Presentation on theme: "Management of Hyperglycemia and Diabetes in the Hospital: Case Studies"— Presentation transcript:
1 Management of Hyperglycemia and Diabetes in the Hospital: Case Studies Bruce W. Bode, MD, FACEAtlanta Diabetes Associates Atlanta, Georgia
2 Hyperglycemia in Hospitalized Patients Hyperglycemia occurred in 38% of hospitalized patients26% had known history of diabetes12% had no history of diabetesNewly discovered hyperglycemia was associated with:Longer hospital staysHigher admission rates to intensive care unitsLess chance to be discharged to home (required more transitional or nursing home care)Hyperglycemia in Patients With Undiagnosed DiabetesNew hyperglycemia was defined as an admission or in-hospital fasting glucose level of 126 mg/dL (7 mmol/L) or more or a random blood glucose level of 200 mg/dL (11.1 mmol/L) or more on 2 or more determinations. Hyperglycemia was present in 38% of patients admitted to the hospital, of whom 26% had a known history of diabetes, and 12% had no history of diabetes before admission.Newly discovered hyperglycemia was associated with a higher in-hospital mortality rate (16%) compared with patients with a history of diabetes (3%) and patients with normoglycemia (1.7%; both P < 0.01).In addition, new hyperglycemic patients had longer hospital stays and a higher admission rate to an intensive care unit, and were less likely to be discharged to home, frequently requiring transfer to a transitional care unit or nursing home facility.The results indicate that in-hospital hyperglycemia is a common finding and represents an important marker of poor clinical outcome and mortality in patients with and without a history of diabetes. Patients with newly diagnosed hyperglycemia had a significantly higher mortality rate and a lower functional outcome than patients with a known history of diabetes or normoglycemia.1. Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978–982.
3 Hyperglycemia Is an Independent Marker of Inpatient Mortality in Patients With Undiagnosed Diabetes In-hospital Mortality Rate (%)Hyperglycemia Is an Independent Marker of Inpatient Mortality in PatientsWith Undiagnosed DiabetesNew hyperglycemia was defined as an admission or in-hospital fasting glucose level of 126 mg/dL (7 mmol/L) or more or a random blood glucose level of 200 mg/dL (11.1 mmol/L) or more on 2 or more determinations. Hyperglycemia was present in 38% of patients admitted to the hospital, of whom 26% had a known history of diabetes, and 12% had no history of diabetes before admission.Newly discovered hyperglycemia was associated with a higher in-hospital mortality rate (16%) compared with patients with a history of diabetes (3%) and patients with normoglycemia (1.7%; both P < 0.01).In addition, new hyperglycemic patients had longer hospital stays and a higher admission rate to an intensive care unit, and were less likely to be discharged to home, frequently requiring transfer to a transitional care unit or nursing home facility.The results indicate that in-hospital hyperglycemia is a common finding and represents an important marker of poor clinical outcome and mortality in patients with and without a history of diabetes. Patients with newly diagnosed hyperglycemia had a significantly higher mortality rate and a lower functional outcome than patients with a known history of diabetes or normoglycemia.1. Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:978–982.Patients With NormoglycemiaPatients With History of DiabetesNewly Discovered HyperglycemiaAdapted from Umpierrez GE, et al. J Clin Endocrinol Metab. 2002;87:978–982.
4 Prevalence of Hyperglycemia in 181 Cardiac Patients Without Known Diabetes Percentage of Population (n = 1181)66% of AMI patients have IGT or previously undiagnosed T2DM on75 g OGTT(35% IGT; 31% DM)Norhammar data demonstrates that 2/3rds of patients admitted to the hospital for an AMI are either hyperglycemic or have undiagnosed DM. Importantly, this does not appear to be stress hyperglycemia in most cases since there is very little change in the pravalence of these disorders when test are repeated 3 months after dischargeAbstractBACKGROUND: Glycometabolic state at hospital admission is an important risk marker for long-term mortality in patients with acute myocardial infarction, whether or not they have known diabetes mellitus. Our aim was to ascertain the prevalence of impaired glucose metabolism in patients without diagnosed diabetes but with myocardial infarction, and to assess whether such abnormalities can be identified in the early course of a myocardial infarction. METHODS: We did a prospective study, in which we enrolled 181 consecutive patients admitted to the coronary care units of two hospitals in Sweden with acute myocardial infarction, no diagnosis of diabetes, and a blood glucose concentration of less than 11.1 mmol/L. We recorded glucose concentrations during the hospital stay, and did standardised oral glucose tolerance tests with 75 g of glucose at discharge and again 3 months later. FINDINGS: The mean age of our cohort was 63.5 years (SD 9) and the mean blood glucose concentration at admission was 6.5 mmol/L (1.4). The mean 2-h postload blood glucose concentration was 9.2 mmol/L (2.9) at hospital discharge, and 9.0 mmol/L (3.0) 3 months later. 58 of 164 (35%, 95% CI 28-43) and 58 of 144 (40%, 32-48) individuals had impaired glucose tolerance at discharge and after 3 months, respectively, and 51 of 164 (31%, 24-38) and 36 of 144 (25%, 18-32) had previously undiagnosed diabetes mellitus. Independent predictors of abnormal glucose tolerance at 3 months were concentrations of HbA(1c) at admission (p=0.024) and fasting blood glucose concentrations on day 4 (p=0.044). INTERPRETATION: Previously undiagnosed diabetes and impaired glucose tolerance are common in patients with an acute myocardial infarction. These abnormalities can be detected early in the postinfarction period. Our results suggest that fasting and postchallenge hyperglycaemia in the early phase of an acute myocardial infarction could be used as early markers of high-risk individuals.Norhammar A. Lancet. 2002;359:
5 Hospital Costs Account for Majority of Total Costs of Diabetes Per Capita Healthcare Expenditures (2002)Hospital Costs Account for Majority of Total Costs of DiabetesThis chart provides a breakdown of the sources of expenditures related to the care of patients with diabetes. Inpatient days (43.9%), nursing home care (15.1%), and office visits (10.9%) constituted the major expenditure groups by service settings.Hogan P, Dall T, Nikolov P. Economic costs of diabetes in the US in Diabetes Care ;26:917–932.DiabetesWithout diabetesHogan P, et al. Diabetes Care. 2003;26:917–932.
6 Case 1: Patient With an Acute MI 53-year-old man with DM 2 on SU, metformin, and glitazone presents with an acute MIBG random is 220 mg/dLWhat do you recommend for glucose control?Sliding-scale rapid analog?Basal/bolus insulin therapy?IV insulin drip?
7 Case 1: Patient With an Acute MI What is your glycemic goal?80 to 110 mg/dL80 to 140 mg/dL80 to 180 mg/dL
8 Glycemic Threshold in Acute MI and Intervention (PTCA) DIGAMI supports BG <180 mg/dLMinimal other data:PTCA reflow better with BG 159 than 209 mg/dLMalmberg K. BMJ. 1997;314:Iwakura K, et al. J Am Coll Cardiol. 2003;41:1-7.
9 DIGAMI Study: Diabetes, Insulin Glucose Infusion in Acute Myocardial Infarction (1997) Acute MI with BG >200 mg/dLControl vs Intensive Insulin TreatmentIntensive Insulin TreatmentIV insulin for >24 hours followed by4 insulin injections/day for >3 monthsMalmberg K, et al. BMJ. 1997;314:
10 Cardiovascular Risk: Mortality After MI Reduced by Insulin Therapy in the DIGAMI Study Standard treatmentIV insulin 48 hours, then 4 injections dailyAll SubjectsLow-risk and Not Previously on Insulin.7.7(N=620)(N=272).6.6Risk reduction (28%)Risk reduction (51%).5P=0.011.5P=0.0004.4.4.3.3Slide 6-11BARRIERS TO INSULIN THERAPYCardiovascular RiskMortality After MI Reduced by Insulin Therapy in the DIGAMI StudyPatients at high risk of cardiovascular disease are often thought to be inappropriate candidates for treatment with insulin because of the belief that hypoglycemia, hyperinsulinemia, or other metabolic effects of insulin might provoke or worsen the outcome of major cardiovascular events. This figure shows data from the Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial. This Swedish trial studied the short- term and long-term effects of intensive insulin treatment of patients with diabetes who were enrolled in the trial at the time of a myocardial infarction. The subjects were immediately randomized to continued management according to the judgment of their physicians, or to intravenous infusion of insulin and glucose for 48 hours followed by a four-injection regimen subsequently for as long as 5 years. Other aspects of management of the infarction included treatment with b-blockers, angiotensin-converting enzyme inhibitors, fibrinolytic agents, and aspirin in high proportions of both groups. The rationale underlying the study was the old observation that, in animal experiments and studies of small numbers of humans, infarct size and outcome are improved by insulin- glucose infusion, in part because of suppression of otherwise elevated free fatty acid levels in plasma. The figure shows the cumulative total mortality rates in the whole population of 620 subjects randomized to the two treatments, as well as the rates for a predefined subgroup of subjects who were judged likely to survive the initial hospitalization and were not previously using insulin. The whole population showed an 11% actual and a 28% relative risk reduction with intensive insulin treatment after 5 years, and the subgroup showed a 15% actual and a 51% relative risk reduction. Most of the benefit was apparent in the first month of treatment and presumably was partly due to immediate intravenous infusion of insulin; however, the survival curves tended to separate further over time, suggesting an ongoing benefit from intensive treatment. This study suggests that insulin is an entirely appropriate treatment for patients with type 2 diabetes and high cardiovascular risk, especially at the time of myocardial infarction.Malmberg K, Rydén L, Hamsten A, Herlitz J, Waldenström, Wedel H, and the DIGAMI study group. Effects of insulin treatment on cause-specific one-year mortality and morbidity in diabetic patients with acute myocardial infarction. Eur Heart J. 1996;17: ; Nattrass M. Managing diabetes after myocardial infarction: time for a more aggressive approach. BMJ. 1997;314:1497; Malmberg K, and the DIGAMI study group. Prospective randomized study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ ;314:.18.104.22.16834512345Years of Follow-upYears of Follow-upMalmberg K, et al. BMJ. 1997;314:
11 Malmberg K et al DIGAMI 2. European Heart J 2005; 26 (650-61) DIGAMI 2 Study48 hospitals in 6 countries3 groups:Group 1: GIK for 24 hours followed by home insulin Rx (N = 474)Group 2: GIK infusion followed by standard glucose control (N = 473)Group 3: Routine metabolic management based on local practice (N = 306)Patients and MethodsMalmberg K et al DIGAMI 2. European Heart J 2005; 26 (650-61)
12 Conclusion Overall mortality was lower than expected Overall mortality similar to nondiabetic populationThe 3 glucose management strategies did not result in differences of metabolic controlTarget glucose levels not achieved in the intensively insulin treatment groupConclusion
13 Overview of GIK Therapy for Acute MI: A 30year Perspective Odds Ratio and ClsYearStudyMortality Rate (%)GIK BetterPlacebo BetterGIKControlO-EVarianceSatler0.01987Rogers6.512.3-1.92.41983Stanley7.316.4-2.52.81978Heng8.30.00.60.21977Hjermann10.620.0-4.86.8P = 0.071971Pentecost15.016.0-0.56.51968MRC21.423.6-5.141.51968Overview of GIK Therapy for Acute MI: A 30-year PerspectiveGlucose–insulin–potassium (GIK) therapy has been advocated for the treatment of acute myocardial infarction since the mid 1960s. However, the results from the clinical trials have been inconclusive, largely because of the small number of patients recruited and discrepancies between protocols used in these studies.A systematic MEDLINE search for all the randomized placebo-controlled studies of GIK therapy in acute myocardial infarction was conducted (1966–1996), and a meta-analysis of the mortality data was performed. Fifteen trials were identified; 5 were excluded because of poor randomization, and one was excluded because recruitment was limited to patients with diabetes. The 9 remaining trials with a total of 1,932 patients were included in the analysis.Hospital mortality was reduced from 21% (205 of 972 patients) in the placebo group to 16.1% (154 of 956) in the GIK group (P = 0.004; odds ratio, 0.72; 95% confidence interval [CI], 0.57 to 0.90). The proportional mortality reduction was 28% (CI, 10% to 43%). The number of lives saved per 1,000 patients treated was 49 (95% CI, 14 to 83). The findings indicate that GIK therapy may have an important role in reducing the in-hospital mortality after acute myocardial infarction.1. Fath-Ordoubadi F, Beatt KJ. Glucose-insulin-potassium therapy for treatment of acute myocardial infarction: an overview of randomized placebo-controlled trials. Circulation. 1997;96:1152–1156.Pilcher13.929.3-2.63.41967Mittra11.828.3-7.06.8P = 0.0071965All Patients16.121.0-24.070.4P = 0.0041GIK = glucose–insulin–potassium; MI = myocardial infarction; CI = confidence interval.Fath-Ordoubadi F, Beatt KJ. Circulation. 1997;96:1152–1156. Reprinted with permission (http://lww.com)
14 CREATE-ECLAWorldwide study with over 20,000 subjects with ST-elevation MI (STEMI)GIK infusion vs ControlOutcome: 30 day CV eventsMehta, S et al: JAMA 293: , 2005
16 Case 1: Patient With an Acute MI For acute MI with elevated glucose, you can either give:1. IV insulin variable drip or2. GIK in type 2’s who are easily controlled or3. ? Intensive SC delivery
17 Case 1: Patient With an Acute MI Now Plans to Go for CABG What is your glycemic goal?80 to 110 mg/dL80 to 140 mg/dL80 to 180 mg/dL
18 Mortality of DM Patients Undergoing CABG Furnary AP, et al. J Thorac Cardiovasc Surg. 2003;123:
19 Glycemic Threshold in CABG Portland data suggest BG:<150 mg/dL for mortality<175 mg/dL for infection<125 mg/dL for atrial fibrillationFurnary AP, et al. J Thorac Cardiovasc Surg. 2003;123:
20 Costs of Hyperglycemia in the Hospital For each 50 mg/dL rise in glucose:Length of Stay increases by 0.76 daysHospital Charges increase by $2824Hospital Costs increase by $1769Furnary et al Am Thorac Surg 2003;75:1392-9
21 Surgical ICU Mortality Effect of Average BG P=0.0009BG>150110<BG<150P=0.026BG<110Van den Berghe G, et al. Crit Care Med. 2003;31:
22 Intensive Insulin Therapy in Critically Ill Patients—Morbidity and Mortality Benefits Percent ReductionMortalitySepsisDialysisPolyneuropathyBlood Transfusion34%46%41%44%50%Intensive Insulin Therapy in Critically Ill Patients—Morbidity and MortalityBenefitsIntensive insulin therapy also reduced overall in-hospital mortality by 34 percent, bloodstream infections by 46 percent, acute renal failure requiring dialysis or hemofiltration by 41 percent, the median number of red-cell transfusions by 50 percent, and critical-illness polyneuropathy by 44 percent, and patients receiving intensive therapy were less likely to require prolonged mechanical ventilation and intensive care.The benefit of intensive insulin therapy was attributable to its effect on mortality among patients who remained in the intensive care unit for more than five days (20.2 percent with conventional treatment, as compared with 10.6 percent with intensive insulin therapy, P = 0.005).The greatest reduction in mortality involved deaths due to multiple-organ failure with a proven septic focusvan den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359–1367.van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.
23 Target Blood Glucose 80–110 mg/dL ICU patients 80–140 mg/dL in other surgical and medical patients70–100 mg/dL in pregnancy
24 Threshold Blood Glucose for Starting IV Insulin Infusion Perioperative care > 140 mg/dLSurgical ICU care > mg/dL*Nonsurgical illness > mg/dL†Pregnancy > 100 mg/dL*Van den Berghe’s study supports 110 mg/dL; Finney’s study supports 145 mg/dL.†If drip indication is failure of SQ therapy, use 180 mg/dL; if indication is specific condition (DM 1/ NPO, MI, etc ), use 140 mg/dL.
25 The Ideal IV Insulin Protocol Easily ordered (signature only)Effective (gets to goal quickly)Safe (minimal risk of hypoglycemia)Easily implementedAble to be used hospital-wide
26 Essentials of a Good IV Insulin Algorithm Easily implemented by nursing staffDilution of insulin per hospital policy (0.5 or 1U/cc)Able to seek BG range via:Hourly BG monitoringAdjusts to the insulin sensitivity of the patientContains transition orders to SC insulin when stable
27 Practical Closed Loop Insulin Delivery A System for the Maintenance of Overnight Euglycemia and the Calculation of Basal Insulin Requirements in Insulin-Dependent Diabetics1/slope = Multiplier = 0.02654Insulin Rate (U/hr)321100200300400Glucose (mg/dL)White NH, et al. Ann Intern Med. 1982;97:
28 Continuous Variable Rate IV Insulin Drip Starting rate units/hour = (BG – 60) x 0.02 where BG is current blood glucose and is the multiplierCheck glucose every hour and adjust dripAdjust multiplier to keep in desired glucose target range (80 to 110 mg/dL or to 140 mg/dL)
29 Continuous Variable Rate IV Insulin Drip Adjust multiplier (initially 0.02) to obtain glucose in target range 80 to 110 mg/dLIf BG >110 mg/dL and not decreased by 15%, increase by 0.01If BG <80 mg/dL, decrease by 0.01If BG 80 to 110 mg/dL, no change in multiplierIf BG is <80 mg/dL, give D50 cc = (100 – BG) x 0.4Give continuous rate of glucose in IVFs (do not feed meals on drip without bolus SC)Once eating, continue drip till 2 hours post SQ insulin
30 Average and Standard Deviation of of All Runs GlucommanderAverage and Standard Deviation of of All Runs1985 to 1998; runs, 120,618 BG’sDavidson et al, Diabetes Care 28(10): , 2005
31 Typical Glucommander Run GlucoseGlucoseHiLowMultiplierMultiplierInsulinInsulinHoursDavidson et al, Diabetes Care 28(10): , 2005
32 Case 1: Patient With an Acute MI Now Post-CABG and Ready to Eat Currently on IV insulin at ~2 units IV/hrWhat do you now do?Sliding scale rapid acting insulin only?Basal/bolus insulin therapy?Premixed insulin therapy?Basal insulin?
34 Plasma insulin (μU/mL) Basal/Bolus Treatment Program With Rapid-acting and Long-acting Analogs75BreakfastLunchDinnerAspart,LisproorGlulisineAspart,Lispro,orGlulisineAspart,Lispro,OrGlulisine50Plasma insulin (μU/mL)GlargineorDetemir254:008:0012:0016:0020:0024:004:008:00Time
35 Converting to SC Insulin If >0.5 U/hr IV insulin required with normal BG, start long-acting insulin (glargine)Must start SC insulin at least 2 hours before stopping IV insulinSome centers start long-acting insulin on initiation of IV insulin or the night before stopping the drip
36 Total Intravenous vs Subcutaneous 24-Hour Insulin Requirements (units) IV Insulin Infusion Under Basal Conditions Correlates Well With Subsequent SC Insulin RequirementTotal Intravenous vs Subcutaneous 24-Hour Insulin Requirements (units)Subcutaneous (units)IntravenousUnits IVHawkins JB Jr, et al. Endocr Pract. 1995;1:
38 Converting to SC Insulin Establish 24-hour insulin requirementExtrapolate from average over last 4-8 hours, if stableGive half the amount as basalGive PC boluses based on CHO intakeStart at CHO/ins 1 CHO = 1.5 units rapid-acting insulinMonitor AC TID, HS, and 3 AMCorrection bolus for all BG >140 mg/dL(Bg-100)/(1700/daily insulin requirement)
39 Case 2: A Person on steroids with new hyperglycemia (BG ~225 mg/dl) What is the best insulin treatment for this patient on steroids? (BG 150 to 300 mg/dL)Sliding scale only with rapid-acting insulin?IV insulin variable rate infusion?NPH or 70/30 twice a day?Basal Insulin once a day?Bolus insulin premeal?Basal Bolus insulin therapy?
40 Plasma insulin (μU/mL) Basal/Bolus Treatment Program With Rapid-acting and Long-acting Analogs75BreakfastLunchDinnerAspart,LisproorGlulisineAspart,Lispro,orGlulisineAspart,Lispro,OrGlulisine50Plasma insulin (μU/mL)GlargineorDetemir254:008:0012:0016:0020:0024:004:008:00Time
41 How to Initiate MDI Starting dose = 0.5 x wt in kg Basal dose (glargine) = 40% to 50% of starting dose given at bedtime or anytimeBolus dose (aspart/lispro) = 15% to 20% of starting dose at each mealCorrection bolus = (BG - 100)/correction factor, where CF=1700/total daily dose
42 How to Initiate MDI Starting dose = 0.5 x wt in kg Weight is 100 kg; 0.5 x 100 = 50 unitsBasal dose (glargine) = 50% of starting dose at HS; 0.5 x 50 = 25 units at HSTotal bolus dose (aspart / lispro) = % of starting dose ÷ 3; x 50 = 25 ÷ 3 = 8 units AC (TID)Correction bolus = (BG - 100)/ CF, where CF=1700/total daily dose; CF=30
43 Correction Bolus Formula Current BG - Ideal BGGlucose correction factorExample:Current BG: 250 mg/dLIdeal BG: 100 mg/dLGlucose correction factor: 30 mg/dL250 –= 5.0 units
45 Case 3: A Person With Diabetes on Tube Feedings What is the best insulin treatment for a DM patient on tube feedings? (BG 150 to 300 mg/dL)Sliding scale only with rapid-acting insulin?IV insulin variable rate infusion?NPH or 70/30 every 8 hours?Glargine every 12 hours?Regular insulin every 6 hours?
46 Case 3: A Person With Diabetes on Tube Feedings (cont’d) What is the best insulin treatment for a DM patient on tube feedings? (BG 150 to 300 mg/dL)If unstable, first give IV insulin and determine the requirement over 24 hours and then change to SC basal (glargine q12h) with supplemental rapid-acting every 4 to 6 hoursCan also use NPH q8h or regular q6h as the basal dose
47 Case 4: A Person With Diabetes on TPN What is the best insulin treatment for a DM patient on TPN? (BG 150 to 300 mg/dL)If unstable, first give IV insulin variable drip and determine the requirement over 24 hours and then add all the insulin to the TPN bagContinue to supplement every 4 to 6 hours with SC rapid-acting insulin using BG – 100 / CF where CF is equal to 3000 divided by weight in kg. On average, CF = 30 to 40
48 Case 5: DM 1 Patient Going for Outpatient Surgery What do you tell the patient to do?Hold insulinTake half their doseTake their basal only with supplement if needed (>140 mg/dL)Hold insulin and will start IV insulin
49 Case 6: DM 1 Patient in DKA (ph 7.0; BG 400 mg/dL: weight 80 kg) What amount of fluids do you give immediately?1 liter saline2 liters saline1 liter 0.45% saline2 liters 0.45% saline
50 Case 6: DM 1 Patient in DKA (ph 7.0; BG 400 mg/dL: weight 80 kg) Do you give NaCO3?When do you start potassium and how much?When do you start dextrose and how much?My preference is 2 liters saline followed by D50.45 saline with 40 meq KCL/liter at mL/hr. Monitor electrolytes q4-8h
52 Case 7: HypoglycemiaWhat is the preferred in hospital treatment of hypoglycemia?Juice with sugar added50% IV dextrose (1 amp or 50cc)50% IV dextrose (1/2 amp or 25cc)50% IV dextrose (based on glucose level)
53 Protocol for Insulin in Hospitalized Patient Treatment of hypoglycemiaAny BG <80 mg/dL: D50 IV = (100 - BG) x 0.4If eating, may use 15 gm of rapid CHO (prefer glucose tablets)Do not hold insulin when BG normal
54 Hospital Diabetes Plan What can we do for patients admitted to the hospital?Protocols for all diabetes/hyperglycemic patientsFinger stick BG AC QID on all admissionsCheck all steroid-treated patientsDiagnose diabetesFBG >126 mg/dLAny BG >200 mg/dL
55 Hospital Diabetes Plan (cont’d) What can we do for patients admitted to the hospital?Document diagnosis in chartHyperglycemia is diabetes until provenBring to all physicians’ attentionNote on problem list and face sheetCheck hemoglobin A1CHold metformin; Hold TZD with CHF, liver dysfunctionStart insulin in all hospitalized patients with BG >140 mg/dL
57 Hospital Diabetes Plan (cont’d) Protocol for insulin in hospitalized patientTreat any patient with BG >140 mg/dL with insulinTreat any BG >140 mg/dL with rapid-acting insulin (BG-100) / (3000 / wt [kg]) or 1700 / total daily insulinTreat any recurrent BG >180 mg/dL with IV insulin if failing SC therapy or >140 mg/dL if NPO, acute MI, perioperative, ICU, or >100 mg/dL if pregnantIf >0.5 U/h IV insulin required, start long-acting insulin
58 Hospital Diabetes Plan (cont’d) Protocol for insulin in hospitalized patientDaily total: Pre-admission or weight (kg) x 0.5 U50% as glargine (basal)50% as total rapid-acting insulin (bolus)Give in proportion to meal’s CHO eatenBG >140 mg/dL: (BG-100) / CFCF = 1700 / total daily insulin or 3000 / wt (kg)Do not use sliding scale as only diabetes management
59 Hospital Diabetes Plan (cont’d) What can we do for patients admitted to the hospital?Get diabetes education consultInstruct patient in monitoring and recordingSee that patient has meter on dischargeDecide on case-specific program for dischargeArrange early follow-up with PCP
60 QuestionsFor a copy or viewing of these slides, contact or hospital protocols, go to: