2 Inpatient Hyperglycemia: General Points Avoid the temptation to “ignore” the patient’s diabetesTry 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.
3 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 hoursGlucose targets in non-pregnant, non-ICU patients should be 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
4 Blood Glucose Targets Labor and Delivery Critical Care Units 100 mg/dlCritical Care Units110 mg/dlNon-Critical Care Unitsmg/dl pre-meal (midpoint 110 mg/dl)180 mg/dl maximalAmerican Diabetes Association, 2005
5 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 hematocritArterial blood is 7% greater that venous blood, with less of a difference in fasting or postabsorptive statesCapillary (fingerstick) blood is similar to arterial bloodFrom 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
6 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 dischargeUtilize the admission as a teaching opportunity for those patients who lack knowledge about their diabetes. Consider Diabetes Education consultation.
7 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 metforminThiazolidinediones may be continuedD/C alpha-glucosidase inhibitors
8 For patients treated with oral agents prior to admission: NPO, poorly controlled on OHA:Use insulin. “Sliding scale” can be used for hours. If it is clear that patients will require insulin on discharge, proceed with the addition of a long/intermediate-acting insulin
9 For patients treated with oral agents prior to admission: Eating, well-controlled on OHA or other oral agent:Continue OHAD/C metformin if unstable, in CHF, dehydrated or with impaired renal functionContinue thiazolidinedionesContinue alpha-glucosidase inhibitors
10 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.
11 For NPO insulin-treated patients: Type 1 DMConsider 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 D5WCheck 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 DMInsulin-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 insulinCheck BG every 6 hoursNOTE: Significantly insulinopenic patients are more easily managed as if they had type 1 diabetes, i.e., with iv insulin
12 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.
13 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)
14 Hypoglycemia orders: Patient alert and cooperative: Non-alert patient: Give 15 gm CHO4 oz juice/soda is 15 gm carbohydrate3-2.5 inch graham crackers is 15 gm carbohydrateRecheck in 15 minutes, repeat until glucose > 70 mg/dlNon-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.
15 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 hours is acceptable. Patients with severe insulin deficiency (all type 1 and some type 2 patients) must also be provided basal insulin replacement.
17 Peri-Op Orders: General Points Type 1 diabetes:Patients need insulin at ALL times, even NPO.Place on iv insulinIf on HS insulin glargine, this can be given as usualType 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 glargineOR
18 Intravenous Insulin Infusion Indications:Diabetic ketoacidosis*Hyperosmolar hyperglycemic state*Uncontrolled diabetes despite subcutaneous insulinTotal parenteral nutrition (TPN)Patients with type 1 diabetes who are NPO, perioperative, in labor and deliveryAny patient post-MI with hyperglycemiaAny ICU patient with hyperglycemia* Should NOT use preprinted iv insulin orders. See Diabetes Care 2004;27(1):S94
19 Continuous Intravenous Insulin Discontinue previous insulin orders (there may be overlapping basal insulin)Carbohydrate is to be given at the same timeEnteral feedingCVND5W 0.45 NS
20 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 mg/dl
21 Dose AdjustmentsFour algorithms with insulin infusion rates for blood sugar ranges are used to determine dose adjustmentsTo make a dose adjustment you need to knowAlgorithm being usedCurrent blood sugarPrevious blood sugar
22 Dose AdjustmentsThe previous blood sugar compared with the current blood sugar may determine the need toMove up to the next higher algorithm (e.g., from algorithm 2 to algorithm 3) orDown to the next lesser algorithm (e.g., from algorithm 2 to algorithm 1)
23 Dose AdjustmentsCurrent blood sugar and where it is located in the algorithm being used may determine the dose adjustmentBlood sugar of 126 mg/dl in algorithm 2 is a rate of 1.5 units/hourIf 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
24 Rate Adjustment Criteria Previous Blood SugarCurrent Blood SugarAdjustmentGreater than 200 mg/dlDecreased by at least 60 mg/dlStay in the same algorithm; adjust rate as per algorithmDoes not decrease by at least 60 mg/dl (or is increasing)Move up to the next higher algorithm; adjust rate as per algorithm
25 Rate Adjustment Criteria Previous Blood SugarCurrent Blood SugarAdjustmentmg/dlDecreased by at least 30 mg/dlStay in same algorithm; adjust rate as per algorithmDoes not decrease by alt least 30 mg/dl (or is increasing)Move up to the next higher algorithm; adjust rate as per algorithm
26 Rate Adjustment Criteria Previous Blood SugarCurrent Blood SugarAdjustmentAny valueDecreased by more than 100 mg/dl in one hourMove down to the next lesser algorithm; adjust rate as per algorithm; if already in algorithm 1, decrease the infusion by half
27 Rate Adjustment Criteria Current Blood SugarAdjustmentBlood sugar less than 70 mg/dlSTOP 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.
28 Rate Adjustment Criteria Current Blood SugarAdjustmentBlood sugar less than 50 mg/dlSTOP 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.
29 Scheduled Subcutaneous Insulin Orders Pre-meal or bolus insulinInsulin typeNumber of unitsBasal insulin
30 Scheduled Subcutaneous Insulin Orders Pre-meal correction insulin algorithms based on insulin sensitivityLow dose algorithm for patients who require up to 40 units of insulin /dayMedium dose algorithm for patients requiring of insulin/dayHigh dose algorithm for patient requiring over 80 units of insulin/dayIndividualized algorithm for correction may be written instead
31 Scheduled Subcutaneous Insulin Orders Targets are specifiedFrequency and timing of blood sugar checks are to be specifiedPoint-of- care test results done within 30 minutes are used to determine correction doseCorrection doses are given pre-meal onlyAspart or lispro 5-15 minutes before the start of the mealRegular 30 minutes before the start of the meal
32 The Goal of Insulin Therapy is Physiologic Replacement American Diabetes Association (2003). Insulin therapy in the 21st century. Alexandria, VA: ADA.
33 Starting Insulin in the Newly Diagnosed Patient Calculate the total daily dose*Determine basal insulin requirement40 to 50% of total daily doseDetermine the mealtime insulin requirement50 to 60% of total daily doseDetermine the correction doseBased on estimate of insulin sensitivity* Total daily dose can be estimated based on iv requirements or weight
34 Transition From IV to SQ Insulin IV insulin covers basal insulin requirements in the NPO patientExample: iv dose is 2 units/hourBasal requirements: 2 u/h x 24 hrs= 48 units48 u x 80% = 38 units basal sq insulin doseFood requirements equal basal requirements when eating:38/3 = 13 units with each mealCorrection 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 meals38 u insulin glargine at bedtimepremeal correction: 1 u for every 25 mg/dl above target* The “1700 rule” is simply an observation that estimates insulin sensitivity
35 Total Daily Dose Based on Weight Patient DescriptionInsulin (units/kg.day)Trained athlete0.5Mod. active man0.6Sedentary man; 1st trimester of pregnancy0.7Mod. stressed man; 2nd trimester of pregnancy0.8Severely stressed man; 3rd trimester of pregnancy0.9Systemic bacterial infection; full term pregnancy1.0Severely ill man
36 Subcutaneous Insulin Dose Based on Weight Example:70 kg man x 0.6 u/kg = 42 units total daily doseBasal insulin = 42 x 50% = 21 unitsFood insulin = 21/3 = 7 units with each mealCorrection insulin = 1700/42 =~40Suggested insulin regimen:7 units rapid acting insulin analog each meal21 units insulin glargine at bedtimePremeal correction insulin 1 unit for every 40 mg/dl above target
37 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.
38 Remember… Most hospitalized patients are discharged Inpatient diabetes treatment should transition smoothly to outpatient managementThink ahead; plan early? Dietary consultation? Diabetes education consultation? Endocrinology consultation