcoming hypoglycemia and hyperglycemia policies which will provide guidance 72

Diabetes Update 2018: Challenging Transitions Questions? 73