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!!