1. Strategies to Reduce Hypoglycemia Presented by: Hennie Garza, M.S., R.Ph., C.D.E, Director of Pharmacy Utilization and Outcomes Senior Care Centers http://www.seniorcarecentersltc.com/ September 18, 2012

2. Define Hypoglycemia Identify Risk Factors for Hypoglycemia Identify signs and symptoms of Hypoglycemia Discuss elements of a hypoglycemia management protocol Review insulin characteristics and discuss strategies to improve patient safety when administering insulin Discuss strategies to reduce hypoglycemia Goals & Objectives

3. A really good reference:  Journal Clinical Endocrinology & Metabolism  January 2012, 97(1):16-38  “MANAGEMENT OF HYPERGLYCEMIA IN HOSPITALIZED PATIENTS IN NON- CRITICAL CARE SETTING: AN ENDOCRINE SOCIETY CLINICAL PRACTICE GUIDELINE”

4. Definition  Hypoglycemia = Plasma glucose less than 70mg/dL  Severe Hypoglycemia = when an individual requires the assistance of another person and cannot be treated with oral carbohydrate due to confusion or unconsciousness.  Cognitive impairment can occur with plasma blood glucoses less than 50mg/dL

5. Risk factors for hypoglycemia  Older age  Greater illness severity (septic shock, mech. Ventilation, renal failure, malignancy, malnutrition  Diabetes  Use of oral glucose lowering agents & insulin  Cessation of nutrition for procedures  Adjustment in amount of nutritional support  Interruption of the routine for glucose monitoring  Failure to adjust therapy when glucose is trending down

6. Signs & symptoms  Perspiring or sweating excessively  Weakness, dizziness, faintness  Hunger or excessive eating  Nervousness, irritability, changes in personality  Blurred/impaired vision  Numbness in tongue and lips  Tachycardia or palpitations  Tremors  Headaches  Altered level of consciousness

7. Does your facility have a protocol?

8. Nurse Strategies for Treatment

9. Recommendations

10. New Beers List 2012

11. Hypoglycemia Case

12. Insulin Time-Action Profiles

13. Human 70/30 mix BID

14. Analog mix 70/30 or 75/25 BID

15. Basal-Bolus with Glargine and Rapid- Acting Analog AC

16. Hypoglycemia Case

17. COSTLY –Nursing time, Test strips, lancets, Insulin waste –Hypoglycemia risk We have better options Reactive instead of proactive Basal insulin can help reduce reliance on sliding scale and reduce hypoglycemia Move to “correctional” or “supplemental” dosing if needed Problems with Sliding Scale

18. Starting Basal Insulin

19. Supplemental Insulin

20. New types of insulin and similar drug names make order-entry problematic –Know your different types of insulin –Use “Tall Man” lettering: NovoLOG, NovoLIN –Do not use the abbreviation “u” for units –Spell out numbers i.e. “give two units” Similar drug packaging contributes to errors (case of missing Novolog but Novolog 70/30) Methods of storage can impact errors Insulin-common mistakes

21.  Communication of Insulin orders problematic –Dangerous Abbreviations will get “U” in trouble –Unclear orders on MAR –Sliding scale insulin orders BIGGEST culprit for errors and bad outcomes—HYPOGLYCEMIA –Multiple sliding scale orders for same resident (morning scale and bedtime scale) Insulin – common mistakes cont’d

22.  Insulin has few actual drug interactions, but hypoglycemia is biggest concern  All facilities should have a HYPOGLYCEMIC protocol to follow  A word about Glucagon  Majority of cases of hypoglycemia are result of sliding scale insulin use  Sliding scale is now on the Beers list! Insulin--hypoglycemia

23. Transitions of care  Care transitions can be challenging  Within the hospital  From acute to post-acute  Medication reconciliation is critical  As patients get better, their insulin needs change  Please work with your post-acute care providers closely

24. Summary  Strategies to reduce hypoglycemia –Identify patients at risk –Set targets for blood glucose –Move to basal insulin instead of solely using sliding scale insulin –Many elderly patients do well with just 1 or 2 basal injections daily –Bedtime sliding scale most problematic in elderly –Don’t forget to adjust based on patient progress

25. Questions/Discussion THANK YOU!!! Hennie Garza, M.S., R.Ph., C.D.E Email address: hgarza@seniorcarecentersltc.com