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Insulin Therapy in the Inpatient and Outpatient Setting Agustin Busta, MD Assistant Professor Albert Einstein College of Medicine.

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Presentation on theme: "Insulin Therapy in the Inpatient and Outpatient Setting Agustin Busta, MD Assistant Professor Albert Einstein College of Medicine."— Presentation transcript:

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2 Insulin Therapy in the Inpatient and Outpatient Setting Agustin Busta, MD Assistant Professor Albert Einstein College of Medicine

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4 OH Franco, et al. Arch Intern Med. 2007;167: Association of DM with total life expectancy and life expectancy with and without cardiovascular disease Women with diabetes had more than double the risk of developing cardiovascular disease and, 2.2 times higher risk of dying among those with CVD, compared with non- diabetic women,“ Diabetic men, compared with non-diabetic men, had more than double the risk of developing CVD and a 1.7 times higher risk of dying once CVD was present. Among those age 50 and older, diabetic men lived an average of 7.5 years less than men without diabetes, and diabetes reduced women's life expectancy by an average of 8.2 years. Life expectancy free of cardiovascular disease was reduced by 7.8 years in men and 8.4 years in women with diabetes.

5 Diabetic men and women 50y and older lived on average 7.5 & 8.2 years less than their nondiabetic equivalents OH Franco, et al. Arch Intern Med. 2007;167: Associations of Diabetes Mellitus with Total Life Expectancy and Life Expectancy with and without Cardiovascular Disease

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7 Khaw KT, et al Ann Intern Med. 2004; 141: Glycemia & Macrovascular Disease in Non-Diabetic Subjects

8 UKPDS Post-trial monitoring

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10 N Engl J Med 2008; 359 UKPDS 10 yr Follow-Up Study- insulin/sulfonylurea group Differences in A1C between intensive & standard glycemic control treatment groups were lost after one year Relative risk reductions at 10 yr in intensive insulin/sulfonylurea group: –9% for any diabetes end point (P=0.04) –24% microvascular disease (P=0.001) –15% myocardial infarction (P=0.01) –13% death from any cause (P=0.007)

11 UKPDS 10 yr Follow-Up Study- Metformin group Differences in A1C between intensive & standard glycemic control treatment groups were lost after one year Relative risk reductions at 10 yr in intensive metformin group: –21% for any diabetes end point (P=0.01) –33% myocardial infarction (P=0.005) –21% death from any cause (P=0.002) N Engl J Med 2008; 359

12 DCCT- EDIC Post ad-hoc analysis shows a decreased of macrovascular complications on patients who received intensive insulin therapy in the DCCT trial.

13 DCCT/EDIC N Engl J Med 2005: 353: Epidemiology of Diabetes Interventions and Complications Study (EDIC) Observational study DCCT participants (type 1 diabetes) Looked at risk factors for long-term complications

14 DCCT-EDIC: Long-term Risk of Macrovascular Complications Years Since Entry* *Diabetes Control and Complications Trial (DCCT) ended and Epidemiology of Diabetes Interventions and Complications (EDIC) began in year 10 (1993). Mean follow-up: 17 years. DCCT/EDIC Research Group. JAMA. 2002;287: Copyright © 2002 American Medical Association. All rights reserved. | Nathan DM, et al. N Engl J Med. 2005;353: Copyright © 2005 Massachusetts Medical Society. All rights reserved. DCCT End of Randomized Treatment EDIC Year 1 EDIC Year 7 12% 10% 8% 6% Hemoglobin A 1C P < P = 0.61 Conventional Intensive Conventional Cumulative Incidence Any Cardiovascular Outcome % risk reduction P = 0.02 Intensive

15 Key points of recent findings: Intensive glucose control in newly diagnosed type 1 or type 2 diabetes has benefits during intensive therapy AND a legacy effect for later micro- and macrovascular benefits Optimal glucose management should start as early as possible & continue as long as possible While the A1C goal for the general population is <7%, treatment must be individualized. N Engl J Med 2008; 359

16 Regression of atherosclerosis in patients with type 2 diabetes drug naive Esposito K, On a study using OAD on 175 drug naïve patients with type 2 diabetes, resulted in a regression of carotid-intima media thickness after controlling postprandial glucose

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18 Type 2 diabetes Years from diagnosis Pre-diabetes Onset Diagnosis Insulin secretion Insulin resistance Postprandial glucose Macrovascular complications Adapted from Ramlo-Halsted BA, Edelman SV. Prim Care. 1999;26: ; Nathan DM. NEJM. 2002;347: Fasting glucose Microvascular complications Natural History of Type 2 Diabetes

19 UKPDS-DM Pancreas Is a continue state of beta cell function impairment that will lead to an state of complete pancreas exhaustation and lead to pancreatic insulin secretion unsuffiency. Pancreas exhaustion rapidly occurred at rate of 2- 4 % year, and in 10 years majority of patient needs insulin Majority of T2dm will fail to maintain targets withA1c with OAD because pancreas run out of insulin

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21 Glycemic Control Declines Over Time With Traditional Monotherapy Adequately controlled and treated with sulfonylureas † Patients with A1C <7% (%) Adequately controlled and treated with metformin * Turner RC, et al. JAMA. 1999;281: *Overweight drug-naïve patients. † Normal weight and overweight drug-naïve patients Patients with A1C <7% (%)

22 NHANES III( ) vs NHANES( )

23 Adapted from Koro et al, Diabetes Care. 2004; 27(1):17-20 Between NHANES III and NHANES , percentage of patients treated with drug therapy increased 7.2% Percentage of patients treated with insulin remained constant at ~27% NHANES III NHANES Orals Diet/ExInsulin OnlyOrals + Ins Constant: 27% of patients treated with insulin Insulin Use Remains Constant NHANES III( ) vs NHANES( )

24 Estimated Cost of Diabetes in U.S. Total: $174 billion Direct Medical Cost: $116 billion Indirect Cost: $58 billion NIDDK, National Diabetes Statistics

25 ACCORD: N Engl J Med 2008; 358(24): ADVANCE: N Engl J Med 2008; 358 (24): VADT: J Diabetes Complications 2003; 17 (6): Recent Clinical Trial Findings: Intensive glucose control in type 2 diabetes: lowers risk of new or worsening microvascular complications (ADVANCE) was associated with increased mortality in patients with longstanding DM and known CVD (ACCORD) increases risk of severe hypoglycemia (ADVANCE, ACCORD and VADT)

26 Product (Manufacturer)Form Rapid Acting (Onset min, duration hrs 3-4) Insulin Analog Aspart - Novolog (Novo Nordisk) Lispro - Humalog (Lilly) Glulisine – Apidra (Aventis) Analog** Short Acting (Onset hr, duration hrs 5-7)* Human Insulin Novolin R (Rugular) (Novo Nordisk) Humulin R (Regular) (Lilly) Human** Purified Insulin Regular Iletin II (Lilly)Pork Intermediate Acting (Onset 1-4 hrs, duration hrs 18-24)* Human Insulin Novolin N (NPH) (Lilly) Humulin N (NPH) (Lilly) Humulin L (Lente) (Lilly) Human** Purified Insulin NPH Iletin III (Lilly)Pork Long Acting (Onset 4-6 hrs, duration hrs 24-34)* Human Insulin Humulin Ultralente (Lilly)Human** Basal Peakless Insulin Glargine-Lantus (Aventis) Detemir – Levemir (Novo Nordisk) Analog** Mixed Insulins 70/30 Insulin Novolin 70/30 (Novo Nordisk) Humulin 70/30 (Lilly) Humulin 50/50 (Lilly) Humalog 50/50 Human** Analog** Product (Manufacturer)Form Analog Mix Humalog 75/25 Mix Novolog Mix 70/30 (combination of fast and intermediate acting insulin with action similar to that of Humalog 75/25 mix) Analog** Insulin for Special Use Buffered Insulin (for pumps) Humulin BR Refills for Novolin Pen Novolin R PenFill Novolin N PenFill Novolin 70/30 PenFill Novolog Mix 70/30 PenFill Prefilled Pens Novolin R Novolin N Novolin 70/30 Novolog Novolog Mix 70/30 Humalog Humalog Mix 75/25 Humalog Mix 50/50 Humulin N Apidra Human** Analog** Human** Analog** Human** Analog** * Onset and duration are rough estimates. They can vary greatly within the range listed and from person to person ** Human insulin is made by recombinant DNA technology AVAILABLE INSULIN PREPARATIONS

27 McMahon G and Dluhy R. N Engl J Med 2007;357: Schematic Time-Activity Curves for Selected Insulin Formulations

28 Physiologic Insulin Secretion: Basal/Bolus Concept Breakfast Lunch Supper Insulin (µU/mL) Glucose (mg/dL) Basal Glucose A.M.P.M. Time of Day Basal Insulin Nutritional Glucose Nutritional (Prandial) Insulin Suppresses Glucose Production Between Meals & Overnight The 50/50 Rule

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31 Treat to Target Study Insulin Glargine vs NPH Insulin Added to Oral Therapy 24-wk, multicenter, randomized, parallel, open- label trial. Compared insulin glargine vs NPH given at HS in type 2 diabetics patients inadequately controlled on 1 or 2 oral agents Insulin dosage adjusted weekly by forced-titration schedule seeking FPG  100 mg/dL Measure achievement of A1C  7% without clinically significant nocturnal hypoglycemia 756 insulin-naïve patients,on Glargine =367,on NPH = 389, mean age = 55yr, duration of diabetes = 8-9 yr, baseline A1c= 8.6%, BMI = 32 kg/m 2. Study Design Riddle M, Rosenstock J, HOE901/4002 Study Group. Diabetes. 2002;51(suppl 2):A113. Abstract 457-P

32 Insulin Glargine vs NPH Insulin Added to Oral Therapy Riddle M, Rosenstock J, HOE901/4002 Study Group. Diabetes. 2002;51(suppl 2):A113. Abstract 457-P 2>100 but <120 mg/dL Treat to target FPG  100 mg/dL 4  120 but <140 mg/dL 6  140 but <180 mg/dL 8  180 mg/dL  in insulin dose (IU/day) Self-monitored FPG (mg/dL)* Start with 10 IU/day bedtime basal insulin dose and adjust weekly *2 consecutive days with no episodes of severe hypoglycemia or PG ≤72 mg/dL Small  (2–4 IU/day/adjustment) in dose allowed when self-monitored PG <56 mg/dL or severe hypoglycemic episode occurs Methods Forced-Titration Schedule

33 *P<0.01; † P<0.002 Riddle M, Rosenstock J, HOE901/4002 Study Group. Diabetes. 2002;51(suppl 2):A113. Abstract 457-P Results Insulin Glargine vs NPH Insulin Added to Oral Therapy NPH Insulin Glargine ITT Analysis FPG, mg/dL mM A1C, % Nocturnal hypoglycemia Patients,* % Final A1C  7% (% patients) 57 Severe hypoglycemia Patients, %

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35 INITIATE Trial 28-weeks, parallel group randomized study comparing the safety and efficacy of biphasic insulin Aspart mix 70/30 bid vs Glargine qd. Primary end point –A1C reduction Secondary end points –Proportion of patients achieving A1C <7.0% and ≤6.5% –PPG control –Safety, including number of hypoglycemic events (major, minor, nocturnal) and adverse events

36 Addition of glargine or biphasic aspart mix 70/30 to oral therapy 233 People with Type 2 Diabetes on 1 or 2 Oral Agents  HbA 1c P<0.01 Events/Patient-year (PG  3.1 mmol/l) P<0.05 Biphasic aspart 70/30.( 66% A1c 7) Glargine. (40% A1C 7 ) Raskin P et al. Diabetes Care. 2005;28: Glycaemic ControlHypoglycaemia Baseline HbA 1c 9.7% Final HbA 1c 6.9% 9.8% 7.4%

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38 Addition of Biphasic, Prandial, or Basal Insulin to Oral Therapy in Type 2 Diabetes Study Overview In an open-label trial, patients with type 2 diabetes with a suboptimal glycated hemoglobin level while receiving a maximally tolerated dose of metformin and sulfonylurea were randomly assigned to receive biphasic, prandial, or basal insulin The addition of a single analogue-insulin formulation resulted in a glycated hemoglobin level of 6.5% or less in a minority of patients at 1 year. Regimens of biphasic or prandial insulin had greater efficacy than did the basal regimen but were associated with greater risks of hypoglycemia and weight gain

39 Holman RR et al. N Engl J Med 2007;357: Primary and Secondary Outcomes at 1 Year

40 Holman RR et al. N Engl J Med 2007;357: Mean (±SE) Percentage Change from Baseline to 1 Year in Glycated Hemoglobin, Fasting Plasma Glucose, Postprandial Glucose, and Body Weight (Panel A) and Mean (+SD) Hypoglycemic-Event Rate (Panel B)

41 Roden M. N Engl J Med 2009;361: Glycated Hemoglobin Level, Hypoglycemia, and Increase in Body Weight at 1 Year and 3 Years

42 Evidence-based guideline-derived treatment algorithm Diagnosis Lifestyle intervention then metformin HbA 1c  6.5 % Add sulfonylurea Meal-time + basal insulin + metformin ± thiazolidinedione Add insulin Start insulin Add thiazolidinedione* HbA 1c  6.5 % HbA 1c  7.5 %HbA 1c  7.0 % HbA 1c  6.5 % IDF. Global Guideline for Type 2 Diabetes *Alternatively, start thiazolidinedione before sulfonylurea, and sulfonylurea later. intensify insulin

43 How should I start insulin therapy for my patients with Type 2 diabetes? According to the IDF Global Guideline for Type 2 Diabetes: –Insulin is the most effective way of reducing hyperglycaemia –Insulin can be started as a basal insulin alone or with premix insulin –Start insulin when glucose control on maximum tablets >7.5 % (HbA1c) –Begin at low dose but titrate up rapidly in first month IDF. Global Guideline for Type 2 Diabetes. 2005

44 ADA/EASD Treatment Algorithm for Type 2 Diabetes DIABETES CARE, VOLUME 31, NUMBER 12, DECEMBER 2008

45 Initiation and adjustment of insulin regimens Start with bedtime intermediate-acting insulin or bedtime(HS) or morning long-acting insulin (can initiate with 10 U or 0.2 units per kg) Check FBG usually daily and increase dose, typically by 2U every 3 days until fasting levels are in target range( mg/dL). Can increase dose in larger increments,eg, by 4 U every 3 days, if FBS >180 mg/dL If hypoglycemia occurs, or FBS 60U A1c ≥ 7% after 2-3 months ? If FBS in target range(70-130mg/dL),check bg before lunch,dinner, and at HS. Depending on bg results,add second injection as below. Can usually begin with ~ 4 U and ajust by 2 U every 3 days until bg is in range Continue regimen. Check A1c every 3 months Pre-lunch bg out of range. Add rapid- acting insulin at breakfast Pre-dinner bg out of range. Add NPH insulin at breakfast or rapid acting at lunch Pre-bed(HS) bg out of range. Add rapid-acting insulin at dinner Yes No A1c ≥ 7% after 3 months Recheck pre-meals bg levels and if out of range, may need to add another injection. If A1c continues to be out of range,check 2-h postprandial levels and adjust preprandial rapid-acting insulin Yes No ADA/EASD Consensus Algorithm 2009

46 Add additional meal-time injections if HbA 1c ≥7.0% after 3 months How should I advance insulin therapy for people with Type 2 diabetes? Nathan DM et al. Diabetes Care. 2006;29: Algorithm driven dose titration – basal regimen* HbA 1c ≥7.0% after 3 months Check pre- breakfast, lunch, dinner, and bedtime PG Add rapid-acting insulin to the meal with the highest excursion Begin 4 U and adjust by 2 U every 3 days based on PG change † *Insulin regimens should be designed taking lifestyle and meal schedule into account; this algorithm provides a basic guideline for initiation and adjustment of insulin. Regimens with once- or twice-daily premixed insulins are also possible. † Inhaled insulin dosing in 1 mg (≈ 3 U) steps. Once daily intermediate or long-acting insulin Begin 10 U or 0.2 U/kg, titrate by 2 U every 3 days using pre-breakfast plasma glucose (PG) until in target range ( mg/dL)

47 Insulin in the Hospital Setting: Glycemic Control and Improved Outcomes

48 The Increasing Rate of Diabetes Among Hospitalized Patients %  Available at: Accessed June 15, Hospitalizations for Diabetes as a Listed Diagnosis Hospital Discharges (millions)

49 Diabetes in Hospitalized Patients At least 4 million patients with diagnosed diabetes are admitted to hospitals annually in the United States In 2000, 12.4% of hospital discharges in the United States listed diabetes as a diagnosis Centers for Disease Control 2004.American Diabetes Association. Diabetes Care. 2005;28(suppl 1):S4-S American Diabetes Association. Diabetes Care 2008;31:

50 Umpierrez G et al. J Clin Endocrinol Metabol. 2002, 87: Levetan CS et al. Diabetes Care. 1998;21: Krinsley JS. Mayo Clin Proc. 2003;78: Falciglia M et al. 66th ADA Scientific Meeting, Hyperglycemia Is Common in Hospitalized Patients Non-critically ill medical / surgical: 38% Intensive care units (ICU): 29% – 100% –Episodes of glucose >110 mg/dL: 100% –Episodes of glucose >200 mg/dL: 31% –Mean glucose >145 mg/dL: 39%(prevalence)

51 Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:978–982. Hyperglycemia in Patients Predictor of Poor Outcome Hyperglycemia occurred in 38% of patients admitted to a community hospital in Atlanta –26% had known history of diabetes –12% had no history of diabetes Newly discovered hyperglycemia was associated with: –Higher in-hospital mortality rate (16%) compared with patients with a history of diabetes (3%) and patients with normoglycemia (1.7%; both P<.01) –Longer hospital stays; higher admission rates to intensive care units (ICUs) –Less chance to be discharged to home (required more transitional or nursing home care)

52 Effect of Hyperglycemia on Hospital Mortality * *P<.01 compared with normoglycemia and known diabetes. * * Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:978–982.

53 * * * * *P<0.05 vs BG<198 mg/dL (11 mmol/L) CAP, community acquired pneumonia McAlister et al. Diabetes Care. 2005;28: N=2471 patients with CAP, Canada Hyperglycemia and Pneumonia Outcomes

54 ~2x Mortality Rate (%) Mean Glucose Value (mg/dL) Krinsley JS. Mayo Clin Proc. 2003;78: N=1826 ICU patients >300 ~4x ~3x Hyperglycemia and Mortality in the MICU

55 Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87: Bolk J et al. Int J Cardiol. 2001;79: Williams LS et al. Neurology. 2002;59: Malmberg K, et al. BMJ. 1997;314:1512. Van den Berghe G et al. N Engl J Med. 2001;345: Capes SE et al. Stroke. 2001;32: Consequences of Poor Glycemic Control in Hospital Patients Hyperglycemia, with or without a diagnosis of diabetes, can result in –Increased Mortality –Increased Morbidity –Admission to the ICU –Need for extended care –Overall poor outcomes

56 Hyperglycemia is a Marker of Poor Outcome Does control of hyperglycemia is important in improving outcomes?

57 Malmberg BMJ 1997;314:1512 DIGAMI Study Diabetes, Insulin Glucose Infusion in Acute Myocardial Infarction (1997) Acute MI With BG > 200 mg/dl Intensive Insulin Treatment IV Insulin For > 24 Hours Four Insulin Injections/Day For > 3 Months Reduced Risk of Mortality By: –28% Over 3.4 Years –51% in Those Not Previous Diagnosed

58 MI = myocardial infarction; DIGAMI = Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction. (Short and long term effect of intensive insulin therapy) 44vs33 All Subjects (N=620) Risk reduction (28%) P=.011 Standard treatment (314) Follow-Up (y) 2345 Low-Risk & Not Previously on Insulin (N=272) Risk reduction (51%) P=.0004 IV insulin 48 hours, then 4 injections daily (306) Follow-Up (y) 2345 Mortality After MI Is Reduced by Insulin Therapy in DIGAMI Malmberg K et al. BMJ. 1997;314:

59 Van den Berghe et al. N Engl J Med. 2001;345: Intensive Insulin Therapy in Critically Ill Patients: The Leuven SICU Study Randomized controlled trial: 1548 patients admitted to a surgical ICU, receiving mechanical ventilation. Patients were assigned to receive either: –Conventional therapy: IV insulin only if BG >215 mg/dL Target BG levels: mg/dL Mean daily BG: 153 mg/dL –Intensive therapy: IV insulin if BG >110 mg/dL –Target BG levels : mg/dL –Mean daily BG: 103 mg/dL

60 ICU Survival 1548 Patients (mostly OHS pts.) All with BG >200 mg/dl Randomized into two groups –Maintained on IV insulin –Conventional group (BG ) –Intensive group (BG ) Conventional Group had 1.74 X mortality Van den Berghe et al. N Engl J Med. 2001;345:

61 Intensive treatment Conventional treatment Intensive treatment, 4.6% mortality Conventional treatment, 8% Survival in ICU (%) In-Hospital Survival (%) Days After Admission 42.5% reduction in mortality with intensive treatment; P<.04 34% reduction in mortality with intensive treatment; P<.01 Intensive Glycemic Control and Survival in Critically Ill Patients Van den Berghe et al. N Engl J Med. 2001;345: Days After Admission

62 Benefits of IV Insulin Treatment in Critically ill Hospitalized Patients 34% 46% 41% 50% 44% Intensive Glycemic Control BG = mg/dL in ICU BG = mg/dL after discharge from ICU Van den Berghe et al. N Engl J Med. 2001;345:

63 Improvement in Deep Sternal Wound Infection With Continuous IV Insulin Target blood glucose <150 mg/dL. IV = intravenous; CII = continuous insulin infusion; DSWI = deep sternal wound infection DSWI (%) Year CII Furnary AP et al. Ann Thorac Surg. 1999;67: (prospective 2467) Patients with diabetes Nondiabetic patients

64 AACE- Endocrine Practice 10 (1): 77-82, 2004; AAE – Endocrine Practice February 2006; ADA- Diabetes Care 27: , 2004 The current ADA guideline for pre-prandial plasma glucose levels is 90–130 mg/dl AACE - Consensus Conference Suggested Blood Glucose Targets Upper Limit Inpatient Glycemic Targets: ICU: 110 mg/dl (6.1 mmol/L) – Non-critical care (limited data) Pre-prandial: 110 mg/dl (6.1 mM) Maximum: 180 mg/dL (10 mM)

65 Clement S et al. Diabetes Care. 2004;27: Insulin: The Most Effective Treatment for Inpatient Glycemic Control Adaptable to increased insulin requirement during acute illness Basal insulin administration can prevent excess gluconeogenesis and ketogenesis Dose can be adapted to various categories of patient nutrition status –IV dextrose –Total parenteral nutrition –Enteral feeding –Nutritional supplements

66 Methods For Managing Hospitalized Patients with Diabetes IV Insulin Drip –Major Surgery, Cardiovascular procedures,NPO, MI, DKA, Steroids, Gastroparesis, MICU, etc Subcutaneous insulin injections: –Basal / Bolus Therapy (MDI) when eating –Basal / Correction Bolus when NPO

67 Initiate or continue IV insulin infusion as soon as patient comes out from the OR as follows: Non-Diabetics –Check Finger Stick (FS) and initiate or adjust insulin infusion as per TIER 1 (Green Wheel) if any BG > 200 mg/dL Diabetics –Check FS and initiate or adjust insulin infusion as follows: –If FS > 250 mg/dL bolus with 4 units of regular insulin IV and then follow IV Insulin rate as per weight (below) –If FS < 250 mg/dL start as per weight (below) –If patient < 70 Kg start as per TIER 1 (Green Wheel) –If patient > 70 Kg start as per TIER 2 (Yellow Wheel)

68 Finger Stick (FS) Monitoring FS Q 1 hour If no change in BG range for two (2) consecutive measurements move-up a tier within the same range If at goal for three (3) consecutive FS can change FS to Q2 hours, and if again at goal for three (3) consecutive measurements can change to FS Q 4 hours Resume monitoring FS Q 1 hour if: –Significant change in clinical condition –Initiation or cessation of corticosteroids and / or vasopressors –Initiation or cessation of hemodialysis Initiation, cessation, or change in nutritional support

69 DIABETES / HYPERGLYCEMIA DISCHARGE SUMMARY Date: Mr./ Ms. □ Diabetes Mellitus Type 1 □ Diabetes Mellitus Type 2 □ Post-Operative Hyperglycemia Who underwent: □ Coronary Artery Bypass Grafting □ Cardiac Valve Surgery □ Other Post-operatively treatment : □ Novolog ( Aspart ) □ Lantus ( Glargine ) □ Oral antihyperglycemic medication(s) □ Diet-control only Important data: HgA1c _____ Ejection Fraction_____ % Serum creatinine _____ AST/ALT_____ Weight _____ LDL-c_____ Your patient ’ s Diabetes/Hyperglycemia discharge plan is as follows: □ Life style improvement- d iet-control only Oral antihyperglycemic medication(s) Insulin(s) □ Glucophage (Metformin) □ Lantus _____ units at _____, daily □ Prandin (Repaglinide) □ Novolog/Humalog at meals □ Januvia (DPP-IV Inh ) □ Sulfonylureas: □ Other □ Other Diabetes follow up appointment : ▢ Dr. Gouller # □ Endo Clinic (212) □ Dr..Busta # □ Dr ……... #420- Date : Location : Fierman Hall. 317East 17th street 7 Floor. Recommendations: 1) HgA1c goal of 7% or lower 2) You may also refer your patient to the Friedman Diabetes Institute for diabetes education.Friedman Diabetes Israel Medical Center317 East 17 th Street, 8 th Floor New York, NY

70 Insulin Onset ofDuration of Preparations Action Peak (h)Action (h) Lispro/Aspart/Glulisine min Regular human min Human NPH1 - 2 h Detemir hflat/ 6-8 * * Insulin Glargine2 - 4 h flat Time course of action of any insulin can vary in different people or at different times in the same person; thus, time periods indicated here should be considered general guidelines only. * Dose dependent 1. Mudaliar S et al. Endocrinol Metab Clin North Am. 2001;30: ; 2. Endotext.com Comparison of Human Insulins and Analogues

71 Insulin Order There are 6 options (order sets) for the initial insulin orders: 1.Patients with type 1 diabetes or type 2 diabetes previously on insulin therapy- patients eating 2.Patients with type 1 diabetes or type 2 diabetes previously on insulin therapy- patients NPO 3.Patients with type 2 diabetes previously on oral agents- insulin- naïve patients - eating 4.Patients with type 2 diabetes previously on oral agents, insulin-naïve patients NPO 5.Patients with newly diagnosed hyperglycemia - patient eating 6.Patients with newly diagnosed hyperglycemia - patient NPO

72 Patients with type 1 diabetes or type 2 diabetes previously on insulin therapy- patients eating Order HgbA1C Order hypoglycemia management nest Use Prior Total Daily Dose (TDD) of insulin, whenever possible, if patient was well controlled. If dose is not known or unable to assess control, TDD should be weight-based. TDD (0.4 u/kg)should be split as follows: –Basal: 50% of TDD : Lantus dose should be calculated as 50% of 0.4units/kg (0.2 units/kg) and given immediately upon arrival to the floor. –Prandial: Novolog should be calculated as 15% of 0.4units/Kg given before each meal (TID AC) –Correction/Supplemental Insulin Scale: Standard (or Low, Medium or High Dose according to risk of hypo or hyperglycemia). Correction Scale is given before meals and is added to Prandial dose. HS Correction Scale may be ordered but separately. Reassess TDD in 24 hours.

73 Patients with type 1 diabetes or type 2 diabetes previously on insulin therapy- patients eating Approximate dose for a 70 kg patient 0.4 u/kg x 70 kg= 28 units a)Lantus 15 units SC Q 24hr (Q HS) b)Novolog 5 units SC Q AC before Breakfast, before Lunch and Before Dinner c)Correction/Supplement Insulin (Novolog) Scale before meals TID AC (Pick Standard, Low Dose, Medium Dose or High Dose)

74 Patients with type 1 diabetes or type 2 diabetes previously on insulin therapy- patients NPO Order HgbA1C Order hypoglycemia management nest Use Prior Total Daily Dose (TDD) of insulin, whenever possible, if patient was well controlled. If dose is not known or unable to assess control, TDD should be weight-based. TDD should be split as follows: –Basal: 50% of TDD : Lantus dose should be calculated as 50% of 0.4 units/kg (0.2 units/kg) and given immediately upon arrival on the unit. –Prandial: None –Correction/Supplemental Insulin Scale: Standard Scale should be given q4-6 hours All Patients will need to be on D ml/hr. Reassess TDD in 24 hours.

75 Patients with type 1 diabetes or type 2 diabetes previously on insulin therapy- patients NPO Approximate dose for a 70 kg patient : 0.4 u/kg x 70 kg = 28 units a)Lantus 15 units SC Q 24hr (Q HS) b)Correction/Supplement Insulin (Novolog) scale (Standard) Q 4h c)D5 1/2NS at 100 cc/hr

76 Patients with type 2 diabetes previously on oral agents, insulin-naïve - patients eating Order HgbA1C Order hypoglycemia management nest Total Daily Dose (TDD) (0.3u/kg)of insulin should be weight- based; insulin should be dosed as follows: –Basal: 50% of TDD: Lantus dose should be calculated as 50% of 0.3 units/kg (0.15 units/kg) and given immediately upon arrival on the unit. –Prandial: Novolog should be calculated as 15% of 0.3 units/kg and given before each meal (TID AC). –Correction/Supplemental Insulin Scale: Standard (or Low, Medium or High Dose according to risk of hypo or hyperglycemia). Correction Scale is given before meals and is added to Prandial dose. HS Correction Scale may be ordered but separately. Reassess TDD in 24 hours.

77 Patients with type 2 diabetes previously on oral agents- insulin-naïve patients - eating Approximate dose for a 70 kg patient: 0.3 u/kg x 70 kg = 21 units a)Lantus 10 units SC Q 24hr (Q HS) b)Novolog 3 units SC Q AC before Breakfast, before Lunch and Before Dinner c)Correction/Supplement Insulin (Novolog) Scale before meals TID AC (Pick Standard, Low Dose, Medium Dose or High Dose)

78 Patients with type 2 diabetes previously on oral agents, insulin-naïve - patients NPO Order HgbA1C Order hypoglycemia management nest Total Daily Dose (TDD) of insulin should be weight-based; insulin should be dosed as follows: –Basal: Lantus dose should be calculated as 0.1 U/kg and given immediately upon arrival to the floor. –Prandial: None –Correction/Supplemental Insulin Scale: Standard Scale should be given q4-6hours. Reassess TDD in 24 hours.

79 Patients with type 2 diabetes previously on oral agents, insulin-naïve - patients NPO Approximate: 0.1 u/kg x70 kg = 7 units a)Lantus 7 units SC Q 24hr (Q HS) b)Correction/Supplement Insulin (Novolog) scale (Standard) Q 4h c)D5 1/2NS at 100 cc/hr

80 Patients with newly diagnosed hyperglycemia - patient eating Order HgbA1C Order hypoglycemia management nest Total Daily Dose (TDD) of insulin should be weight-based; insulin should be dosed as follows: –Basal: 50% of TDD: Lantus dose should be calculated as 50% of 0.3 units/kg and given immediately upon arrival to the floor. –Prandial: Novolog should be calculated as 15% of 0.3 units/kg and given before each meal (TID AC). –Correction/Supplemental Insulin Scale: Standard (or Low, Medium or High Dose according to risk of hypo or hyperglycemia). Correction Scale is given before meals and is added to Prandial dose. HS Correction Scale may be ordered but separately. Reassess TDD in 24 hours.

81 Patients with newly diagnosed hyperglycemia - patient eating Approximate: 0.3u/kg x 70 kg = 21 units a)Lantus 10 units SC Q 24hr (Q HS) b)Novolog 3 units SC Q AC before Breakfast, before Lunch and Before Dinner c)Correction/Supplement Insulin (Novolog) Scale before meals TID AC (Pick Standard, Low Dose, Medium Dose or High Dose)

82 Patients with newly diagnosed hyperglycemia - patient NPO Order HgbA1C Order hypoglycemia management nest Total Daily Dose (TDD) of insulin should be weight-based; insulin should be dosed as follows: –Basal: None –Prandial: None –Correction/Supplemental Insulin Scale: Standard Scale should be given q4-6hours. Reassess TDD in 24 hours.

83 Patients with newly diagnosed hyperglycemia - patient NPO Approximate: Correction/Supplement Insulin (Novolog) scale (Standard) Q 4h

84 Hypoglycemia Treatment of Hypoglycemia Patient alert : gm of carbs ( 8 onz of juice, 2 crackers=10 carbs, glucose tablets) Non alert patient : 1 amp D50 or 1 mg glucagon IM (repeat q 15 min ) RULE OF THUMB : 15 gm of carbs will increased glucose levels mg/dL Do Not Hold Insulin When BG Normal


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