1. Canadian Diabetes Association Clinical Practice Guidelines In-Hospital Management of Diabetes Chapter 16 Robyn Houlden, Sara Capes, Maureen Clement, David Miller

2. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CONTINUE pre-hospital diabetes regimen if appropriate, otherwise … USE insulin as the treatment of choice DO NOT use sliding scale insulin alone DO use BASAL + BOLUS + CORRECTION insulin regimen AVOID hypoglycemia 2013 In-hospital Management Checklist

3. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Approximately 1/3 of in-patients have been found to have hyperglycemia Many have pre- existing diabetes prior to admission Hyperglycemia In-hospital Hyperglycemia is Common

4. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Inzucchi SE. NEJM 2006;355;1903 Hyperglycemia and Acute Ilness

5. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Hyperglycemia Increases risks of postoperative infections and delirium Prolonged hospital stay, resource utilization Increased renal dysfunction and renal allograft rejection in transplant Adverse Effects of Hyperglycemia

6. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Patient TypeGlucose Target (mmol/L) Therapy of choice Non-critically illFasting 5-8 Random <10 Pre-hospital regimen OR basal-bolus- correction Critically ill8-10IV insulin infusion CABG intraop5.5-10IV insulin infusion Other periop5-10As appropriate CABG = coronary artery bypass graft; IV = intravenous; Intraop = intraoperative; periop = perioperative In-hospital Glycemic Targets

7. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association In the absence of routine insulin, sliding scale insulin regimen (bolus insulin on a prn basis) is purely reactive rather than proactive and allows for hyperglycemia to occur before responding BG (mmol/L)Bolus insulin (U) <4Call MD 4.1 – 10.00 10.1 – 13.02 13.1 – 16.04 16.1 – 19.06 >19.0Call MD Queale WS. et al. Arch Int Med 1997;157 Sliding Scale Alone is Inefficient

8. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 4.0 10.0 BreakfastLunchDinnerBedtime BG (mmol/L)Bolus insulin (U) < 4Call MD 4.1 – 10.00 10.1 – 13.02 13.1 – 16.04 16.1 – 19.06 > 19.0Call MD 6.0 Bolus insulin QID 14.0 6.0 16.5 3.0 Sliding Scale alone What do you do? +4 U 0 U +6 U QID: four times daily; SSI: sliding-scale insulin; BG: blood glucose Sliding Scale Insulin Alone Results in Variable Glucose Control BG (mmol/L)

9. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Use BASAL + BOLUS + CORRECTION In-hospital circumstances may warrant temporarily holding other antihyperglycemic medications (eg. renal or hepatic impairment) Insulin = treatment of choice BASAL + BOLUS + CORRECTION Insulin BOLUS + CORRECTION BASAL BreakfastLunchDinner

10. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association BASAL + BOLUS + CORRECTION Results in Smoother Glycemic Control 4.0 10.0 BreakfastLunchDinnerBedtime BG (mmol/L)Bolus insulin (U) < 4Call MD 4.1 – 10.00 10.1 – 13.02 13.1 – 16.04 16.1 – 19.06 > 19.0Call MD 6.0 12.0 6.0 Correctional Insulin AC meals What do you do? 6+2 U 6+0 U 6U What do you do? 6+0 U 6.0 ROUTINE Bolus insulin Basal insulin 6U 18 U Routine Basal

11. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association * * ŧ ŧ † † RABBIT 2RABBIT 2 Surgery Adapted from: Umpierrez GE, et al. Diabetes Care 2007;30:2181-86. Adapted from: Umpierrez GE, et al. Diabetes Care 2011;34:256-61. Basal-Bolus (BBI) Regimen Achieves Better Control than Sliding Scale (SSI) Alone Blood glucose (mmol/L) ¶ ¶ ¶ * * * Admit 12345678910 Duration of treatment (days) 5.6 6.7 7.8 8.9 10.0 11.1 12.2 13.3 *p < 0.01; ¶ p < 0.05. ¶ SSI BBI 1 Randomi -zation 23456789 Duration of treatment (days) 6.7 7.8 8.9 10.0 11.1 13.3 *p < 0.001, ŧp = 0.02, †p = 0.01 SSI BBI

12. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Protocols for hypoglycemia avoidance, recognition and management should be implemented with nursing-initiated treatment Patients at risk of hypoglycemia should have ready access to an appropriate source of glucose at all times Insulin protocols and order sets may be used to improve adherence to optimal insulin use and glycemic control Avoid Hypoglycemia

13. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 1.Provided that their medical conditions, dietary intake, and glycemic control are acceptable, people with diabetes should be maintained on their pre- hospitalization oral anti-hyperglycemic agents or insulin regimens [Grade D, Consensus] Recommendation 1

14. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association Recommendation 2 2.For hospitalized patients with diabetes treated with insulin, a proactive approach that includes basal, bolus, and correction (supplemental) insulin, along with pattern management, should be used to reduce adverse events and improve glycemic control, instead of the reactive sliding-scale insulin approach that uses only short- or rapid-acting insulin [Grade B, Level 2]

15. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 3.For the majority of non critically ill patients treated with insulin, pre-meal BG targets should be 5.0 to 8.0 mmol/L in conjunction with random BG values <10.0 mmol/L, as long as these targets can be safely achieved [Grade D, consensus] 4.For most medical/surgical critically ill patients with hyperglycemia, a continuous IV insulin infusion should be used to maintain glucose levels between 8.0-10.0 mmol/L [Grade D, consensus] 2013 Recommendations 3 and 4

16. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 5.To maintain intraoperative glycemic levels between 5.5-10.0 mmol/L for patients with diabetes undergoing CABG, a continuous IV insulin infusion protocol administered by trained staff, [Grade C, Level 3] should be used 6.Perioperative glycemic levels should be maintained between 5.0-10.0 mmol/L for most other surgical situations, with appropriate protocol and trained staff to ensure safe and effective implementation of therapy and to minimize the likelihood of hypoglycemia [Grade D, Consensus] 2013 Recommendations 5 and 6

17. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 7.In hospitalized patients, hypoglycemia should be avoided: –Protocols for hypoglycemia avoidance, recognition and management should be implemented with nurse –initiated treatment, including glucagon for severe hypoglycemia when IV access is not readily available [Grade D, consensus] –Patients at risk of hypoglycemia should have ready access to an appropriate source of glucose (oral or IV) at all times, particularly when NPO or during diagnostic procedures [Grade D, Consensus] 2013 Recommendation 7

18. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association 8.Healthcare professional education, insulin protocols and order sets may be used to improve adherence to optimal insulin use and glycemic control [Grade C, Level 3] 9.Measures to assess, monitor, and improve glycemic control within the inpatient setting should be implemented, as well as diabetes-specific discharge planning [Grade D, Consensus] 2013 Recommendation 8 and 9

19. guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association CDA Clinical Practice Guidelines http://guidelines.diabetes.cahttp://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca http://diabetes.ca – for patients