Glucose Management in Noncritical Hospitalized Patients

Glucose Management in Noncritical Hospitalized Patients October 17, 2015 Archana R. Sadhu, MD., FACE Director of System Diabetes Program Director of Transplant Endocrinology Assistant Professor, Weill Cornell Medical College Adjunct Assistant Professor, Texas A & M Medical School Houston Methodist OBJECTIVES Understand the impact of glycemic control on clinical outcomes for noncritically ill medical and surgical patients Review current guidelines and glycemic targets for noncritically ill patients Review strategies for safe and effective glycemic control from admission until discharge Discuss challenges to glycemic control unique to the hospital setting 2 HYPERGLYCEMIA*: A COMMON COMORBIDITY IN MEDICAL-SURGICAL PATIENTS IN A COMMUNITY HOSPITAL 12% 26% 62% Normoglycemia Known history of diabetes Newly discovered Hyperglycemia n = 2,020 * Hyperglycemia: Fasting BG 126 mg/dl or Random BG 200 mg/dl X 2 Adapted from Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978 982. 3 1

HYPERGLYCEMIA IS AN INDEPENDENT MARKER OF INPATIENT MORTALITY IN PATIENTS WITH UNDIAGNOSED DIABETES P < 0.01 P < 0.01 18 16 14 12 In-hospital 10 Mortality Rate (%) 8 6 4 2 0 1.7 Patients With Normoglycemia 3 Patients With History of Diabetes 16 Newly Discovered Hyperglycemia Adapted from Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978 982. 4 CAUSES OF INPATIENT HYPERGLYCEMIA Illness related stress counter regulatory hormones and cytokines cause insulin resistance Undiagnosed diabetes mellitus Medications: steroids, immunosuppressants, sympathomimetics, anesthetic agents, octreotide Parenteral and enteral nutrition Physical Inactivity Inappropriate insulin use e.g. Sliding scale insulin 5 LINK BETWEEN HYPERGLYCEMIA AND POOR OUTCOMES: POTENTIAL MECHANISMS Immune dysfunction Infection dissemination Metabolic stress response Stress hormones and peptides Glucose Insulin FFA Ketones Lactate Cellular injury/apoptosis Inflammation Tissue damage Altered tissue/wound repair Acidosis Infarction/ischemia Organ dysfunction Prolonged hospital stay Disability Death Reactive O 2 species Transcription factors Secondary mediators Clement S et al. Diabetes Care, 2004; 27:553 591, 6 2

FFA - Nonmetabolic Insulin Action TNF-α - phosphorylation IL-6 Iκß (inhibitor κß) - mixed meal + liver INSULIN CRP + - APPs enos NF-Kβ + SAA Translocation to the nucleus NO inos NO Adhesion molecules Proinflammatory genes transcription transcription ICAM-1 VCAM-1 TNF-α IL-6 IL-8, MMPs E-selectin MCP-1 Monocyte/Macrophage Endothelial Cell http://resources.aace.com THE IMPACT OF HYPERGLYCEMIA IN NONCRITICALLY ILL PATIENTS INPATIENT HYPERGLYCEMIA HAS BEEN SHOWN TO BE A MARKER OF POOR OUTCOMES Critical Illness: ICU, cardiothoracic surgery, acute myocardial infarction Surgery: orthopedic, vascular, colorectal, bariatric, trauma Medical: COPD exacerbation, pneumonia Neurology: Stroke, Cerebral Aneurysm, Subarachnoid Hemorrhage Obstetrics: Labor and Delivery 9 3

INCREASED WOUND AND NOSOCOMIAL INFECTIONS Perioperative Glycemic Control and the Risk of Infectious Complications in a Cohort of Adults with Diabetes* Relative Odds of Wound Infections 121-206 (P< 0.05 for 207-229 1.17 411 diabetics who underwent upward trend) CABG 230-252 1.86 Leg and chest wounds, pneumonia, and UTI 253-353 1.78 Early postoperative glucose control predicts nosocomial infections rate in diabetic patients ǂ Relative risk for serious post-op infections increasedto 5.7 when glucose >220 mg/dl *Golden SH et al. Diabetes Care. 1999;22:1408-1411 ǂ Pomposelli Golden SH JJ et et al. al. Diabetes J Parenteral Care. 1999;22:1408-1411. Ent Nut. 1998;22:77-81 10 IN-HOSPITAL COMPLICATIONS WITH AND WITHOUT DIABETES IN NONCARDIAC SURGERY N=3,184 Thirty-day mortality and in-hospital complication rates in patients with and without diabetes: blood infection (combined bacteraemia and sepsis); urinary tract infection (UTI), acute myocardial infarction (AMI), and ARF. *P < 0.001; NS; P < 0.017. Frisch, A et al. Dia Care 2010;33:1783-1788 11 IMMEDIATE PRE-OP GLUCOSE AND MORTALITY Case controlled study of 2151 patients who underwent elective non-cardiac surgery Pre-op random glucose measurements defined as: -Normal : < 110 mg/dl - Pre-DM: 110-200 mg/dl -DM: > 200 mg/dl Prediabetes: 1.7 fold increased mortality compared to normal Diabetes: 2.1 fold increased mortality 100 mg/dl 200 mg/dl Normal Prediabetes Diabetes Noordzij P et al. Eur J Endocr 2007;156:137-142 12 4

ASSOCIATION OF MEAN GLUCOSE BEFORE AND AFTER SURGERY Before surgery Patients WITHOUT diabetes had higher odds ratio of 30 day mortality with higher mean glucoses No diabetes After surgery No diabetes All patients Patients with Diabetes Patients without Diabetes Frisch, A et al. Dia Care 2010;33:1783-1788 13 PRE-OP GLYCEMIC CONTROL - ORTHOPEDICS 115 patients with Type 2 DM s/p TKA* Preoperative HgA1c 8% was an independent risk factor of wound complications (OR 6.07) Duke Study**: >1 million patients who underwent joint replacement surgery from 1988-2005 Uncontrolled diabetes had higher adjusted odds ratio of: Stroke (OR 3.42) UTI (OR 1.97) Postop hemorrhage (OR 1.99) Wound infection (OR 2.28) Ileus (OR 1.99) Death (OR 3.23) 14 *Han H, Kang S. Clinic in Orthopedic Surgery,2013;5:118-123 **Marchant, MH et al. J Bone Joint Surg 2009; 91:1621-9 COLORECTAL AND BARIATRIC SURGERY WITH POSTOPERATIVE GLUCOSE >180 MG/DL N=11,633 Outcomes stratified by perioperative hyperglycemia (>180 mg/dl at any point on the day of surgery, postoperative day 1, or postoperative day 2) for diabetic patients (A) and nondiabetic patients (B). * P < 0.01; P < 0.05. 15 Kwon S, et al. Ann Surg 2013; 257(1):8-14 5

EARLY (48H) POSTOPERATIVE GLUCOSE LEVELS AND SSI AFTER VASCULAR SURGERY <103 mg/dl 103-117 mg/dl 117-151 mg/dl >151 mg/dl P for trend=0.003; * P=0.006; ** P=0.28; *** P=0.69 Adapted from Vriesendorp. Eur J Vasc Endovasc Surg 2004; 28:520-5 16 HYPERGLYCEMIA AND STROKE A: Predicted probability of in hospital adjusted mortality B: Predicted probability of adjusted symptomatic intracranial hemorrhage Shihab Masrur et al. J Am Heart Assoc 2015;4:e002193 17 GUIDELINES FOR HYPERGLYCEMIA MANAGEMENT OF NONCRITICALLY PATIENTS 6

DANGERS OF SLIDING-SCALE INSULIN REGIMENS Reactive therapy provides supplemental insulin after hyperglycemia occurs No basal (long term) insulin coverage: Will cause DKA in patients with Type 1 diabetes Does not consider nutritional changes or diurnal insulin requirements Non physiologic dosing that results in: Increased incidence of hyperglycemic and hypoglycemic episodes 1 1 Queale WS et al. Arch Intern Med. 1997;157:545-552 19 ROLLER COASTER EFFECT OF SLIDING-SCALE INSULIN Time 20 RABBIT-2 TRIALS: BASAL / BOLUS SUBCUTANEOUS INSULIN THERAPY IN MEDICAL PATIENTS 130 insulin naïve patients with Type 2 diabetes Discontinued all oral antidiabetic drugs on admission Randomized to: - Basal- Bolus Arm: glargine and glulisine - Standard Arm : Sliding Scale Insulin alone Starting Total Daily Dose (TDD): 0.4 units/kg/d x BG between 140-200 mg/dl 0.5 units/kg/d x BG between 201-400 mg/dl Half as glargine and half as glulisine divided daily with meals Umpierrez GE et al. Diabetes Care. 2007;30:2181 2186. 21 7

RABBIT-2 TRIAL: BASAL -BOLUS INSULIN THERAPY HAS BETTER GLYCEMIC CONTROL IN NON ICU MEDICAL PATIENTS * P<0.05. BG (mg/dl) 240 220 200 180 160 140 120 100 Admit 1 * * * * * * * Sliding scale Basal bolus 2 3 4 5 6 7 8 9 10 Days of Therapy Sliding scale regular insulin (SSRI): given 4 times daily. Basal-bolus regimen: glargine once daily; glulisine before meals. 0.4 U/kg/d x BG between 140-200 mg/dl 0.5 U/kg/d x BG between 201-400 mg/dl Umpierrez GE et al. Diabetes Care. 2007;30:2181 2186. 22 BLOOD GLUCOSE LEVELS IN PATIENTS WHO FAILED SSRI: TRANSITION TO BASAL BOLUS INSULIN 300 P: NS P: 0.02 280 Blood Glucose (mg/dl) 260 240 220 200 180 160 SSRI Lantus plus Glulisine 140 120 100 0 Admit 1 21 32 43 54 16 27 38 94 10 5 11 6 12 7 Days of Therapy Failure was defined as 3 consecutive BG values > 240 mg/dl during SSRI Umpierrez GE et al. Diabetes Care. 2007;30:2181 2186. 23 RABBIT-2 SURGERY: BASAL-BOLUS INSULIN THERAPY HAS LOWER POSTOPERATIVE COMPLICATIONS Results: Daily blood glucose (BG): Lower mean fasting, lower mean daily glucose more glucose readings < 140 mg/dl Reduced composite endpoints of postoperative complications: - Reduced at 8.6 % vs. 24.3% (P=0.003) - Wound infection: 2.9 vs. 10.3% (P=0.247) - Pneumonia: 0 vs. 2.8% (P=0.247) - Acute renal failure: 3.8 vs. 10.3% (P=0.106) Umpierrez GE et al. Diabetes Care. 2011; 34:256 261 Umpierrez GE et al. Diabetes Care 34:256 261, 2011 24 8

DPP4-INHIBITORS IN THE HOSPITAL SETTING Randomized, open-label pilot study of general medical and surgical patients (n=90) T2D on diet, any orals, low dose insulin ( 0.4 units/kg/day) 3 Arms: sitagliptin alone, sitagliptin + glargine, or basal + bolus insulin RESULTS No difference in mean daily glucose No difference in number of target glucose readings No difference in hypoglycemia No difference in LOS Less total daily insulin dose and number of injections in the sitagliptin group Umpierrez G. E. et al. Diabetes Care 2013;36:3430-3435 25 CHALLENGES TO ORAL DIABETES THERAPIES IN THE HOSPITAL Many restrictions to use of orals in the hospital: Renal or hepatic impairment (e.g. metformin, sulfonylureas, TZD) Volume overload (TZD) Changing nutritional status or malnutrition (insulin secretagogues) Contrast dye for imaging or procedures (metformin) Slow pharmacokinetic profiles of oral agents infective for rapid changes in glucose and insulin requirements Risk of hypoglycemia is unclear in the hospital setting 26 CURRENT GUIDELINES FOR GLUCOSE TARGETS Non ICU Patients: Premeal glucose targets <140 mg/dl Random blood glucose (BG) <180 mg/dl To avoid hypoglycemia, reassess insulin regimen if BG levels fall below 100 mg/dl Some patients may be maintained with a glucose range below and/or above these cut-points Hypoglycemia = BG <70 mg/dl Severe hypoglycemia = BG <40 mg/dl Umpierrez et al, Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline. JCEM, 2012, 97(1):16-38 Moghissi ES et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15:353-369. http://www.aace.com/pub/pdf/guidelines/inpatientglycemiccontrolconsensusstatement.pdf. 27 9

STRATEGIES TO ACHIEVE GLYCEMIC CONTROL IN CRITICALLY ILL PATIENTS ADMISSION #1: HIP FRACTURE 66 year old female with osteoporosis admitted with a hip fracture History of T2DM for 12 years, Hypothyroidism, CAD, CKD 3-4 DM Meds: metformin 1000mg BID, glyburide 5 mg bid, sitagliptin 100 mg QD Admission Labs: Glucose 220 mg/dl, Cr= 1.6, A1c = 9.2% Underwent ORIF and postoperative glucose is now 330 mg/dl How should we treat her diabetes? Continue metformin and pioglitazone but increase glyburide dose Discontinue all oral agents and start Sliding Scale insulin therapy Q 4-6 hours Start a basal (intermediate or long acting) + bolus (rapid acting ) insulin regimen 29 USE INSULIN TO 30 10

KEY CONCEPTS OF EFFECTIVE INSULIN THERAPY Basal insulin Controls hepatic glucose production Food(prandial prandial) insulin Based on meal carbohydrate content Correction(supplemental supplemental) insulin Treats acute elevation in blood glucose 31 INSULIN REVIEW Generic Brand Onset Peak Duration Administration time Rapid Acting Insulin Lispro Humalog 5-15 min 40-50 min 3-5 hrs 5-10 minutes before meals Insulin Aspart Novolog Insulin Glulisine Apidra Short Acting Insulin Regular Humulin R 0.5-1 hr 1.5-2 hrs 5-7 hrs 30-60 minutes before meals Insulin Regular Novolin R Intermediate Acting Insulin NPH Humulin N once before breakfast 1-4 hrs 4-14 hrs 10-20 hrs and once in the evening Insulin NPH Novolin N (may see q8h) Mixed Insulins Insulin Humulin 50/50, Regular/Insulin Humulin 70/30, 30 min 1-3 hrs 10-20 hrs NPH Novolin 70/30 once before breakfast Humalog Insulin Mix and once before dinner 50/50, Lispro/Insulin Humalog Lispro Protamine 15-30 min 0.5-6.5 hrs 10-20 hrs Mix 75/25 Long Acting Insulin Detemir Levemir 0.75-2 hrs 6-9 hrs 12-24 hrs once daily at same scheduled time (may Insulin Glargine Lantus 1-2 hrs No peak 24 hrs sometimes see BID) 32 INITIATING A BASAL BOLUS INSULIN REGIMEN No clue where to start??? 33 11

A COMPREHENSIVE DIABETES/HYPERGLYCEMIA MANAGEMENT ORDER SET Step 1: Order glucose monitoring Glucose monitoring is QAC and QHS for patients on a diet OR Q4 hours for patients who are NPO, on tube feeds or TPN. 34 BASAL INSULIN Ordering Basal Insulin Step 2: Order basal insulin type and dose Default frequencies are present but can be changed to other options in drop down menus 35 A WEIGHT BASED DOSING TABLE IS INCLUDED IN THE ORDER SET INITIAL DOSING FOR BASAL + BOLUS INSULIN REGIMEN Actual Body Weight (kg): 50 60 70 80 90 A: Basal (Lantus (insulin glargine) once daily) Insulin Sensitive (BMI less than 20, ESRD) 5 6 7 8 9 Insulin Average (BMI 20-30, less than 2 agents, admit blood glucose (BG) less than 200mg/dL) 10 12 14 16 18 Insulin Resistant (BMI more than30, on more than 2 agents, admit BG more than 200, on steroid therapy 15 18 21 24 27 Adjust: if fasting BG greater than 140mg/dL and none less than 70mg/dL +2 +2 +3 +4 +5 Adjust: if fasting BG less than 70mg/dL -2-3 -4-5 -5 B: Mealtime TID--Humalog (insulin lispro) (Caution if poor appetite; may use different dose each meal) Insulin Sensitive 2 2 3 3 3 Insulin Average 3 4 5 5 6 Insulin resistant 5 6 7 8 9 Adjust: if fasting BG greater than 140mg/dL and none less than 70mg/dL +1 +1 +2 +2 +3 Adjust: if premeal BG less than 70mg/dL -2-2 -2-3 -3 C: Corrective Humalog (Insulin lispro): Start algorithm #2 (unless ESRD, then start #1) Total Daily Dose (TDD) calculations above are based on: Choose patients level of insulin resistance Insulin sensitive 0.2 units/kg/day Insulin Average 0.4 units/kg/day (sensitive/average/resistant) and match to Insulin Resistant 0.6 units/kg/day patient s weight in kg to find the dose of Lantus and Lispro with meals. 36 12

NUTRITIONAL (PRANDIAL) INSULIN Step 3: Order a mealtime insulin dose for breakfast, lunch and dinner Nursing Instructions: If patient is NPO or premeal glucose is less than 80, hold the mealtime insulin. If premeal glucose is 80-100, give ½ dose of mealtime insulin. May be given up to 10 minutes before meal or immediately after meal if oral intake is Uncertain. If corrective dose is needed, add to mealtime dose. 37 CORRECTION SCALE Step 4: Order a low, medium or high dose correction scale Nurse may change the dosing to premeal if patient is eating or Q 4 hours if patient is NPO, or on Tube feeds or TPN. 38 HYPOGLYCEMIA TREATMENT, LABS, CONSULTS Hypoglycemia treatment is included in the order set Optional orders for labs: hemoglobin A1c and lipid panel Optional orders for consultations: Endocrinology, Diabetes Education, and Nutrition 39 13

ADMISSION #1 READY FOR DISCHARGE Patient has been treated with basal bolus insulin regimen Glucose has been between 100-180 mg/dl Uncomplicated postop recovery Cr is 1.8 What should the discharge regimen be? Reassess pre-admission regimen: Outpatient DM Meds: metformin 1000mg bid, glyburide 5mg bid, sitagliptin 100mg daily Labs: Admission glucose 220 mg/dl HgbA1c 9.2%, creatinine 1.6, 40 CONSIDERATIONS WITH NON- INSULIN DIABETES MEDICATIONS Renal Insufficiency: Metformin: Cr > 1.5 (egfr < 60 cc/min) in men and > 1.4 in women for metformin Sulfonylureas (exception of glipizide) Reduce doses for some DPP4 Inhibitors, GLP1-RA agonists and SGLT-2 inhibitors Hepatic Insufficiency: Metformin and TZD: LFT s >2-3x upper normal Volume Overload: TZDs: Renal failure, liver failure, heart failure 41 DISCHARGE REGIMENS A1c Regimen <7% Continue previous regimen 7-8% Increase doses of previous agents or add additional oral on non-insulin agent. If already on max dose of 2 oral agents, consider basal insulin 8-9% Add basal insulin to previous oral or non-insulin regimen or if already on basal insulin, change to multiple daily injections >9% Multiple daily injections What is the A1c? Other Considerations for Patient centered Approach: Costs Patient compliance Risks of hypoglycemia Weight management Follow up as outpatient 42 14

ADMISSION #2: SOB 56 year old male admitted to the floor with pneumonia and COPD exacerbation History of T2DM for 6 years DM Meds: Metformin 1000mg BID, canagliflozin 300mg daily Labs: Glucose 190 mg/dl, Cr= 1.0, HgbA1c = 6.7% Started on antibiotics and solumedrol 60mg iv daily How should we treat his diabetes? 1. Continue metformin and canagliflozin 2. Discontinue orals and start sliding scale insulin therapy every 4-6 hours 3. Start basal + bolus insulin therapy 43 INSULIN REGIMENS FOR CORTICOSTEROIDS Insulin Requirement High a.m. dose corticosteroids 8 12 6 10 Consider NPH with rapid acting regimens Dose basal insulin higher during the day than overnight Dose prandial insulin higher towards the end of the day May need a ratio of higher prandial than basal insulin (60-70% prandial vs. 30-40% basal) 44 SUGGESTED INSULIN DOSING FOR STEROID TAPER Prednisone Dosage (mg/day) 40 0.4 30 0.3 20 0.2 10 0.1 Insulin Dosage (U/kg) Clore J, Thurby-Hay L. Glucocorticoid-induced hyperglycemia. Endocr Pract. 2009; 15:469-474 45 15

ADMISSION # 3: TRANSFER FROM ICU 72 year old female admitted with fever, SOB and hypotension Admitted to medical ICU for urosepsis and SIRS No history of Type 2 Diabetes but has HTN, Hyperlipidemia, CAD, Gout. Labs: Glucose= 225 mg/dl, repeat was 253 mg/dl HgbA1c = 5.9% Creatinine = 1.8 AST/ALT = normal Managed with pressors, corticosteroids, antibiotics and vent support Excellent glycemic control was achieved with intravenous insulin infusion 46 ADMISSION #3 CONTINUED Over the next few days, the patient improves significantly. Pressors are weaned off and steroids are reduced. She is extubated. Tube feedings were started and titrated to goal rate 24 insulin requirements from insulin infusion while on stable TF rates are 65 units Renal and liver function returning to normal Ready for transfer to floor on current TF regimen with plans for swallow study in a few days. What should we do with the insulin regimen? D/C insulin gtt and start sliding scale insulin Transition to a basal + bolus SC insulin regimen with sliding scale 47 SUBCUTANEOUS INSULIN REGIMENS FOR NPO, PARENTERAL OR ENTERAL NUTRITION Options for Insulin Regimen: NPH ~ 70 % of iv requirements divided Q 6-8 hours Lispro/Aspart Q 4 hours correction 1. Glargine/Detemir daily + Rapid Acting Q4 hours 2. NPH Q6-8 hours + Rapid Acting Q 4 hours 3. 70/30 Mixed Insulin BID - TID Q8 h Sample calculation of transition from insulin drip: Prior 24 hours intravenous insulin = 65 units 70% = 46 units NPH 15 units q8 hours with lispro/aspart correction q4 hours. Glargine/Detemir: ~ 70% of iv requirements Lispro/Apsart Q 4 hours correction - 48 6 10 2 6 16

ADMISSION # 3 - CONTINUED Several days later the patient passes the swallow evaluation. Hydrocortisone is tapered off The TF are discontinued at 10 am Last NPH dose was at 8 am as scheduled At 1 pm, she has a hypoglycemia to 45 mg/dl What happened? 49 HYPOGLYCEMIA WITH SUDDEN INTERRUPTION IN CALORIES Have Dextrose readily available for patients and start at the same rate as the nutritional rate if on TPN or tube feeds Continue iv dextrose until tube feeds resumed or effect of long acting insulin is worn off ADJUST THE INSULIN THERAPY OR NOTIFY THE PRIMARY PROVIDER 50 SPECIAL REGIMENS FOR CONTINUOUS TPN OR TUBE FEEDS For patients on continuous tube feeds or TPN, recommend a special regimen of NPH Q 8 hours with lispro Q 4 hours Special nursing instructions: Start 10% Dextrose 10% IV during any interruption in tube feeds or TPN upto a max of 40 cc/hr. HOLD next insulin dose and notify prescriber for further orders. 51 17

ADMISSION # 3 DISCHARGE REGIMEN Blood sugars have been normal without additional insulin on stable oral diet Ready for discharge Does the patient need insulin or oral agents for discharge? On admission : HgbA1c = 5.9% 52 HOSPITAL HYPERGLYCEMIA REQURIES DISCHARGE FOLLOW UP In those with previously diagnosed diabetes, newly diagnosed diabetes, or elevated A1c Initiate therapy or revise preadmission regimen as required In those without previously diagnosed diabetes Differentiation between hospital-related hyperglycemia and undiagnosed diabetes requires follow-up testing (FBG, 2H OGTT, A1c) once metabolically stable using established criteria 53 DISCHARGE TRANSITION Diabetes Education Survival Skills Nutrition counseling for carbohydrate and calorie restriction Reassessment of admission treatment regimen Transition to non insulin therapy, if appropriate Outpatient follow-up and referrals for on going care Clear, written medication instructions for patients 54 18

ADMISSION #4: HOSPITAL ACQUIRED CONDITION 32 year old male admitted for Left femoral-popliteal bypass H/o Type 1 DM for >20 years on Lantus 15 units QHS and Humalog with carb counting. HgbA1c was 6.7% on this regimen On admission he was placed NPO after midnight and ordered a sliding scale On the morning of surgery, patient was found to be confused, tachypneic with shallow respirations Labs: Glucose =426, Potassium = 5.6, ph =7.2 Bicarb=14, anion gap of 16, positive serum ketones What happened??? 55 DANGERS OF SLIDING-SCALE INSULIN REGIMENS Reactive therapy provides supplemental insulin after hyperglycemia occurs No basal (long term) insulin coverage: Will cause DKA in patients with Type 1 diabetes Does not consider nutritional changes or diurnal insulin requirements Non physiologic dosing that results in: Increased incidence of hyperglycemic and hypoglycemic episodes 1 1 Queale WS et al. Arch Intern Med. 1997;157:545-552 56 DKA MANAGEMENT PROTOCOL Insulin Therapy: - Initial Bolus dose = 0.1 units/kg - Continuous infusion = 0.1 units/kg/hr - Continue drip until acidosis is resolved Fluid Resuscitation: -Normal Saline until BG < 250, the D5%NS Electrolyte Repletion -Potassium Add to iv fluids if K < 5.3 meq/l -Bicarb replacement if ph < 7.0 - Phosphate replacement 57 19

CONTINUOUS SUBCUTANEOUS INSULIN PUMPS (CSII) Increased utilization of CSII as outpatient in both Type 1 and Type 2 diabetes Lack of knowledge by medical personnel in the hospital setting No definitive guidelines Some small, single center studies have shown that continuing CSII is safe in the hospital Standardized hospital protocols, order sets and patient consents are recommended Endocrine consultation Noschese et al. Endo Prac 2009; 15(5): 415-424 Nassar et al. J Diabetes Sci Techbol. 201;4(4):863-72 58 CHALLENGES TO GLYCEMIC CONTROL IN THE HOSPITAL SETTING BARRIERS IN THE HOSPITAL Diabetes/hyperglycemia often overlooked on admission and throughout the hospitalization Hypoglycemia feared and often over-treated Lack of familiarity with the increasing types of diabetes therapies currently available Hyperglycemia is not the primary diagnosis and therefore not a priority Traditional sliding scale protocols continue to prevail 60 20

BARRIERS IN THE HOSPITAL Increased workload on nursing When insulin used, timing may still be problematic Lack of coordination between departments, e.g., nutrition, radiology, nursing, etc. Complexity of individualized dosing + need to make daily adjustments 61 CONDITIONS PREDISPOSING PATIENTS TO HYPOGLYCEMIA Advanced age Sepsis/shock Malnutrition Burns Gastrointestinal malabsorption Cerebrovascular accident Hypoglycemia unawareness Altered Mental Status Goldberg PA et al. Diabetes Spectrum. 2005;18:28-33. Congestive heart failure Renal insufficiency Adrenal/pituitary insufficiency Liver disease Pregnancy Alcoholism Polypharmacy (drug interactions) 62 IATROGENIC CAUSES OF HYPOGLYCEMIA Sudden NPO status or reduction in oral intake Enteral feeding or TPN discontinued Glucose monitoring and insulin administration are not timed appropriately Premeal insulin given and meal delayed or not ingested Unexpected transport from nursing unit after rapid-action insulin given Reduction in corticosteroid dose Clement S et al. Diabetes Care. 2004;27:553-591. American Diabetes Association. Diabetes Care. 2008;31:S12-S54. 63 21

INPATIENT DIABETES TEAMS Multidisciplinary experts in diabetes are needed to form a effective team: 1. Clinician: physician or physician extender 2. Nurse 3. Diabetes Educator 4. Nutritionist 5. Pharmacist 64 THANK YOU FOR YOUR ATTENTION! 22