Stepwise approach to inpatient diabetes management
Erin KeelyErin Keely
At the Ottawa Hospital:At the Ottawa Hospital:(From Test Strip Usage)(From Test Strip Usage)
On any given day, 250-300 patients On any given day, 250-300 patients admitted to Ottawa Hospital have admitted to Ottawa Hospital have diabetes (25-30%)!diabetes (25-30%)!
Impact of Diabetes on Length of Stay – Impact of Diabetes on Length of Stay – The Ottawa HospitalThe Ottawa Hospital
Compiled by S. Brez, APN Endocrinology and Metabolism
SpecialtySpecialty ALOS No DMALOS No DM
(days)(days)ALOS DMALOS DM
(days)(days)
CivicCivic General General CivicCivic GeneralGeneral
General Medicine
99 99 1313 1313
General Surgery
77 66 2323 1111
Vascular Surgery
1010 N/AN/A 2121 N/AN/A
Orthopedic Surgery
77 77 1818 1414
Mean for Hospital
66 66 1515 1212
Increasing information on diabetes Increasing information on diabetes and cancerand cancer
Hyperglycemia in the Hospitalized Patient: Classification DiabetesDiabetes
Previously Diagnosed – type 1 or type 2Previously Diagnosed – type 1 or type 2 Previously UndiagnosedPreviously Undiagnosed
Confirmed after dischargeConfirmed after discharge Secondary diabetes (glucocorticoids)Secondary diabetes (glucocorticoids)
Hospital-related hyperglycemiaHospital-related hyperglycemia Reverts to normal after dischargeReverts to normal after discharge
Glycemic Targets in Hospitalized Patients
Medical/surgical floorsMedical/surgical floors 6.1 -10.0 mmol/L6.1 -10.0 mmol/L
Increase risk of infection if glucose > 12 mmol/lGlucosuria if >16-18 mmol/l
Potential Benefits of Improving Glucose Control in the Hospital
Reduce mortalityReduce mortalityReduce morbidityReduce morbidityReduce costs of careReduce costs of care
Length of stay (LOS)Length of stay (LOS) Cost of inpatient complicationsCost of inpatient complications Fewer rehospitalizationsFewer rehospitalizations
Goals of Inpatient Diabetes Management Avoid HypoglycemiaAvoid Hypoglycemia
Avoid HyperglycemiaAvoid Hyperglycemia
Assessment of Patient’s diabetes careAssessment of Patient’s diabetes care
Assessment of Risk FactorsAssessment of Risk Factors
Common Errors in Inpatient Glucose Management Admission orders
Withdrawal or outpatient treatment regimen Failure to modify outpatient regimen
Overly high glycemic targets
Lack of therapeutic Adjustments
Overuse of Sliding Scale!!!! Overuse of Sliding Scale!!!! Overuse of Sliding Scale!!!!
Classification of oral agents
Insulin secretagogues Sulfonylureas
Diabeta, diamicron (regular and MR) Amaryl
Meglitinides Gluconorm Starlix
Insulin sensitizers Metformin Glitazones
Actos Avandia
Incretins DPP-4 inhibitors GLP-1 analogues
CHO absorption acarbose
Principles of InPatient Diabetes Management Type 1 different than type 2Type 1 different than type 2 Be safeBe safe Be proactiveBe proactive Try to continue pre-admission treatmentTry to continue pre-admission treatment
Unless NPO or decreased intakeUnless NPO or decreased intake HgbA1c> 8.0 – 10 %HgbA1c> 8.0 – 10 % Glucose > 10-12 mmol/LGlucose > 10-12 mmol/L Frequent hypoglycemiaFrequent hypoglycemia
Types of Insulin
Two main manufacturers Novolin, Humulin
duration of action rapid aspart, lyspo, apidra short regular (toronto) intermediateNPH, lente Very long glargine, detemir
Action Profiles of Bolus & Basal Insulins
Pla
sm
a In
sulin
lev
els
HoursNote: action curves are approximations for illustrative purposes. Actual patient response will vary.
regular 6-10 hours
NPH 12–20 hours
lispro/aspart 4–6 hours
BASAL INSULINS
detemir ~ 6-23 hours (dose dependant)
glargine ~ 20-26 hours
Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12
BOLUS INSULINS
• Expected insulin changes during the day Expected insulin changes during the day • for individuals with a healthy pancreas.for individuals with a healthy pancreas.
*Insulin effect images are theoretical representations and are not derived from clinical trial data.
Basal-Bolus Approachtherapy addresses:
Bolus needs: Lispro, Aspart Basal needs: Glargine, Detemir , NPH
Meal Meal Meal
Principles of insulin managment
““Usual” = ProactiveUsual” = Proactive BasalBasal
NPHNPH LevemirLevemir LantusLantus
Meal-timeMeal-time RegularRegular NovorapidNovorapid HumalogHumalog
Pre-mixedPre-mixed
““Corrective” = ReactiveCorrective” = Reactive sliding scalesliding scale
Amount depends on Amount depends on insulin sensitivityinsulin sensitivity
One size does not fit One size does not fit all!!all!!
Use same type of Use same type of insulin as meal-timeinsulin as meal-time
So What to Do??So What to Do??
Diabetes Pocket CardDiabetes Pocket Card
1.1. Is patient on diet/oral agents/insulinIs patient on diet/oral agents/insulin
2.2. Is patient going to eat, be NPO, Is patient going to eat, be NPO, tube/parenteral feedstube/parenteral feeds
3.3. Look at glucose trends and adjustLook at glucose trends and adjust
Patient with Diet controlled diabetes
OrderOrder::
Blood glucose monitoring QIDBlood glucose monitoring QID
Consider doing a HgbA1cConsider doing a HgbA1c
Consider oral hypoglycemic agent or Consider oral hypoglycemic agent or insulin if blood sugars in hospital insulin if blood sugars in hospital persistently >11.0 mmol/Lpersistently >11.0 mmol/L
Patient with diabetes on oral hypoglycemic agents
Continue oral agentsContinue oral agents Caution if on metformin or actos (pioglitazone) Caution if on metformin or actos (pioglitazone)
and renal, cardiac or hepatic dysfunctionand renal, cardiac or hepatic dysfunction
If blood sugars persistently >10.0 mmol in If blood sugars persistently >10.0 mmol in hospital:hospital: Step 1: maximize oral agents, add another oral Step 1: maximize oral agents, add another oral
agent (from a different class)agent (from a different class)
Step 2: if not at target, add insulinStep 2: if not at target, add insulin
Do not use
Metformin: If congestive heart failure If renal failure If requiring a test with IV contrast dye
Thiazolidinediones If Congestive Heart Failure
How to start InsulinHow to start Insulin
Discontinue oral agents except metforminDiscontinue oral agents except metformin Corrective sliding scale aloneCorrective sliding scale alone (if temporary) – if (if temporary) – if
needs >8-10 units for longer than 48 hrs, consider needs >8-10 units for longer than 48 hrs, consider starting “usual” insulinstarting “usual” insulin
Start “usual insulin”Start “usual insulin” basal – 0.2-0.3 u/kg/day (either NPH split ac breakfast basal – 0.2-0.3 u/kg/day (either NPH split ac breakfast
and supper) or levemir/lantus qhsand supper) or levemir/lantus qhs Mealtime – 0.1-0.2 u/kg/day (breakfast and supper if Mealtime – 0.1-0.2 u/kg/day (breakfast and supper if
using NPH, all 3 meals if levemir/lantus)using NPH, all 3 meals if levemir/lantus) Continue corrective scaleContinue corrective scale
Why don’t sliding scales work?
Action is Retrospective not Prospective
Higher risk of Hyper and Hypoglycemia
Threshold for insulin administration may be too high
Sliding scales can be useful and effective if used appropriately (I.e. as supplemental insulin only)
Same amounts given if eating meal or not
How to Use Sliding Scale Insulin
Sliding scale insulin can be effective IF used appropriately
Never use sliding scale alone (unless for 1 to 2 days to get idea of insulin requirements)
Should be used in addition to oral agents or long acting insulin
NEVER NEVER NEVER use sliding scale alone in patient with TYPE 1 DIABETES
Choosing a sliding scaleChoosing a sliding scale
Total Daily Insulin Dose = Lantus 40 units + Novorapid 5 with meals
= 40 units + 5 units x B, L, D
= 55 units
XX
Correction InsulinCorrection Insulin
How do I change the scale?
If patient hypoglycemic and needs less insulin, choose scale to the LEFT
If patient hyperglycemic and needs more insulin, choose scale to the RIGHT
Patient on InsulinPatient on Insulin DetermineDetermine if patient is Type 1 or Type 2!! If unsure if patient is Type 1 or Type 2!! If unsure
treat as type 1 (i.e. needs insulin all of the time)treat as type 1 (i.e. needs insulin all of the time)
NEVERNEVER put a patient with type 1 Diabetes on sliding put a patient with type 1 Diabetes on sliding scale alone even if not eatingscale alone even if not eating
Insulin requirementsInsulin requirements may be more or less than as may be more or less than as required as outpatientrequired as outpatient
Likely needs Likely needs long-acting insulinlong-acting insulin (unless Type 2 and (unless Type 2 and sugars are excellent without it)sugars are excellent without it)
Patient on InsulinPatient on Insulin
OrderOrderBlood glucose monitoring QIDBlood glucose monitoring QIDContinue outpatient regimen unless Continue outpatient regimen unless
contraindicated (patient not eating, contraindicated (patient not eating, Type 1 with DKA, etc..)Type 1 with DKA, etc..)
Patient on insulin and eatingPatient on insulin and eating
If HgbA1c < 8, continue preadmissionIf HgbA1c < 8, continue preadmission
If HgbA1c > 8, or CBG > 10 If HgbA1c > 8, or CBG > 10 Start usual insulinStart usual insulin Use corrective scaleUse corrective scale Adjust based on glucose patternAdjust based on glucose pattern
Dosage Titration Practical ExampleDosage Titration Practical Example
BreakfastBreakfast
8u H8u HLunchLunch
8u H8u HDinner Dinner
8u H8u HBedBed
16u N16u N
3.43.4 8.98.9 9.49.4 9.29.2
BreakfastBreakfast
8u H8u HLunchLunch
8u H8u HDinner Dinner
8u H8u HBedBed
14u N14u N
5.15.1 9.29.2 9.49.4 9.29.2
1. First adjust insulin that caused the low blood glucose
2. Then adjust insulin that caused first high BG of the day
Pre-opPre-opGoal Blood sugar 6-10 mmolGoal Blood sugar 6-10 mmol
Start IV D5W at 75 to 100 cc/hourStart IV D5W at 75 to 100 cc/hour Previously on oral agents/dietPreviously on oral agents/diet
Hold oral agents if not eatingHold oral agents if not eating No basal insulinNo basal insulin No meal-time insulinNo meal-time insulin Corrective scale onlyCorrective scale only
Previously on insulinPreviously on insulin 1/2 – 2/3 usual basal insulin1/2 – 2/3 usual basal insulin No meal-time insulinNo meal-time insulin Corrective scaleCorrective scale
NPO Patient with Diabetes on Oral Agents
Hold oral agents: Humalog or NovoRapid sliding scale may be
added q 4-6 h in case of hyperglycemia:
Note: 1 unit of humalog usually decreases blood sugar by 2 to 3 mmol/L
OR IV Insulin
NPO Patient with Diabetes on Insulin (2+ shots/day)
Option 1: IV Insulin
OR
Option 2: Subcutaneous Insulin:
NPO Patient with Diabetes on Insulin (2+ shots/day): SC insulin option
Order 70-80% of long acting insulin (will need for basal insulin requirements)
Add sliding scale to control marked hyperglycemia
Remember to order IV D5W to prevent catabolism
Patient with Diabetes on FeedsPatient with Diabetes on Feeds
IF feeds are continuous, no previous insulin:IF feeds are continuous, no previous insulin: Put patient on basal insulin Put patient on basal insulin
0.3-0.4 units/kg/day0.3-0.4 units/kg/day Lanuts qhs or NPH q. 12 hLanuts qhs or NPH q. 12 h
Use corrective scaleUse corrective scale If feeds stopped suddenly start D5W at 100cc/hr!If feeds stopped suddenly start D5W at 100cc/hr!
IF feeds are continuous, previous insulin:IF feeds are continuous, previous insulin: 2/3 usual basal insulin2/3 usual basal insulin No meal-time insulinNo meal-time insulin Use corrective scaleUse corrective scale If feeds stopped suddenly start D5W at 100cc/hr!If feeds stopped suddenly start D5W at 100cc/hr!
IF getting bolus feeds:IF getting bolus feeds: Basal- 0.2 u/kg/day or 2/3 usual basalBasal- 0.2 u/kg/day or 2/3 usual basal Give meal-time insulin before bolus feed (3-4 units Give meal-time insulin before bolus feed (3-4 units
rapid insulin before 250 cc feed)rapid insulin before 250 cc feed) If feeds stopped suddenly start D5W at 100cc/hr!If feeds stopped suddenly start D5W at 100cc/hr!
Patient on TPNPatient on TPN
2 options:2 options: Insulin included in TPNInsulin included in TPN Subcutaneous insulin if neededSubcutaneous insulin if needed
Start long-acting insulin at time when has Start long-acting insulin at time when has TPN running (i.e. if receives overnight, start TPN running (i.e. if receives overnight, start NPH when feeds start and titrate up)NPH when feeds start and titrate up)
How to control glucose levels on TPN
Very poorly studied In the TPN bag or subcutaneous? If subcutaneous
0.3-0.4 units/kg/day NPH q. 12 hr levemir/lantus q. 12 or 24 hr
regular q. 6 h rapid q. 4 h
If in TPN bag 0.1 units regular/gm of CHO plus s.c. sliding scale
3-6 gm/kg/day dextrose = 210-420 gm 50% dextrose = 21-42 units insulin in 24 hr supply
Next day add 80% of insulin given as sliding scale to insulin bag
Assess Blood Glucoses at Daily, Adjusting Insulin Doses as Appropriate
Blood glucose targets can only be achieved Blood glucose targets can only be achieved via continuous management of the insulin via continuous management of the insulin programprogram
There is no “autopilot” insulin regimen for There is no “autopilot” insulin regimen for a hospitalized patient!a hospitalized patient!
Pre-Printed Insulin Orders
X X 2
X40
X33 3
XX
X
Consult Diabetes Specialty Team – Consult Diabetes Specialty Team – RN +/- MDRN +/- MD Insulin pumpInsulin pump Severe or frequent hypoglycemiaSevere or frequent hypoglycemia Poorly controlled prior to admission (eg. Poorly controlled prior to admission (eg.
HbA1c>10%)HbA1c>10%) Unrecognized diabetes complicationsUnrecognized diabetes complications IS BEING D/C ON INSULIN AND WAS NOT IS BEING D/C ON INSULIN AND WAS NOT
ON INSULIN PRIOR TO ADMISSION – and ON INSULIN PRIOR TO ADMISSION – and PLEASE, not on day of d/c!!PLEASE, not on day of d/c!!
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