1. Inpatient Glycemic Management
Shruti Scott, DO, MPH
UCI Hospitalist Program
July 24, 2013
I am part of the medication safety review committee and hypoglycemia continues to be the leading cause of all medication induced errors. Insulin management amongst our diabetic patients is not easy and its not black and white either. Many factors need to be taken into consideration when you evaluate your diabetic patients: due they have an infection that is causing their blood sugars to be higher then their baseline, are they experiencing nausea and/or vomiting leading to decreased po intake, what is there po intake in the hospital, are they being placed on steroids, etc.

3. Pharmacokinetics of Insulin Products
Rapid (lispro, aspart, glulisine) (Humalog/Novolog/Apidra)
Insulin
Level
Short (regular)
Intermediate (NPH)
Long (glargine)
This slide demonstrates in graphic fashion the peak and duration of action of the various insulin formulations now available. Note that pre-mixed insulin products (i.e., 70/30, etc.) are not shown.
Long (detemir)
Hours
Adapted from Hirsch I. N Engl J Med. 2005;352:174–183.

4. Case 1
Tom has Type 2 DM, weighs 85 kg and is admitted for diabetic foot ulcer. He takes Metformin 1000mg bid, glipizide 10mg daily at home. He has a normal GFR. His hemoglobin A1c is 10 and his blood sugars since admission have ranged How do you manage his DM?

5. Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: Effect of structured subcutaneous insulin orders and an insulin management algorithm
Insulin management algorithm (front) introduced at UCSD in May 2005 (marking the onset of Time Period 3).
© This slide is made available for non-commercial use only. Please note that permission may be required for re-use of images in which the copyright is owned by a third party.
Journal of Hospital Medicine Volume 4, Issue 1, pages 3-15, 12 JAN 2009 DOI: /jhm.391

7. Case I Answer: Tom weighs 85kg, normal GFR
Using standard, 0.4unit/kg = 34 units TDD
Lantus 17 units QAM and Lispro 5 units tid before meals
Lispro Correctional
Learning Points:
Hold oral diabetes meds when inpatient (to minimize hypoglycemia and for better glycemic control)
DO NOT place diabetic patients only on Correctional Insulin
Use weight based method to get accurate insulin requirement
Adjust insulin dose for GFR: GFR > 50, no correction
GFR 30-50, 20% reduction
GFR < 30, 30-50% reduction
Its ok to only use Correctional insulin for pre-diabetics or borderline diabetic patients bc they still have enough endogenous insulin production to meet basal needs; or in patients with good glycemic control just on oral medications

8. Case 1 Learning Points Each order will have 2 or 3 types of insulin:
Basal
- provides continuous insulin coverage to diminish BS swings
Nutritional
- treats the anticipated BG increase with meals
Correctional
- corrects current BS level
Nutritional and Correctional coverage should be the same type of insulin (both Lispro or both Regular)
Correction insulin is designed to be given independent of nutritional intake.
Also remember, studies have shown that the long acting insulins (glargine or levemir) plus the rapid acting insulins (aspart or lispro) mimic physiologic production of insulin better then any other combination (such as NPH, 70/30 combos).

9. Case 2
Tom has Type 2 DM and was admitted for diabetic foot ulcer. Today is HD3 and his blood sugars have been stable with Lantus 22 units qhs, Humalog 5 units tid and Humalog Correctional. Tomorrow he is having a L foot amputation. How should his insulin regimen be adjusted?

10. Case 2 Answer Choices Hold Humalog morning dose
Cont Humalog morning dose
Hold Lantus evening dose
Decrease evening dose of Lantus
Cont evening Lantus dose
Start IVFs (NS, D5 or D10 – does it matter?)
Do nothing
Page endocrine fellow and ask him/her

11. Case 2 Answer Hold Humalog nutritional dose while pt is NPO
Cont evening Lantus dose (basal insulin)
Start IVFs (either D5 or D10)
Continue Humalog correctional coverage

12. Case 2
Learning Points
Start D5 or D10 if carb source is interrupted (NPO). The infusion rate will have to take into account the patient’s general condition (CHF, cirrhosis)
Do not hold basal insulin if long acting (levemir or glargine)
1 L of D5 1/2NS provides less calories than a small candy bar (170 calories per L)
In the Quest NPO Order Set, the number of calories (per liter IVF) is provided for you
Remember, Type I DM requires insulin AND carb source (D5 or D10) at all times (even when NPO, to prevent DKA). So if Type I diabetic is NPO, DO NOT hold basal insulin and DO start D5 or D10

13. Case 3
Tom has Type 2 DM and was admitted for diabetic foot ulcer. Today is HD3 and his blood sugars have been stable with NPH 22 units bid and Regular Correctional. Tomorrow he is having a L foot amputation. How should his insulin regimen be adjusted?

14. Pharmacokinetics of Insulin Products
Rapid (lispro, aspart, glulisine) (Humalog/Novolog/Apidra)
Insulin
Level
Short (regular)
Intermediate (NPH)
Long (glargine)
This slide demonstrates in graphic fashion the peak and duration of action of the various insulin formulations now available. Note that pre-mixed insulin products (i.e., 70/30, etc.) are not shown.
Long (detemir)
Hours
Adapted from Hirsch I. N Engl J Med. 2005;352:174–183.

15. Case 3 Answer Continue evening NPH dose Half morning NPH dose
Start patient on D5 or D10
Continue Correctional insulin
Alternatively
On admission, change from NPH to Lantus for better glycemic control

16. Case 4
Tom has Type 2 DM, admitted for diabetic foot ulcer and today is HD3. He is treated with Humalog 5 units tid & Lantus 22 units qhs. Tom has premeal bs of 65 before lunch, does not have any symptoms of hypoglycemia, what should you do?

18. PRIORITY: DRINK UP! If possible, PO FIRST
Treat the SYMPTOMS, not just the number
4 oz Juice/8 oz FF milk = 15 gram carb
15 grams carb can increase BG 30-50mg/dl
The Rule
Treat with 15 grams of carb
Recheck in 15 minutes
Retreat with 15 grams of carb and recheck every 15 minutes until BG is > 75mg/dl

19. Things to think about BG within range 70-100mg/dl
- DO NOT HOLD INSULIN (basal insulin)
- may need dose adjustment
Check to see how much patient is eating
Has patient been experiencing nausea or vomiting
For our patient Tom, if he has few premeal blood glucose readings that are low, need to decrease Lispro nutritional insulin from 5 units tid to 3 units tid

20. Case 5
Jerry is a 65 yo male who is receiving continuous TPN. He has a h/o DM, weighs 80kg and is on continuous TPN. His blood glucose readings have ranged , how do you manage his DM and hyperglycemia?

21. Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: Effect of structured subcutaneous insulin orders and an insulin management algorithm
Insulin management algorithm (front) introduced at UCSD in May 2005 (marking the onset of Time Period 3).
© This slide is made available for non-commercial use only. Please note that permission may be required for re-use of images in which the copyright is owned by a third party.
Journal of Hospital Medicine Volume 4, Issue 1, pages 3-15, 12 JAN 2009 DOI: /jhm.391

22. Case 5 Answer Start Lantus 12 units qhs Start Regular 5 units Q6H
Regular Correctional
Learning Points
For patients who are receiving continuous feeds (either TPN or tube feeds), check blood glucose levels Q6H
Regular correctional insulin preferred over Rapid acting (Aspart/Lispro) since patient is not taking food in orally and regular lasts longer then rapid acting
Use weight based method. He weighs 80kg and 0.4 units/kg/day = 32 units total daily dose
You can do 40% long acting and use 60% as short acti

23. Inpatient Diabetes Management Pearls
Hold all oral DM meds and noninsulin injectable meds on admission
If patient is on insulin, give them 2/3 of their home dose (basal and nutritional) as they don’t eat the same foods in the hospital vs at home
Always account for renal function
When NPO, always give carb source or 125 or depending on overall fluid state)
Pt should be on same insulin for nutritional and correctional

24. Diabetic Goals Avoid Hypoglycemia Avoid Severe Hyperglycemia
3. Adequate Nutrition
4. Pre-discharge education
harmful due to the effects of counter-regulatory hormones, especially catecholamines, which may possibly induce arrhythmias and other cardiac events. Studies show increased overall mortality with patients who have at least one hypo episode in the hospital even after discharge.
2) Immune system impaired, Volume depletion, Electrolyte abnormalities through osmotic diuresis
3) For the majority of critically ill patients, the American Diabetes Association and the American College of Endocrinology recommend a blood glucose target of 140 to 180 mg/dL
Oral agents should never be administered to patients who are not eating.