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Manejo del Paciente Diabetico en la Unidad de Cuidados Intensivos y Sala General Guillermo E. Umpierrez, MD, FACP, FACE Professor of Medicine Director,

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Presentation on theme: "Manejo del Paciente Diabetico en la Unidad de Cuidados Intensivos y Sala General Guillermo E. Umpierrez, MD, FACP, FACE Professor of Medicine Director,"— Presentation transcript:

1 Manejo del Paciente Diabetico en la Unidad de Cuidados Intensivos y Sala General Guillermo E. Umpierrez, MD, FACP, FACE Professor of Medicine Director, Grady Hospital Clinical Research Unit Emory University School of Medicine Director, Diabetes & Endocrinology Section Grady Hospital CIN (Research Unit) Grady Health System

2 Hiperglucemia en el Hospital: Agenda 1.Magnitud del Problema:  Cual es la frecuencia e impacto de hiperglucemia y diabetes en el hospital?  Cuales criterios diagnosticos debemos de utilizar?  Que niveles de glucosa son recomendables? Umpierrez et al. J Clin Endocrinol Metabol. 97(1):16-38, Como debemos de manejar la hiperglucemia en UCI y en en sala generales?  Insulina – Que tipo, regimen, y como comenzar?  Incretinas – debemos de utilizarlas en el hospital?  Alta hospitalaria– Cual es el papel de la HBA1c, que regimen utilizar? HbA1c?

3 Distribution of patient-day-weighted mean POC-BG values for ICU Swanson et al. Endocrine Practice, October 2011 Data from ~12 million BG readings from 653,359 ICU patients - mean POC-BG: 167 mg/dL

4 Hyperglycemia: Scope of the Problem Hyperglycemia: Scope of the Problem Kosiborod M, et al. J Am Coll Cardiol. 2007;49(9): :283A-284A. No Diabetes 26% Diabetes < < >200 78% >200 Mean BG, mg/dL Patients, %

5 Perioperative Hyperglycemia in Patients With and Without Diabetes Undergoing CABG Surgery Perioperative Hyperglycemia in Patients With and Without Diabetes Undergoing CABG Surgery No-DMDMP-value # of pts BMI29±633±8p<0.001 Admission BG111±28171±72p<0.001 HbA1c6.1±0.28.0±2p<0.001 Pre-op BG108±23155±51p<0.001 Intra-op BG138±20157±31p<0.001 ICU BG135±16149±18p<0.001 Periop BG >14083%98%P=0.48 Started CII88%94%P=0.06 Insulin dose, Units61±84161±229 Transition to basal insulin after CII 48%98%P<0.001 Pasquel et al, Endocrine Society 2014, submitted. Unpublished

6 Hyperglycemia*: A Common Comorbidity in Medical-Surgical Patients in a Community Hospital 62% 12% 26% Normoglycemia Known Diabetes New Hyperglycemia Umpierrez G et al, J Clin Endocrinol Metabol 87:978, 2002 n = 2,020 * Hyperglycemia: Fasting BG  126 mg/dl or Random BG  200 mg/dl X 2 or Random BG  200 mg/dl X 2

7 Diagnosis & recognition of hyperglycemia and diabetes in the hospital setting Admission Assess all patients for a history of diabetes Obtain laboratory BG testing on admission Umpierrez et al. J Clin Endocrinol Metabol. 97(1):16-38, 2012 No history of diabetes BG<140 mg/dl (7.8 mmol/L) Initiate POC BG monitoring according to clinical status History of diabetes BG monitoring No history of diabetes BG >140 mg/dl Start POC BG monitoring x 24-48h Check A1C A1C ≥ 6.5%

8 A1C for Diagnosis of Diabetes in the Hospital  HbA1c should be measured in non-diabetic subjects with hyperglycemia (BG>140 mg/dl or 7.8 mmol/L) and in subjects with diabetes if not done within 2-3 months prior to admission.  In the presence of hyperglycemia, a patient with HbA1c > 6.5% can be identified as having diabetes.  Implementation of A1C testing can be useful:  assess glycemic control prior to admission  assist with differentiation of newly diagnosed diabetes from stress hyperglycemia  designing an optimal regimen at the time of discharge Umpierrez et al, J Clin Endocrinol Metabol, 2012

9 Hyperglycemia in the ICU: Lecture Agenda 1.Scope of the Problem:  What is the frequency of hyperglycemia and diabetes?  Why should we care about hyperglycemia in the ICU?  Mechanisms for hyperglycemia in acute critical illness and ICU 2.How should we manage hyperglycemia in the ICU and non-ICU settings?  Insulin regimens  Incretin-base regiments  Other agents?

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11 N= 55,530 patients records in ICU and non-ICU, Emory University Hospital. Composite of complications: pneumonia, acute renal or respiratory failure, acute MI, bacteremia, and death. Patients with admission BG >400 mg/dL, DKA, and GFR <15 were excluded. Hyperglycemia and Hospital Complications: What glucose level predicts complications?

12 Thirty Day Mortality and Hospital Complications in Diabetic and Non-diabetic subjects Undergoing General Non-Cardiac Surgery †p = 0.1 * p= #p=0.017 † * * * * # * % A Frisch et al. Diabetes Care, May 2010

13 Adverse Events Stratified by Perioperative Hyperglycemia BG at any point on the day of surgery, post-op day 1 and 2 N= 11,633, colorectal and bariatric surgery; 29.1% with hyperglycemia DiabetesNo Diabetes * * * * § § p <0.05 * P <0.01 Known et al. Ann Surg 2013 Proportion of Patients (%) BG > 180 mg/dl BG < 180 mg/dl

14 Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes Total In-patient Mortality Normoglycemia Known New Diabetes Hyperglycemia Diabetes Hyperglycemia 1.7% 3.0% 16.0% * Mortality (%) * P < 0.01 Umpierrez GE et al, J Clin Endocrinol Metabol 87:978, 2002

15 Inpatient Hyperglycemia: ICU and non-ICU Lecture Outline 1.What is the frequency of hyperglycemia and diabetes? 2.What is the association between hyperglycemia and outcomes? 3.Does treatment of hyperglycemia in ICU and non-ICU matters? What is the evidence for intensive glycemic control? What is the evidence for intensive glycemic control? 4.How should we manage hyperglycemia in non- ICU setting

16 Prospective study of 2,467 consecutive diabetics who underwent open heart surgery. DSWI, deep sternal wound infection; SCI, subcutaneous insulin; CII, continuous insulin infusion DSWI (%) Year Furnary AP, et al. Ann Thorac Surg. 1999;67:352–362. CIISCI Portland Diabetes Project: Insulin Infusion Reduces DSWI SCI Group: Day of surgery: 241 mg/dL POD #1: 206 mg/dL CII Group: Day of surgery: 199 mg/dL POD #1: 176 mg/dL

17 Hyperglycemia and surgical ICU morbidity and mortality

18 Intensive Glucose Management in RCT TrialNSetting Primary OutcomeARRRRR Odds Ratio (95% CI) P-value Van den Berghe MICUHospital mortality 2.7%7.0% 0.94 * ( ) N.S. Glucontrol ICUICU mortality -1.5%-10% 1.10 * ( ) N.S. Ghandi ORComposite2%4.3% 1.0 * ( ) N.S. VISEP ICU28-d mortality 1.3%5.0% 0.89 * ( ) N.S. De La Rosa SICU MICU 28-d mortality -4.2% * -13% * NRN.S. NICE-SUGAR ICU3-mo mortality -2.6% ( ) < 0.05 * not significant Griesdale DE, et al. CMAJ. 2009;180(8):

19 Favors IIT Favors Control Hypoglycemic Events Intensive Insulin Therapy and Hypoglycemic Events in Critically Ill Patients No. Events/Total No. Patients StudyIITControlRisk ratio (95% CI) Van den Berghe et al39/7656/ ( ) Henderson et al7/321/ ( ) Bland et al1/ ( ) Van den Berghe et al111/59519/ ( ) Mitchell et al5/350/ ( ) Azevedo et al27/1686/ ( ) De La Rosa et al21/2542/ ( ) Devos et al54/55015/ ( ) Oksanen et al7/391/ ( ) Brunkhorst et al42/24712/ ( ) Iapichino et al8/453/ ( ) Arabi et al76/2668/ ( ) Mackenzie et al50/1219/ ( ) NICE-SUGAR206/301615/ ( ) Overall 654/613898/ ( ) Risk Ratio (95% CI)

20 NICE-SUGAR Trial: Hypoglycemia and Mortality The NICE-SUGAR Study Investigators. N Engl J Med 2012;367:

21 Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4) AACE/ADA Recommended Target Glucose Levels in ICU Patients  Starting threshold of no higher than 180 mg/dL Recommended Acceptable Not recommended <110 Not recommended > Critical Society Guidelines   ICU Target Glucose Goal < 150 mg/dl  Start Insulin Therapy when BG ≥ 150 mg/dL   Maintain BG values <180 mg/dL Jacobi, et al. Crit Care Med 2012;40:3251–3276 Jacobi, et al. Crit Care Med 2012;40:3251– American College of Physicians (ACP)  ICU Target Glucose Goal < 200 mg/dl Annals Intern Med 2012

22 Glycemic Targets in NON-ICU Setting Glycemic Targets in NON-ICU Setting 1.Premeal BG target of <140 mg/dl (7.8 mmol/L) and random BG <180 mg/dl (10 mmol/L) for the majority of patients. 2.Glycemic targets be modified according to clinical status. 3.For avoidance of hypoglycemia, diabetic therapy be reassessed when BG<100 mg/dl (5.5 mmol/L). Umpierrez et al. J Clin Endocrinol Metabol. 97(1):16-38, 2012 American College of Physicians recommended a target BG <200 mg/dl (11.1 mmol/L), Ann Intern Med 2012

23 Hyperglycemia in the ICU: Lecture Agenda 1.Scope of the Problem:  What is the frequency of hyperglycemia and diabetes?  Why should we care about hyperglycemia in the ICU? 2.How should we manage hyperglycemia in the ICU and non-ICU settings?

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25 Protocol Hypo definition % patients RR Leuven SICU 1 <40 mg/dL 5.1%7 Leuven MICU 2 <40 mg/dL 19%6 Glucontrol 3 <40 mg/dL 8.6%-- VISEP 4 <40 mg/dL 17.4%4.11 NICE SUGAR 5 <40 mg/dL 6.5%13.7 GLUCO-CABG 6 <40 mg/dl 0%-- Van Den Berghe G, et al. N Engl J Med. 2001:345:1359; Van Den Berghe G, et al. N Engl J Med. 2006;354: ; Brunkhorst FM et al. N Engl J Med. 2008; 358: ; Preiser JC, SCCM, 2007; Finfer S, et al. N Engl J Med. 2009;360(13): ; Umpierrez, ADA 2014 Hypoglycemia Rates in Intensive IV Insulin Protocols

26 ProtocolIITCIT Leuven SICU Leuven MICU De la Rosa Glucontrol VISEP NICE SUGAR GLUCO-CABG Van Den Berghe G, et al. N Engl J Med. 2001; Van Den Berghe G, et al. N Engl J Med. 2006;De la Rosa,et al, Crit Care 2008; Brunkhorst et al. N Engl J Med. 2008; Preiser JC, SCCM, 2007; Nice Sugar, NEJM 2009; Umpierrez 2014 (ADA, unpublished) Glycemic Values Achieved with IV Insulin Protocols IIT: Intensive insulin therapy; CIT: Control, conventional/Conservative insulin therapy Results are expressed as mean BG during hospital stay, mg/dL

27 1.ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care & Diabetes Care. 2009;31(suppl 1):S1-S110.. Antihyperglycemic Therapy Insulin Recommended OADs Not Generally Recommended Recommendations for Managing Patients With Diabetes in the Hospital Setting

28  D/C oral antidiabetic drugs on admission  Insulin naïve: starting total daily dose (TDD):  0.3 U/kg to 0.5 U/kg  Lower doses in the elderly and renal insufficiency  Previous insulin therapy: reduce outpatient insulin dose by 20-25%  Basal bolus regimen: Half of TDD as basal and half as rapid-acting insulin before meals Insulin Therapy in patients with T2D Umpierrez et al, Diabetes Care 30:2181–2186, 2007; Baldwin et al, Diabetes Care 10:1970-4, 2011; Rubin et al, Diabetes Care 34:1723-8, 2011

29 Inpatient Management in non-ICU Setting Sliding Scale Regular Insulin Basal Bolus Insulin Regimen In insulin naïve patients with T2DM, does treatment with basal bolus regimen with glargine once daily and glulisine before meals is superior to sliding scale regular insulin? RABBIT-2D TRIAL: - Research Question: - Research Question: Umpierrez et al, Diabetes Care 30:2181–2186, 2007

30  D/C oral antidiabetic drugs on admission  Starting total daily dose (TDD):  0.4 U/kg/d x BG between mg/dL  0.5 U/kg/d x BG between mg/dL  Half of TDD as insulin glargine and half as rapid- acting insulin (glulisine)  Insulin glargine - once daily, at the same time/day.  Glulisine- three equally divided doses (AC) Randomized Basal Bolus versus Sliding Scale Regular Insulin in patients with type 2 Diabetes Mellitus (RABBIT-2 Trial) Umpierrez et al, Diabetes Care 30:2181–2186, 2007

31 Rabbit 2 Trial: Changes in Glucose Levels With Basal-Bolus vs. Sliding Scale Insulin Umpierrez GE, et al. Diabetes Care. 2007;30(9): Days of Therapy BG, mg/dL Admit 1 Sliding-scale Basal-bolus b P<.05. a a a b b b b a P<.05. Sliding scale regular insulin (SSRI) was given 4 times daily Basal-bolus regimen: glargine was given once daily; glulisine was given before meals. 0.4 U/kg/d x BG between mg/dL 0.5 U/kg/d x BG between mg/dL Hypoglycemia rate:  Basal Bolus Group:  BG < 60 mg/dL: 3%  BG < 40 mg/dL: none  SSRI:  BG < 60 mg/dL: 3%  BG < 40 mg/dL: none

32 Inpatient Management in non-ICU Setting Basal Bolus Insulin Regimen NPH and Regular Insulin-Spilt- Mixed Regimen In patients with T2DM on diet, oral agents or insulin treatment, does treatment with basal bolus regimen with detemir once daily and aspart before meals is superior to NPH and Regular split-mixed insulin regimen? DEAN TRIAL: - Research Question: - Research Question: Umpierrez et al, J Clin Endocrinol Metab 94: 564–569, 2009

33 DEAN Trial: Changes in Mean Daily Blood Glucose Concentration BG, mg/dL Duration of Therapy, d Data are means  SEM. Detemir + aspart NPH + regular Basal-bolus regimen: detemir was given once daily; aspart was given before meals. NPH/regular regimen: NPH and regular insulin were given twice daily, two thirds in AM, one third in PM. Umpierrez GE, et al. J Clin Endocrinol Metab. 2009;94(2): P=NS Pre-Rx BG  NPH/Regular  BG < 40 mg/dl: 1.6%  BG < 60 mg/dl: 25.4%  Detemir/Aspart  BG < 40 mg/dl: 4.5%  BG < 40 mg/dl: 32.8% DEAN Trial: Hypoglycemia

34 Randomized Controlled Study Comparing Basal Bolus with Insulin Analogs vs Human Insulins in General Medicine Patients Bueno, Benitez eta al ADA Scientific Meeting, New Orleans Basal bolus with glargine QD + glulisine AC versus NPH b.i.d. & regular AC U/kg/d x BG: mg/dL U/kg/d x BG: mg/dL

35 Basal Bolus Regimen Analogs vs. Human Insulins Bueno, Benitez eta al ADA Scientific Meeting, New Orleans

36 Hypoglucemias por brazo de intervención ALL N= 134 Analogs N=66 Human N=68 p-value Patients with Hypoglycemia, n (%) 49 (37)23 (35)26 (38) OR:1.16 p: 0.68 Severe Hypoglucemia, n (%) 22 (16)517 OR:2.93 P:0.04 Mild Hypoglucemia, n (%) Patients withn ≥2 episodes, n (%) 26 (19)1016 OR:2.08 P:0.2 Bueno, Benitez eta al ADA Scientific Meeting, New Orleans

37 Umpierrez et al, Diabetes Care 34 (2):1–6, 2011 Primary Outcomes: Differences between groups in mean daily BG Composite of hospital complications: wound infection, pneumonia, respiratory failure, acute renal failure, and bacteremia In patients with T2DM on diet, oral agents or insulin treatment, does treatment with basal bolus regimen with glargine and glulisine is superior to SSRI? Research Question: Randomized study of basal bolus insulin therapy in the management of general surgery patients with T2DM (Rabbit Surgery)

38 * * * * Mean BG before meals and at bedtime during basal bolus and SSI therapy Breakfast Lunch Dinner Bedtime *p<0.001 Glargine+Glulisine Sliding Scale Insulin Umpierrez et al, Diabetes Care 34 (2):1–6, 2011

39 Postoperative Complications P=0.003 P=NS P=0.05P=0.10 P=0.24 Glargine+Glulisine Sliding Scale Insulin Umpierrez et al, Diabetes Care 34 (2):1–6, 2011 * Composite of hospital complications: wound infection, pneumonia, respiratory failure, acute renal failure, and bacteremia.

40 Insulin Glargine + Insulin Glulisine SSI P<0.001 Percent of patients with hypoglycemia during basal bolus and SSI therapy BG <70 mg/dL BG <60 mg/dL BG <40 mg/dL There were no differences in hypoglycemia between patients treated with insulin prior to admission compared to insulin-naïve patients. Umpierrez et al, Diabetes Care 34 (2):1–6, Insulin Glargine + Insulin Glulisine SSI P<0.001

41 Insulin Treatment in in Non-ICU Setting Do you need basal bolus in ALL patients? T2DM with BG > 140 mg/dl (7.7 mmol/l) Basal insulin - Start at U/Kg/day* - Correction doses with rapid acting insulin AC - Adjust basal as needed NPO Uncertain oral intake Adequate Oral intake Basal Bolus TDD: U/Kg/day -½ basal, ½ bolus -- adjust as needed

42 Basal Plus Correction vs. Basal Bolus Basal plus supplements  Starting glargine*: 0.25 units/kg  Correction with glulisine for BG >140 mg/dl per sliding scale Basal Bolus Regimen  Starting TDD*: 0.5 U/kg  Glargine: 0.25 U/kg  Glulisine: 0.25 U/kg in three equally divided doses (AC)  Correction with glulisine for BG >140 mg/dl per sliding scale * Reduce TDD to 0.15 U/kg in patients ≥70 yrs and/or serum creatinine ≥ 2.0 mg/dL * Reduce TDD to 0.3 U/kg in patients ≥70 yrs and/or serum creatinine ≥ 2.0 mg/dL Umpierrez et al, Diabetes Care 2013

43 Basal-PLUS vs Basal Bolus: 300 medical & surgical non-ICU patients Preliminary results: Basal bolus 51 patients, basal-plus: 49 patients Basal Plus: glargine once daily 0.25 U/kg plus glulisine supplements Basal Bolus: TDD: 0.5 U/kg/d Glargine 50% glulisine 50% Umpierrez et al, Diabetes Care 2013

44 Differences in glycemic control and frequency of treatment failures in patients treated with basal bolus, basal plus and sliding scale regular insulin Umpierrez et al, Diabetes Care, 2013

45 Basal-PLUS vs Basal Bolus: Medicine and Surgery Patients MedicineSurgery BG AC & HS Daily BG BG AC & HS Smiley et al, Diabetes Care 2013

46 Inpatient Management in non-ICU Basal Bolus or Basal Plus Regimens Management of Patients With Diabetes in Non-ICU Settings What about Incretin-Based Therapy?

47 DPP-4 Therapy in Hospitalized Patients  Study Type: Multicenter, prospective, open-label randomized clinical trial  Patient Population: Patients with T2D admitted to general medicine and surgery services at 3 hospitals: Emory University, Grady, and University of Michigan  Treatment Groups*  Group 1. Sitagliptin once daily (n=30)  Group 2. Sitagliptin plus glargine insulin once daily (n=30)  Group 3. Basal bolus regimen with glargine once daily and lispro before meals (n=30)  * All groups received supplemental doses of lispro for BG > 140 mg/dl before meals Umpierrez et al. Care. 36(11):3430-5, 2013

48 Randomi- zation Mean Daily BG During Treatment Umpierrez et al. Care. 36(11):3430-5, 2013

49 Mean BG before meals and at bedtime during Treatment Data is mean ± SE P=0.22P=0.15 P=0.52P=0.57 Umpierrez et al. Care. 36(11):3430-5, 2013

50 Mean Daily Blood Glucose (mg/dL) Randomization Blood Glucose ( 180 mg/dl) and Mean Daily Glucose concentration p= 0.91 p= 0.08 Umpierrez et al. Care. 36(11):3430-5, 2013

51 Use admission A1C to adjust therapy at discharge 7% 8% 9% 10% Adjust original therapy, ADD another agent or basal insulin Return to original therapy ADD basal insulin therapy ADD basal or REPLACE with basal/bolus Umpierrez G et al, J Clin Endocrinol Metabol, 2012 Recommendations for Managing Patients With Diabetes After Hospital Discharge

52 A1C < 7% Re-start outpatient treatment regimen (OAD and/or insulin) A1C 7%-9% Re-start outpatient oral agents and D/C on glargine once daily at 50-80% of hospital dose A1C >9% D/C on basal bolus at same hospital dose. Alternative: re-start oral agents and D/C on glargine once daily at 80% of hospital dose Discharge Insulin Algorithm Discharge Treatment Umpierrez et al, ADA Scientific Sessions, 2012

53 Hospital Discharge Algorithm Based on Admission HbA1C for the Management of Patients with T2DM 8.75% 7.9% 7.35% % Umpierrez et al, ADA Scientific Sessions, 2012

54 Hospital Discharge Algorithm Based on Admission HbA1C for the Management of Patients with T2DM Primary outcome: - change in A1C at 4 wks and 12 wks after discharge All Patients OADOAD + Glargine Glargine+ Glulisine Glargine # patients, n (%)22481 (36)61 (27)54 (24)20 (9) A1C Admission, %8.7±2.56.9±1.59.2± ±2.38.2±2.2 A1C 4 Wks F/U, %7.9±1.7*7.0±1.48.0±1.4ψ8.8±1.8ψ7.7±1.7 A1C 12 Wks F/U, %7.3±1.5*6.6±1.17.5±1.6*8.0±1.6*6.7±0.8* BG<70 mg/dl, n (%)62 (29)17 (22)17 (30)23 (44)5 (25) BG<40 mg/dl, n (%)7 (3)3 (4)0 (0)3 (6)0 (0) * p< vs. Admission A1C; ψp=0.08 Umpierrez et al, ADA Scientific Sessions, 2012

55 Management of diabetes in non-critical care setting So… What really have we learned?

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59 Guillermo E. Umpierrez, MD Thank you!

60 Inpatient Management of Medical and Surgical Patients with Type 2 diabetes- ICU and non-ICU Guillermo E. Umpierrez, MD, FACP, FACE Professor of Medicine Director, Grady Hospital Clinical Research Unit Emory University School of Medicine Director, Diabetes & Endocrinology Section Grady Hospital CIN (Research Unit) Grady Health System

61 External Industry Relationships * Company Name(s)Role Equity, stock, or options in biomedical industry companies or publishers None Board of Directors or officer None Royalties from from external entity None Industry funds to Emory for my research Sanofi-Aventis Merck Novo Nordisk Boehringer Ingelhein Investigator-Initiated Research Projects Dr. Guillermo Umpierrez, Personal/Professional Financial Relationships with Industry

62 Hyperglycemia in non-critical care setting: Lecture Agenda 1.Scope of the Problem:  What is the frequency and impact of hyperglycemia and diabetes?  What diagnosis criteria should we use?  What target glucose should we aim? Umpierrez et al. J Clin Endocrinol Metabol. 97(1):16-38, How should we manage hyperglycemia in ICU and non-ICU setting?  Insulin regimens – Which and how to start?  Incretin-base regimens – are they safe & effective?  Discharge algorithm – What is the role of the admission HbA1c?

63 Blood Glucose (mg/dL) < > P< *P<0.001 Postop Mortality BG <200 n= % BG >200 n= % * Postop Mortality (%) Adjusted for 19 clinical and operation variables Furnary AP et al. Circulation. 1999:100 (Suppl I): I Hyperglycemia: A Predictor of Mortality Following CABG in Diabetics CABG, coronary artery bypass graft. First Postop Glucose >200 2x LOS 3x Vent duration 7x mortality !!!

64 Hyperglycemia and Pneumonia Outcomes BG (mg/dl) < < <250 ≥250 ** * * * p: < 0.05 vs BG < 198 mg/dl (11 mmol/L) Admission glucose (mg/dl) % McAllister et al, Diabetes Crae 28: , 2005 N= 2,471 patients with CAP

65 Pharmacologic Therapy in Non-ICU Setting  Patients treated with insulin at home require scheduled SQ insulin therapy in the hospital (1)  Avoid prolonged use of sliding scale insulin as sole method for glycemic management (2)  Scheduled SQ insulin consists of basal or intermediate acting insulin in combination with RAI or Regular insulin administered before meals in patients who are eating(1)  Include correction insulin as a component of scheduled SQ insulin for treatment of BG above desired range (2) GE Umpierrez, R Hellman, MT Korytkowski, M Kosiborod, GA Maynard, VM Montori, JJ Seley, GV den Berghe. J Clin Endocrinol Metabol. 97(1):16-38, 2012

66 Basal Bolus Insulin Regimen  D/C oral antidiabetic drugs on admission  Starting total daily dose (TDD): 0.5 U/kg/day  TDD reduced to 0.3 U/kg/day in patients ≥ 70 years of age or with a serum creatinine ≥ 2.0 mg/dL *If a patient was not able to eat, insulin glargine was given but, insulin glulisine was held until meals were resumed.  Half of TDD as insulin glargine and half as insulin glulisine* –Glargine - once daily, at the same time of the day –Glulisine- three equally divided doses (AC) Umpierrez et al, Diabetes Care 34 (2):1–6, 2011


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