Inpatient Management of Diabetes Mellitus

William Harper, MD, FRCPC

Endocrinology & Metabolism

Assistant Professor of Medicine, McMaster University

DKA

1. Monitored setting if Hi-risk• elderly & CAD, pH < 7.0, severe K disturbance,

decreased LOC

2. IV Fluid Resuscitation (6-8L deficit)

3. Potassium (“no pee no K”)

4. IV insulin

5. Identify & Rx underlying cause• Noncompliance, infection, MI, etc.

DKA: IV Fluids

• IV NS 1L/h x 2-3h or longer so no more tachycardia, hypotension, orthostatic changes, low JVP.

• Then change to 1/2 NS:• 500 cc/h x 1-3h

• 250 cc/h x 4-6h

• If hypotension recalcitrant to fluids consider AI (Schmidt PGAS II) and send stat cortisol then give solucortef 100 mg IV q8h.

DKA: Mortality

• Adults 2-4%• Hypokalemia

• MI, CVA, etc.

• Kids 0.2-0.4%• Cerebral edema

DKA: Potassium• Need K with initial IV fluid & insulin Rx

unless:• Anuric

• K > 5.5 mEq/L or hyperkalemic ECG changes

Initial [K] Replacement

> 5.5 mEq/L nil (initially)

5.2-5.5 mEq/L 10 mEq/h

4-5.2 mEq/L 20 mEq/h

3-4 mEq/L 30 mEq/h

< 3 mEq/L 40 mEq/h

> 20 mEq/h:Cardiac monitor

> 60 mEq/L:Central line

DKA: IV Insulin

• Humulin R or Novolin Toronto• Bolus 0.1-0.2 U/kg IV• Then IV gtt @ 0.1-0.2 U/kg/h (50 U of regular insulin in 500cc D5W; 1U/10cc)• Monitor: CBG q1h• Monitor: Venous BS, electrolytes, creatinine q2h• Aim is to demonstrate correction of Anion Gap (AG) and

decrease in BS 4.4 mM/L/h• Monitoring serial serum ketones NOT useful:ßHß (not detected) DKA Rx Acetoacetate (detected)

DKA: IV Insulin

• Using insulin to treat 2 different and separate metabolic disturbances in DKA:

1. Ketoacidosis

2. Hyperglycemia

DKA: IV Insulin

• If AG not correcting and/or BS not decreasing then increase IV gtt rate 1.5-2X

• If BS < 13 but AG still not corrected do NOT decrease insulin IV gtt.

• Instead start IV glucose gtt:• D5W-D10W @ 100-200 cc/h

• Once AG corrected than titrate IV insulin to BS

• When BS < 13 and AG normal: reduce IV insulin gtt to 1-2 U/h and add IV glucose if not already done.

DKA: IV Insulin

• Can consider switch to SC insulin when:• AG normalized

• BS < 15 mM

• Insulin IV gtt requirements < 2U/h

• Patient able to eat

• Overlap insulin IV gtt with 1st SC insulin by 3-4h to avoid recurrent ketosis.

DKA: Other Rx

• Bicarbonate• May exacerbate hypokalemia• Only give if pH < 6.9 AND evidence of cardiovascualr

instability (arrythmia, CHF, hypotension)• 1-2 amps bicarb in 1L D5W IV over 2h until pH > 7.1

• Phosphate• Routine IV not recommended• Rx symptomatic hypophosphatemia (rhabdo, unexplained

CHF or respiratory failure, severe confusion)• 10cc K Phos soln (3.0mEq Pi and 4.4 mEq K/cc) in 1L NS IV

over 8-12h

DKA: Other Rx

• Cerebral Edema• Usually only kids

• Persistent decreased LOC despite standard Rx of DKA

• CT scan to confirm diagnosis

• Decadron 10 mg IV

• Mannitol 25 mg IV

HONC

• BS > 55

• Serum OSM > 350

• Coma 25-50%

• Mortality rate 25-70%

HONC

1. Coma Management• ABCs, O2, narcan, D50W, thiamine, etc.

2. IV Fluid Resusciation (10L free water defecit)

3. Insulin• IV fluids will decrease BS by 4 mM/L/h by itself

• For most patients insulin not absolutely neccesary

• Insulin IV bolus 5-10 U, gtt @ 1-2 U/h

4. Potassium (replace as in DKA)

5. Identify & Rx underlying precipitant

BS > 11.1 mmol/L

Renal threshold for glycosuria (normal GFR)

Decreased WBC functionChemotaxsisPhagocytosis

Decreased Wound Healing

Goals of Inpatient DM Management

• “Avoid hypoglycemia and marked hyperglycemia”

• Target BS: 7.0 - 11.0 mM

• Avoid Hypoglycemia

• Precipitating arrhythmia or other cardiac events

• Inducing seizure, focal or cognitive defects periop

• Avoid Marked Hyperglycemia (BS > 11.1 mM)

• Treat (and avoid) DKA, HONC

DM Inpatient Management

1. Eating

2. NPO: temporary (for a test)

3. NPO: prolonged

DM Inpatient Management

1. Eating:OHA (T2DM)

Insulin (T2DM and T1DM)

OHA: Drug BG HbA1c Side-effects

Sulfonylurea FBG 20% 1.5-2.0% Hypoglycemia

Weight gain

Biguanide FBG 20% 1.5-2.0% Lactic acidosis

GI intolerance

TZD FBG 2.2-3.6 mM

1.0-1.6% Edema

Weight gain

α-glucosidase Inhibitor

FPG 14%

PPG 25%

0.5% GI intolerance

Meglitinide FPG 4 mM

PPG 5.6 mM

1.8% Hypoglycemia

Insulin

Type Starts Peaks Duration

Humalog

NovoRapid

5-10 min 1-2 hrs 3.5 hrs

Regular 30 min 2-4 hrs 6-8 hrs

NPH

Lente

1-2 hrs 6-10 hrs 16-24 hrs

Ultralente 4-6 hrs 8-24 hrs 24-36 hrs

Glargine Immediately None Up to 24 hrs

BIDS Therapy

• T2DM: “Introduction to insulin”

• Keep on OHAs

• Start NPH 0.2 U/kg SC qhs

• Increase by 2-4 U q4d until FBS 4-7

• If dose > 30-40U or if BS high late in day despite OK FBS than split into 2 injections with 2/3 acB and 1/3 acD

Starting Insulin Regimen• TDD = 0.5-0.7 U/kg

• “2/3, 1/3” Regimens• 2/3 of TDD acB, 1/3 acD

• 2/3 of TDD as Long-acting, 1/3 as short acting

• Pre-mix: acB 30/70 acD 30/70

• MDI Regimens• 2/3, 1/3 Regimen: move acD long acting to qhs

• i.e. acB N, H acD H qhs N

• ac meals H qhs N (bolus 60%, basal 40%)

• ac meals H UL q12h (bolus 50%, basal 50%)

Insulin Regimens

acB acL acD qhs

Bedtime NPH (+/-bids) N

NPH bid N N

30/70 bid 30/70 30/70

MDI (3 injections) H + N H N

MDI (>4 injections) H (+/-N) H H N

MDI (>4 injections) H + UL H H UL

CSII (Insulin Pump)

Guideline for Insulin Adjustments

1. Adjust the insulin that accounts for the high or low reading.

2. Always compare an abnormal BS reading with the one previous.

3. If insulin dose is:• Less than 8U, adjust by 1U

• 8-20U, adjust by 2U

• > 20 U, adjust by 10% (increase), 20% (decrease)

4. Don’t forget to compensate for a successful adjustment

acB acL acD qhs Rx

22

(5R)

9 3.1

(O.J.)

15 acB N20 R10

acD R5

qhs N10

20 15 7 8 acB N20 R10

acD R5

qhs N10

22 17(RN calls)

acB N20 R10

Surgeon: ?Internal Medicine: ?Endocrinologist: ?

acB acL acD qhs Rx

22

(5R)

9 3.1

(O.J.)

15 acB N20 R10

acD R5

qhs N10

20 15 7 8 acB N20 R10

acD R5

qhs N10

22 17(RN calls)

acB N20 R10

Surgeon: Give 5 U Regular SC now

Internist: Increase qhs N to 12 tonight and acB R to 12 tomorrow

Endocrine: Increase qhs N to 12 start tonightDecrease acB N15 R7 starting tomorrow AMCheck 3AM BS tonight

Guideline for Insulin Adjustments

1. Adjust the insulin that accounts for the high or low reading.

2. Always compare an abnormal BS reading with the one previous.

3. If insulin dose is:• Less than 8U, adjust by 1U

• 8-20U, adjust by 2U

• > 20 U, adjust by 10% (increase), 20% (decrease)

4. Don’t forget to compensate for a successful adjustment

SC Insulin Supplemental Scale

CBG Action

< 4.0 Call MD

4.1-11.0 nil

11.1-15.0 Humalog 7U SC (0.1U/kg)

15.1-19.9 Humalog 10U SC (0.15 U/kg)

> 20.0 Call MD

DM Inpatient Management

1. Eating

2. NPO: temporary (for a test)

3. NPO: prolonged

NPO for a test: T2DM on Diet Rx

• Schedule test for the AM

• Hold OHAs on AM of test

• CBG @ 7AM:

< 3.0 Consider postpone test

3.1-4.0 IV D5W gtt @ 75-100 cc/h

4.1-11.0 Proceed with test, no Rx necessary

> 11.1 IV insulin gtt

IV D5W gtt @ 75-100 cc/h

> 20.0 Check urine ketones, consider postpone test

NPO for a test: T1/T2DM on Insulin

• Schedule the test for the AM

• Hold AM Insulin on day of test

• CBG @ 7AM:

< 3.0 Consider postpone test

3.1-11.0 Give ½ of total AM insulin dose as NPH SC

IV D5W gtt @ 75-100 cc/h

> 11.1 IV insulin gtt

IV D5W gtt @ 75-100 cc/h

> 20.0 Check urine ketones, consider postpone test

DM Inpatient Management

1. Eating

2. NPO: temporary (for a test)

3. NPO: prolonged• Patient put on D5W if not on feeds or TPN

• IV insulin gtt

• SC NPH or UL q12h (+/- supplemental scale)

Insulin IV gtt

• Add 50 U of Human regular insulin (Humulin R or Novolin Toronto) to 500cc D5W (1U/10cc).

• Flush & discard first 50cc.• Infuse insulin solution by IVAC (intravenous

infusion pump), piggybacked into D5W running at 100cc/h.

• Start insulin @ 0.9 U/h (9cc/h) or start at a rate dependent on patient’s insulin dose: IV insulin gtt rate = ( ½ TDD ) / 24

Insulin IV gtt

CPG q1h x 2, then q2h (if BS stable x 2-3 readings consider q4h):

Adjust Insulin IV infusion rate as per scale below:

<4.0 Call MD

4.1-5.0 0.7 U/h ( 7cc/h)

5.1-6.0 0.9 U/h ( 9cc/h)

6.1-7.0 1.2 U/h (12cc/h)

7.1-9.0 1.5 U/h (15cc/h)

9.1-11.0 2.0 U/h (20cc/h)

11.1-13.0 2.5 U/h (25cc/h)

13.1-15.0 3.0 U/h (30cc/h)

15.1-17.0 3.5 U/h (35cc/h)

17.1-20.0 4.0 U/h (40cc/h)

>20.1 Call MD

Evidence to support Inpatient BS control?

DIGAMI• AMI, prior dx DM or BS > 11 mM• IV insulin gtt started @ 5 U/h• Titrated to keep BS 7-10.9 mM• Insulin IV > 24h MDI > 3 months• No in-hospital mortality benefit.• Rx Increased hospitalization by 1.8d• 0.5% reduction HbA1c @ 3 months• @ 1 year % on Insulin: 72% Rx Group 49% Cntrl Group• 1 year mort: ARR 7.5% NNT 13• 3.4 y mort: ARR 11% NNT 9

Evidence to support Inpatient BS control?

Leuven, Belgium Study• ICU patients (63% CV Sx)• If BS > 6.1 mM: Rx with IV insulin gtt & TPN +/- tube feeds• Start IV insulin @ 2-4 U/h, titrated to BS 4.4-6.1 mM• Ave insulin dose: Rx group 3.0 U/h Cntrl group 1.4 U/h• Once out of ICU relaxed treatment goal to < 11.1 mM• Mortality in ICU: ARR 3.4% NNT 29• Mortality in-hospital: ARR 3.7% NNT 27• Greatest reduction in mortality was sepsis-related.• Insulin Rx reduced: bacteremia, ARF needing HD, need for PRBC,

critical illness polyneuropathy, duration of ventilation and length of stay in ICU

• To what extent were benefits nutrition related as opposed to insulin related?