1. Inpatient Management of Diabetes Mellitus
William Harper, MD, FRCPC
Endocrinology & Metabolism
Assistant Professor of Medicine, McMaster University

2. DKA Monitored setting if Hi-risk IV Fluid Resuscitation (6-8L deficit)
elderly & CAD, pH < 7.0, severe K disturbance, decreased LOC
IV Fluid Resuscitation (6-8L deficit)
Potassium (“no pee no K”)
IV insulin
Identify & Rx underlying cause
Noncompliance, infection, MI, etc.

3. DKA: IV Fluids
IV NS 1L/h x 2-3h or longer so no more tachycardia, hypotension, orthostatic changes, low JVP.
Then change to 1/2 NS:
500 cc/h x 1-3h
250 cc/h x 4-6h
If hypotension recalcitrant to fluids consider AI (Schmidt PGAS II) and send stat cortisol then give solucortef 100 mg IV q8h.

4. DKA: Mortality Adults 2-4% Kids 0.2-0.4% Hypokalemia MI, CVA, etc.
Cerebral edema

5. DKA: Potassium Need K with initial IV fluid & insulin Rx unless:
Anuric
K > 5.5 mEq/L or hyperkalemic ECG changes
Initial [K]
Replacement
> 5.5 mEq/L
nil (initially)
mEq/L
10 mEq/h
4-5.2 mEq/L
20 mEq/h
3-4 mEq/L
30 mEq/h
< 3 mEq/L
40 mEq/h
> 20 mEq/h:
Cardiac monitor
> 60 mEq/L:
Central line

6. DKA: IV Insulin Humulin R or Novolin Toronto Bolus 0.1-0.2 U/kg IV
Then IV U/kg/h
(50 U of regular insulin in 500cc D5W; 1U/10cc)
Monitor: CBG q1h
Monitor: Venous BS, electrolytes, creatinine q2h
Aim is to demonstrate correction of Anion Gap (AG) and decrease in BS 4.4 mM/L/h
Monitoring serial serum ketones NOT useful:
ßHß (not detected) DKA Rx Acetoacetate (detected)

7. DKA: IV Insulin
Using insulin to treat 2 different and separate metabolic disturbances in DKA:
Ketoacidosis
Hyperglycemia

8. DKA: IV Insulin
If AG not correcting and/or BS not decreasing then increase IV gtt rate 1.5-2X
If BS < 13 but AG still not corrected do NOT decrease insulin IV gtt.
Instead start IV glucose gtt:
cc/h
Once AG corrected than titrate IV insulin to BS
When BS < 13 and AG normal: reduce IV insulin gtt to 1-2 U/h and add IV glucose if not already done.

9. DKA: IV Insulin Can consider switch to SC insulin when:
AG normalized
BS < 15 mM
Insulin IV gtt requirements < 2U/h
Patient able to eat
Overlap insulin IV gtt with 1st SC insulin by 3-4h to avoid recurrent ketosis.

10. DKA: Other Rx Bicarbonate Phosphate May exacerbate hypokalemia
Only give if pH < 6.9 AND evidence of cardiovascualr instability (arrythmia, CHF, hypotension)
1-2 amps bicarb in 1L D5W IV over 2h until pH > 7.1
Phosphate
Routine IV not recommended
Rx symptomatic hypophosphatemia (rhabdo, unexplained CHF or respiratory failure, severe confusion)
10cc K Phos soln (3.0mEq Pi and 4.4 mEq K/cc) in 1L NS IV over 8-12h

11. DKA: Other Rx Cerebral Edema Usually only kids
Persistent decreased LOC despite standard Rx of DKA
CT scan to confirm diagnosis
Decadron 10 mg IV
Mannitol 25 mg IV

12. HONC
BS > 55
Serum OSM > 350
Coma 25-50%
Mortality rate 25-70%

13. HONC Coma Management IV Fluid Resusciation (10L free water defecit)
ABCs, O2, narcan, D50W, thiamine, etc.
IV Fluid Resusciation (10L free water defecit)
Insulin
IV fluids will decrease BS by 4 mM/L/h by itself
For most patients insulin not absolutely neccesary
Insulin IV bolus 5-10 U, 1-2 U/h
Potassium (replace as in DKA)
Identify & Rx underlying precipitant

14. BS > 11.1 mmol/L Renal threshold for glycosuria (normal GFR)
Decreased WBC function
Chemotaxsis
Phagocytosis
Decreased Wound Healing

15. Goals of Inpatient DM Management
“Avoid hypoglycemia and marked hyperglycemia”
Target BS: mM
Avoid Hypoglycemia
Precipitating arrhythmia or other cardiac events
Inducing seizure, focal or cognitive defects periop
Avoid Marked Hyperglycemia (BS > 11.1 mM)
Treat (and avoid) DKA, HONC

16. DM Inpatient Management
Eating
NPO: temporary (for a test)
NPO: prolonged

17. DM Inpatient Management
Eating:
OHA (T2DM)
Insulin (T2DM and T1DM)

18. α-glucosidase Inhibitor
OHA:
Drug BG
HbA1c
Side-effects
Sulfonylurea
FBG 20% %
Hypoglycemia
Weight gain
Biguanide
Lactic acidosis
GI intolerance
TZD
FBG mM %
Edema
α-glucosidase Inhibitor
FPG 14%
PPG 25%
0.5%
Meglitinide
FPG 4 mM
PPG 5.6 mM
1.8%

20. Insulin Type Starts Peaks Duration Humalog NovoRapid 5-10 min 1-2 hrs
Regular
30 min
2-4 hrs
6-8 hrs
NPH
Lente
6-10 hrs
16-24 hrs
Ultralente
4-6 hrs
8-24 hrs
24-36 hrs
Glargine
Immediately
None
Up to 24 hrs

21. BIDS Therapy T2DM: “Introduction to insulin” Keep on OHAs
Start NPH 0.2 U/kg SC qhs
Increase by 2-4 U q4d until FBS 4-7
If dose > 30-40U or if BS high late in day despite OK FBS than split into 2 injections with 2/3 acB and 1/3 acD

22. Starting Insulin Regimen
TDD = U/kg
“2/3, 1/3” Regimens
2/3 of TDD acB, 1/3 acD
2/3 of TDD as Long-acting, 1/3 as short acting
Pre-mix: acB 30/70 acD 30/70
MDI Regimens
2/3, 1/3 Regimen: move acD long acting to qhs
i.e. acB N, H acD H qhs N
ac meals H qhs N (bolus 60%, basal 40%)
ac meals H UL q12h (bolus 50%, basal 50%)

23. Insulin Regimens acB acL acD qhs Bedtime NPH (+/-bids) N NPH bid N N
MDI (3 injections) H + N H N
MDI (>4 injections) H (+/-N) H H N
MDI (>4 injections) H + UL H H UL
CSII (Insulin Pump)

24. Guideline for Insulin Adjustments
Adjust the insulin that accounts for the high or low reading.
Always compare an abnormal BS reading with the one previous.
If insulin dose is:
Less than 8U, adjust by 1U
8-20U, adjust by 2U
> 20 U, adjust by 10% (increase), 20% (decrease)
Don’t forget to compensate for a successful adjustment

25. acB acL acD qhs Rx 22 (5R) 9 3.1 (O.J.) 15 20 7 8 17 acB N20 R10
acD R5
qhs N10 20 7 8
acD R5
qhs N10 17
(RN calls)
Surgeon: ?
Internal Medicine: ?
Endocrinologist: ?

26. acB acL acD qhs Rx 22 (5R) 9 3.1 (O.J.) 15 20 7 8 17 acB N20 R10
acD R5
qhs N10 20 7 8
acD R5
qhs N10 17
(RN calls)
Surgeon: Give 5 U Regular SC now
Internist: Increase qhs N to 12 tonight and acB R to 12 tomorrow
Endocrine: Increase qhs N to 12 start tonight
Decrease acB N15 R7 starting tomorrow AM
Check 3AM BS tonight

27. Guideline for Insulin Adjustments
Adjust the insulin that accounts for the high or low reading.
Always compare an abnormal BS reading with the one previous.
If insulin dose is:
Less than 8U, adjust by 1U
8-20U, adjust by 2U
> 20 U, adjust by 10% (increase), 20% (decrease)
Don’t forget to compensate for a successful adjustment

28. SC Insulin Supplemental Scale
CBG
Action
< 4.0
Call MD
nil
Humalog 7U SC (0.1U/kg)
Humalog 10U SC (0.15 U/kg)
> 20.0

29. DM Inpatient Management
Eating
NPO: temporary (for a test)
NPO: prolonged

30. NPO for a test: T2DM on Diet Rx
Schedule test for the AM
Hold OHAs on AM of test
7AM:
< 3.0 Consider postpone test
IV D5W cc/h
Proceed with test, no Rx necessary
> 11.1 IV insulin gtt
IV D5W cc/h
> 20.0 Check urine ketones, consider postpone test

31. NPO for a test: T1/T2DM on Insulin
Schedule the test for the AM
Hold AM Insulin on day of test
7AM:
< 3.0 Consider postpone test
Give ½ of total AM insulin dose as NPH SC
IV D5W cc/h
> 11.1 IV insulin gtt
> 20.0 Check urine ketones, consider postpone test

32. DM Inpatient Management
Eating
NPO: temporary (for a test)
NPO: prolonged
Patient put on D5W if not on feeds or TPN
IV insulin gtt
SC NPH or UL q12h (+/- supplemental scale)

33. Insulin IV gtt
Add 50 U of Human regular insulin (Humulin R or Novolin Toronto) to 500cc D5W (1U/10cc).
Flush & discard first 50cc.
Infuse insulin solution by IVAC (intravenous infusion pump), piggybacked into D5W running at 100cc/h.
Start 0.9 U/h (9cc/h) or start at a rate dependent on patient’s insulin dose:
IV insulin gtt rate = ( ½ TDD ) / 24

34. Insulin IV gtt
CPG q1h x 2, then q2h (if BS stable x 2-3 readings consider q4h):
Adjust Insulin IV infusion rate as per scale below:
< Call MD
U/h ( 7cc/h)
U/h ( 9cc/h)
U/h (12cc/h)
U/h (15cc/h)
U/h (20cc/h)
U/h (25cc/h)
U/h (30cc/h)
U/h (35cc/h)
U/h (40cc/h)
> Call MD

35. Evidence to support Inpatient BS control?
DIGAMI
AMI, prior dx DM or BS > 11 mM
IV insulin gtt 5 U/h
Titrated to keep BS mM
Insulin IV > 24h  MDI > 3 months
No in-hospital mortality benefit.
Rx Increased hospitalization by 1.8d
0.5% reduction 3 months
@ 1 year % on Insulin: 72% Rx Group 49% Cntrl Group
1 year mort: ARR 7.5% NNT 13
3.4 y mort: ARR 11% NNT 9

36. Evidence to support Inpatient BS control?
Leuven, Belgium Study
ICU patients (63% CV Sx)
If BS > 6.1 mM: Rx with IV insulin gtt & TPN +/- tube feeds
Start IV 2-4 U/h, titrated to BS mM
Ave insulin dose: Rx group 3.0 U/h Cntrl group 1.4 U/h
Once out of ICU relaxed treatment goal to < 11.1 mM
Mortality in ICU: ARR 3.4% NNT 29
Mortality in-hospital: ARR 3.7% NNT 27
Greatest reduction in mortality was sepsis-related.
Insulin Rx reduced: bacteremia, ARF needing HD, need for PRBC, critical illness polyneuropathy, duration of ventilation and length of stay in ICU
To what extent were benefits nutrition related as opposed to insulin related?