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Glycemic Control in theHospitalized Patient
How do you do it?
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Hospitalization of the Patient WithDiabetes
Acute metabolic complications
Chronically poor metabolic control Acute or chronic complications of diabetes
Newly diagnosed diabetes (children)
Uncontrolled diabetes during pregnancy
Acute or chronic problems unrelated todiabetes
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Barriers to Inpatient DiabetesManagement
Increased insulin requirement due to illness
Exaggerated variability in subcutaneous insulinabsorption
NPO status; inconsistent oral intake; interruptionof meals by procedures
Unpredictable arrival of meals Inability of patient to participate in management
decisions
Medication errors
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Why be concerned about short-termglycemic control in hospital?
Critical illness
Acute myocardial infarction
Post-operative infection/wound healing
In-hospital mortality
Stroke
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NEJM 2001;345:1359
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BMJ 1997;314:1512
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Mortality in DIGAMI 2
European Heart Journal 2005;26:650
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Fasting Blood Glucose in DIGAMI 2
European Heart Journal 2005;26:650
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HbA1c in DIGAMI 2
European Heart Journal 2005;26:650
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Ann Thorac Surg 1999;67:352-62
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J Clin Endocrinol Metab 2002;87:978
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Stroke 2001;32:2426
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Glucose: the 6thvital sign
Measure blood glucose in all patients
admitted with acute illness All patients with type 1 diabetes will require
at least basal insulin replacement
Most insulin treated patients will requirecontinued insulin therapy
Consider insulin therapy in any patient withrandom blood glucose > 180 mg/dl
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Key Concepts of Insulin Therapy
Basalinsulin
Controls hepatic glucose production Food(prandial) insulin
Based on meal carbohydrate content
Correction(supplemental) insulin Treats acute elevation in blood glucose
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Basal
Bolus
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Indications for IV Insulin Therapy
DKA/ HHS
Critical illness Major surgery
Cardiopulmonary bypass surgery
Transplantation surgery Abdominal surgery (NPO post-op)
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IV Insulin Therapy- Considerations
Define target blood glucose.
Define threshold for initiating therapy.
Determine starting dose (& bolus) based onglucose level.
Adjust infusion rate based on rate of change inblood glucose. Infusion rates will vary dependingon individual patients insulin sensitivity.
Define when to interrupt therapy for low bloodglucose.
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IV to SC Insulin
Begin subcutaneous basal insulin while the patientcontinues to receive iv insulin.
Add prandial insulin when the patient is able to resumeoral intake.
Taper iv insulin, maintaining predetermined targets. IVinsulin can be discontinued when: IV insulin requirements are
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Use of Subcutaneous Insulin inHospital
Unpredictable
Best choice for insulin treated patient who
is able to eat
Options:
Once daily NPH insulin (type 2 diabetes only)
Twice daily split-mix insulin/pre-mix insulin
MDI or CSII
Listen to the experienced patient
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Starting Insulin in the Newly DiagnosedPatient
Calculate the total daily dose
Determine basal insulin requirement
40 to 50% of total daily dose
Determine the mealtime insulinrequirement
50 to 60% of total daily dose
Determine the correction dose
Based on estimate of insulin sensitivity
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Daily Insulin Requirements
Patient Description Insulin (units/kg.day)
Trained athlete 0.5
Mod. active man 0.6
Sedentary man; 1st trimester
of pregnancy0.7
Mod. stressed man; 2ndtrimester of pregnancy
0.8
Severely stressed man; 3rd
trimester of pregnancy 0.9
Systemic bacterial infection;full term pregnancy
1.0
Severely ill man 1.5-2.0
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Oral Agents in the Hospital
Classes
Insulin secretagogues (sulfonylureas; meglitinides)
Alpha-glucosidase inhibitors (acarbose; miglitol) Biguanides (metformin)
Thiazolidinediones (pioglitazone; rosiglitazone)
Limitations
Mild glucose elevations
Able to eat and ingest medicines
No comorbid conditions that contraindicate use
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Challenging Clinical Situations
The NPO patient
The patient receiving corticosteroids The patient receiving TPN
The patient on enteral nutritional support
Continuous
Intermittent
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The NPO Patient with Diabetes
Basal insulin as insulin glargine
Previous insulin: TDD
Insulin nave: 0.4 units/kg
(if on iv insulin, taper after insulin glargine is
added)
Regularinsulin supplement q4-6 hours
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Corticosteroid Therapy andDiabetes
Minimal elevation of fasting glucose
Exaggeration of postprandial hyperglycemia
Lack of sensitivity to exogenous insulin
Consider:
Prandial insulin in patients without prior history
of diabetes 70% prandial insulin, 30% basal insulin in
patients with established diabetes history
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TPN and Diabetes
TPN commonly leads to hyperglycemia inthe absence of diabetes.
Insulin requirements are increased inpatients with diabetes; 75% of patientswith type 2 diabetes not previously treatedwith insulin will require insulin with TPN.
IV insulin should be infused separatelyuntil requirements are known; insulin canthen be added to the TPN solution.
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Enteral Nutrition and Diabetes
Enteral nutritional support can result inhyperglycemia, even in the absence of diabetes. Inpatients with established diabetes, insulin
requirements increase substantially. High fat formulas (monounsaturated fats) achieve
better metabolic control that traditional highcarbohydrate preparations.
Blood glucose control may be attainable with longacting subcutaneous insulin preparations- insulinglargine (with constant nutrition). Previous diabetes: TDD
Insulin nave: 0.6 units/kg
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Intermittent Enteral Nutrition
Basal insulin as NPH at the start of
nutritional support Previous diabetes: TDD
Insulin nave: 0.4 units/kg
Regular insulin usually required at start offeeding
25 to 50% of NPH dose
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Summary
Aggressive glycemic control in hospitalizedpatients improves clinical outcomes.
Management of diabetes in an inpatient settingrequires familiarity with the use of both iv and scinsulin, both in intensive care units and ongeneral nursing units.
The time-honored traditions of sliding scaleinsulin, and of withholding insulin for proceduresand euglycemia should be buried along withfractional urine testing.
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Remember
Most hospitalized patients are discharged
Inpatient diabetes treatment should
transition smoothly to outpatientmanagement
Think ahead; plan early
? Dietary consultation
? Diabetes education consultation
? Endocrinology consultation
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