Inpatient Hyperglycemia Management

Inpatient Hyperglycemia: General Points Avoid the temptation to “ignore” the patient’s diabetes Try to distinguish type 1 and type 2 diabetes. Patients with type 1 diabetes will require at least some basal insulin at ALL times, even when NPO. Assess pre-admission medications and recent glycemic control. Diet should be individualized, based on body weight and other comorbidities. Consider a nutrition services consult.

General Points, continued Order fingerstick glucose monitoring 4 times daily in all patients with diabetes (pre-meal and hs if eating; q6h if NPO) for at least the first 48 hours Glucose targets in non-pregnant, non-ICU patients should be 90-130 mg/dl, with glucose readings before meals. * Revise insulin doses every 1-2 days based on results of fingerstick glucose testing. * Current position statements suggest premeal targets <110 mg/dl, and < 180 mg/dl at all other times for non-ICU patients

Blood Glucose Targets Labor and Delivery Critical Care Units 100 mg/dl Critical Care Units 110 mg/dl Non-Critical Care Units 90-130 mg/dl pre-meal (midpoint 110 mg/dl) 180 mg/dl maximal American Diabetes Association, 2005

Glucose Measurements The standard measure is venous or plasma glucose Whole blood glucose is 12-15% less than venous glucose, and may be influenced by hematocrit Arterial blood is 7% greater that venous blood, with less of a difference in fasting or postabsorptive states Capillary (fingerstick) blood is similar to arterial blood From a practical standpoint, capillary blood or arterial blood are used for glucose measurements in hospital, and in a fasting state, are sufficiently close to venous measurements to guide therapy

General Points, continued Do NOT leave patients on regular insulin “sliding scale” as the ONLY form of treatment. Try to approximate the at home regimen as long as possible BEFORE discharge Utilize the admission as a teaching opportunity for those patients who lack knowledge about their diabetes. Consider Diabetes Education consultation.

For patients treated with oral agents prior to admission: NPO, well-controlled on oral hypoglycemic agents (OHA): D/C OHA and use TEMPORARY insulin “sliding scale” NPO, well-controlled on oral agent that does not result in hypoglycemia: D/C metformin Thiazolidinediones may be continued D/C alpha-glucosidase inhibitors

For patients treated with oral agents prior to admission: NPO, poorly controlled on OHA: Use insulin. “Sliding scale” can be used for 24-48 hours. If it is clear that patients will require insulin on discharge, proceed with the addition of a long/intermediate-acting insulin

For patients treated with oral agents prior to admission: Eating, well-controlled on OHA or other oral agent: Continue OHA D/C metformin if unstable, in CHF, dehydrated or with impaired renal function Continue thiazolidinediones Continue alpha-glucosidase inhibitors

For patients treated with oral agents prior to admission: Eating, but poorly controlled on oral agents: Consider adding a second agent, HOWEVER, since this often takes weeks to optimize, it is usually preferable to proceed with insulin therapy.

For NPO insulin-treated patients: Type 1 DM Consider using an iv insulin infusion. (This technique is underutilized in hospital) Alternatively, give 1/2-2/3 of intermediate/long-acting insulin + “sliding scale” Unless markedly hyperglycemic, provide D5W Check BG every 6 hours (q 1-2 hours on iv insulin) NOTE: Insulin is NEVER to be stopped entirely in patients with type 1 diabetes. Type 2 DM Insulin-treated patients may demonstrated excellent control when diet restricted alone, and may require only “sliding scale” Alternatively, give ½ of long/intermediate-acting insulin + “sliding scale” Unless markedly hyperglycemic, provide D5W with insulin Check BG every 6 hours NOTE: Significantly insulinopenic patients are more easily managed as if they had type 1 diabetes, i.e., with iv insulin

For insulin-treated patients who are eating: Continue usual insulin regimen. It may be desirable for the knowledgeable and skilled patient to perform diabetes self-management while in hospital.

Fingerstick Glucose Monitoring Perform 4 times daily (ac and hs) for patients on most insulin regimens. Perform 1-2 times daily for patients on oral agents or only one insulin injection, if in good control. Fingerstick glucose should be recorded on a bedside log, along with the corresponding insulin administered (all types of insulin)

Hypoglycemia orders: Patient alert and cooperative: Non-alert patient: Give 15 gm CHO 4 oz juice/soda is 15 gm carbohydrate 3-2.5 inch graham crackers is 15 gm carbohydrate Recheck in 15 minutes, repeat until glucose > 70 mg/dl Non-alert patient: Give 25 gm dextrose iv (1/2 amp D50W) or 1 mg glucagon im (if no venous access). Recheck glucose after 5-10 minutes, retreat as necessary. If severe, or related to OHA or long-acting insulin, consider iv dextrose as D5W or D10W. Investigate cause and modify treatment regimen as indicated.

Think Twice When Ordering “Sliding Scales” Regular insulin “sliding scale” should be discouraged as the sole diabetes treatment in hospitalized patients, since it does little more than respond in a belated fashion to poor glycemic control. Instead, treatment of hyperglycemia in a proactive fashion is preferred, with use of long-acting insulins in combination with short and rapid acting insulins, i.e., physiologic insulin replacement. In certain patients who are NPO, or in those in whom it is difficult to predict requirements, “sliding scale” for 24-48 hours is acceptable. Patients with severe insulin deficiency (all type 1 and some type 2 patients) must also be provided basal insulin replacement.

Peri-Op Orders: General Points Type 1 diabetes: Patients need insulin at ALL times, even NPO. Place on iv insulin If on HS insulin glargine, this can be given as usual Type 2 diabetes: Hold OHA, metformin, and alpha-glucosidase inhibitors on the day of procedure. Hold sustained release metformin the day before. Thiazolidinediones can be given, if pills allowed. If on insulin, give ½ of intermediate insulin (NPH) in the morning, or continue insulin glargine OR

Intravenous Insulin Infusion Indications: Diabetic ketoacidosis* Hyperosmolar hyperglycemic state* Uncontrolled diabetes despite subcutaneous insulin Total parenteral nutrition (TPN) Patients with type 1 diabetes who are NPO, perioperative, in labor and delivery Any patient post-MI with hyperglycemia Any ICU patient with hyperglycemia * Should NOT use preprinted iv insulin orders. See Diabetes Care 2004;27(1):S94

Continuous Intravenous Insulin Discontinue previous insulin orders (there may be overlapping basal insulin) Carbohydrate is to be given at the same time Enteral feeding CVN D5W 0.45 NS

Continuous Intravenous Insulin Insulin infusion is Regular insulin 100 units/100 ml of Sodium Chloride 0.9 % (1 unit of insulin/1 ml of NS) Target blood sugar can be specified but is recommended to be 90-130 mg/dl

Dose Adjustments Four algorithms with insulin infusion rates for blood sugar ranges are used to determine dose adjustments To make a dose adjustment you need to know Algorithm being used Current blood sugar Previous blood sugar

Dose Adjustments The previous blood sugar compared with the current blood sugar may determine the need to Move up to the next higher algorithm (e.g., from algorithm 2 to algorithm 3) or Down to the next lesser algorithm (e.g., from algorithm 2 to algorithm 1)

Dose Adjustments Current blood sugar and where it is located in the algorithm being used may determine the dose adjustment Blood sugar of 126 mg/dl in algorithm 2 is a rate of 1.5 units/hour If the blood sugar is greater than 140 mg/dl and it is increasing, it will be necessary to move up to the next higher algorithm

Rate Adjustment Criteria Previous Blood Sugar Current Blood Sugar Adjustment Greater than 200 mg/dl Decreased by at least 60 mg/dl Stay in the same algorithm; adjust rate as per algorithm Does not decrease by at least 60 mg/dl (or is increasing) Move up to the next higher algorithm; adjust rate as per algorithm

Rate Adjustment Criteria Previous Blood Sugar Current Blood Sugar Adjustment 140-200 mg/dl Decreased by at least 30 mg/dl Stay in same algorithm; adjust rate as per algorithm Does not decrease by alt least 30 mg/dl (or is increasing) Move up to the next higher algorithm; adjust rate as per algorithm

Rate Adjustment Criteria Previous Blood Sugar Current Blood Sugar Adjustment Any value Decreased by more than 100 mg/dl in one hour Move down to the next lesser algorithm; adjust rate as per algorithm; if already in algorithm 1, decrease the infusion by half

Rate Adjustment Criteria Current Blood Sugar Adjustment Blood sugar less than 70 mg/dl STOP THE INFUSION. Recheck blood sugar every 15 minutes. Resume insulin infusion at the next lesser algorithm when the glucose is greater than 110 mg/dl. If already using algorithm 1, decrease the infusion by half. The half life of intravenous insulin is 5-10 minutes.

Rate Adjustment Criteria Current Blood Sugar Adjustment Blood sugar less than 50 mg/dl STOP THE INFUSION. If patient alert and able to take fluids , give 15 grams of carbohydrate orally. If patient confused or unconscious, or NPO, give 25 ml of 50 % Dextrose IV. Recheck blood sugar every 15 minutes. Repeat oral carbohydrate or IV 50% Dextrose every 15 minutes until blood sugar is greater than 70 mg/dl. Resume insulin infusion at the next lesser algorithm when the glucose is greater than 110 mg/dl. If already using algorithm 1, decrease the infusion by half.

Scheduled Subcutaneous Insulin Orders Pre-meal or bolus insulin Insulin type Number of units Basal insulin

Scheduled Subcutaneous Insulin Orders Pre-meal correction insulin algorithms based on insulin sensitivity Low dose algorithm for patients who require up to 40 units of insulin /day Medium dose algorithm for patients requiring 40-80 of insulin/day High dose algorithm for patient requiring over 80 units of insulin/day Individualized algorithm for correction may be written instead

Scheduled Subcutaneous Insulin Orders Targets are specified Frequency and timing of blood sugar checks are to be specified Point-of- care test results done within 30 minutes are used to determine correction dose Correction doses are given pre-meal only Aspart or lispro 5-15 minutes before the start of the meal Regular 30 minutes before the start of the meal

The Goal of Insulin Therapy is Physiologic Replacement American Diabetes Association (2003). Insulin therapy in the 21st century. Alexandria, VA: ADA.

Starting Insulin in the Newly Diagnosed Patient Calculate the total daily dose* Determine basal insulin requirement 40 to 50% of total daily dose Determine the mealtime insulin requirement 50 to 60% of total daily dose Determine the correction dose Based on estimate of insulin sensitivity * Total daily dose can be estimated based on iv requirements or weight

Transition From IV to SQ Insulin IV insulin covers basal insulin requirements in the NPO patient Example: iv dose is 2 units/hour Basal requirements: 2 u/h x 24 hrs= 48 units 48 u x 80% = 38 units basal sq insulin dose Food requirements equal basal requirements when eating: 38/3 = 13 units with each meal Correction requirements are based on the “1700 rule”* 1700 / total daily dose or 1700/76 = ~25 (1 u lowers glucose 25 mg/dl) Regimen: 13 u rapid acting insulin analog before meals 38 u insulin glargine at bedtime premeal correction: 1 u for every 25 mg/dl above target * The “1700 rule” is simply an observation that estimates insulin sensitivity

Total Daily Dose Based on Weight Patient Description Insulin (units/kg.day) Trained athlete 0.5 Mod. active man 0.6 Sedentary man; 1st trimester of pregnancy 0.7 Mod. stressed man; 2nd trimester of pregnancy 0.8 Severely stressed man; 3rd trimester of pregnancy 0.9 Systemic bacterial infection; full term pregnancy 1.0 Severely ill man 1.5-2.0

Subcutaneous Insulin Dose Based on Weight Example: 70 kg man x 0.6 u/kg = 42 units total daily dose Basal insulin = 42 x 50% = 21 units Food insulin = 21/3 = 7 units with each meal Correction insulin = 1700/42 =~40 Suggested insulin regimen: 7 units rapid acting insulin analog each meal 21 units insulin glargine at bedtime Premeal correction insulin 1 unit for every 40 mg/dl above target

Remember… Aggressive glycemic control in hospitalized patients improves clinical outcomes. Management of diabetes in an inpatient setting requires familiarity with the use of both iv and sc insulin, both in intensive care units and on general nursing units. The time-honored traditions of “sliding scale” insulin, and of withholding insulin for procedures and euglycemia should be buried along with fractional urine testing.

Remember… Most hospitalized patients are discharged Inpatient diabetes treatment should transition smoothly to outpatient management Think ahead; plan early ? Dietary consultation ? Diabetes education consultation ? Endocrinology consultation