1. In-Patient Management of Hyperglycemia Rey Vivo, MD Assistant Professor of Medicine Texas Tech University Health Sciences Center

2. Case 1: Floor Patient 40M diabetic is admitted to the regular floor with protracted vomiting and is diagnosed with acute pyelonephritis. He takes metformin at home but does not check his glucose. Weight is 100 kg. HbA1C is 10. IV dextrose is started. In-patient glycemic values range between 250-300 mg/dL despite regular insulin sliding scale Q6. What is the best regimen while in the hospital? 40M diabetic is admitted to the regular floor with protracted vomiting and is diagnosed with acute pyelonephritis. He takes metformin at home but does not check his glucose. Weight is 100 kg. HbA1C is 10. IV dextrose is started. In-patient glycemic values range between 250-300 mg/dL despite regular insulin sliding scale Q6. What is the best regimen while in the hospital? A. Continue metformin + TZD A. Continue metformin + TZD B. D/C oral agents and start Lantus 5 U PM B. D/C oral agents and start Lantus 5 U PM C. D/C oral agents and start Lantus 30 units PM + regular insulin SS C. D/C oral agents and start Lantus 30 units PM + regular insulin SS D. D/C oral agents and start 70/30 insulin 20 units BID D. D/C oral agents and start 70/30 insulin 20 units BID

3. Answer Pre-prandial goal: 90-130 mg/dL (floor) Pre-prandial goal: 90-130 mg/dL (floor) : close to 110 mg/dL (ICU) : close to 110 mg/dL (ICU) Basal insulin (NPH or Lantus) Basal insulin (NPH or Lantus) : start at 0.2-0.3 U/kg/day : adjust 10-20% of total dose Q1-2 days Correction insulin by SS Q6 hours Correction insulin by SS Q6 hours Avoid hypoglycemia! Avoid hypoglycemia! (Beware of “brittle” diabetics.)

4. Harmful Hyperglycemia Enhanced tissue injury, poor wound healing Enhanced tissue injury, poor wound healing Increased inflammation, oxidative stress Increased inflammation, oxidative stress Lowered immune resistance Lowered immune resistance Endothelial dysfunction Endothelial dysfunction Platelet aggregation Platelet aggregation Potentiation of myocardial and cerebral ischemia Potentiation of myocardial and cerebral ischemia

5. Important Factors Severity of illness Severity of illness Concurrent medications Concurrent medications Diet Diet History of DM, meds and control History of DM, meds and control

6. Types of Insulin ONSETPEAKDURATION RAPID-acting Humalog 15-30 mins. 30 min-2.5 hrs. 3-5 hrs. SHORT-acting Regular (R) 30 min-1 hr. 2-5 hrs. 5-8 hrs. INTERMEDIATE-acting NPH (N) 1-2 hrs. 4-12 hrs. 18-24 hrs. LONG-acting Lantus 1-1.5 hrs. None 18-24 hrs. PRE-MIXED 70/30 30 mins. 2-4 hrs. 14-24 hrs. The Cleveland Clinic Health Information Center

7. Insulin Advantages Safe for any age Safe for any age Safe for heart, kidney, liver dysfunction Safe for heart, kidney, liver dysfunction Rapid onset and clearance Rapid onset and clearance Few drug interactions Few drug interactions

8. Case 1-B: Eating by mouth After 2 days, the patient feels better and starts eating. In the last 24 hours, his glucose values ranged between 180-220 mg/dL and he received total correction regular insulin dose of 20 units. What is the best approach now? After 2 days, the patient feels better and starts eating. In the last 24 hours, his glucose values ranged between 180-220 mg/dL and he received total correction regular insulin dose of 20 units. What is the best approach now? A. Do no changes A. Do no changes B. Retain current insulin therapy and resume metformin + TZDs B. Retain current insulin therapy and resume metformin + TZDs C. Increase Lantus to 32 U PM + regular insulin SS C. Increase Lantus to 32 U PM + regular insulin SS D. Increase Lantus to 36 U PM + 2 U regular insulin pre-meals D. Increase Lantus to 36 U PM + 2 U regular insulin pre-meals E. Increase Lantus to 36 U PM + regular insulin 5 U pre-meals + regular insulin SS E. Increase Lantus to 36 U PM + regular insulin 5 U pre-meals + regular insulin SS

9. Answer When a patient starts eating… May continue oral agents IF no contraindications or if glucose controlled May continue oral agents IF no contraindications or if glucose controlled GLUCOSE TOXICITY GLUCOSE TOXICITY Recommendation: Basal + Recommendation: Basal + Prandial (0.05-0.1 U/kg/day) + Correction insulin Prandial (0.05-0.1 U/kg/day) + Correction insulin

10. Case 2: Cont. Enteral Feeds 70M with stroke requires continuous G-tube feeding. Pre- hospital glucose regimen was sulfonylurea and metformin. Glucose values are consistently greater than 180 mg/dL with a caloric intake of 20 kcal/hr and his projected need is 70 kcal/hr. Weight is 70 kg. Which regimen is best? 70M with stroke requires continuous G-tube feeding. Pre- hospital glucose regimen was sulfonylurea and metformin. Glucose values are consistently greater than 180 mg/dL with a caloric intake of 20 kcal/hr and his projected need is 70 kcal/hr. Weight is 70 kg. Which regimen is best? A. Sulfonylurea + metformin at home doses A. Sulfonylurea + metformin at home doses B. Sulfonylurea + metformin + regular insulin SS B. Sulfonylurea + metformin + regular insulin SS C. NPH insulin 7 U AM and 7 U PM + Humalog SS Q4 C. NPH insulin 7 U AM and 7 U PM + Humalog SS Q4 D. NPH insulin 10 U AM and 5 U PM + Humalog SS Q4 D. NPH insulin 10 U AM and 5 U PM + Humalog SS Q4 E. 70/30 insulin 7 U Q12 + Humalog SS Q4 E. 70/30 insulin 7 U Q12 + Humalog SS Q4

11. Answer Insulin for continuous enteral feeding: Insulin for continuous enteral feeding: Basal + correction Basal + correction May divide insulin doses equally for AM and PM May divide insulin doses equally for AM and PM Adjustment for correction insulin example: Adjustment for correction insulin example: If total correction in last 24 hrs. is 10 units, may add 10 to Lantus or 5 for each NPH dose Increase insulin dose as feeding is increased Increase insulin dose as feeding is increased For TPN, may add regular insulin to bag For TPN, may add regular insulin to bag

12. Case 3: IV to SQ 65M with 20-year history of DM has glucose values of 100-180 mg/dL while on an insulin drip at 2 U/hr in the ICU after CABG. He has been treated pre-operatively with NPH 40 U and regular insulin 10 U pre-meals with good control. Which regimen is best in transitioning to subQ insulin? 65M with 20-year history of DM has glucose values of 100-180 mg/dL while on an insulin drip at 2 U/hr in the ICU after CABG. He has been treated pre-operatively with NPH 40 U and regular insulin 10 U pre-meals with good control. Which regimen is best in transitioning to subQ insulin? A. D/C drip and start regular insulin sliding scale (SS) A. D/C drip and start regular insulin sliding scale (SS) B. D/C drip and start NPH 5 U + regular insulin SS B. D/C drip and start NPH 5 U + regular insulin SS C. Continue drip for 2 hours and start NPH 20 U + regular insulin SS C. Continue drip for 2 hours and start NPH 20 U + regular insulin SS D. Continue drip for 2 hours and start Lantus 20 U + regular insulin SS D. Continue drip for 2 hours and start Lantus 20 U + regular insulin SS

13. Answer Use insulin type that has worked. Use insulin type that has worked. NPH acts faster than Lantus which has slower onset (maximal effect may not be seen for a few days). NPH acts faster than Lantus which has slower onset (maximal effect may not be seen for a few days). Starting basal insulin at half the pre-operative dose is generally safe. Starting basal insulin at half the pre-operative dose is generally safe. When the patient starts to eat, consider pre- prandial insulin. When the patient starts to eat, consider pre- prandial insulin.

14. Case 4: ICU patient A 70F is admitted to ICU for ARDS and hooked to a mechanical ventilator. She has no history of DM but glucose measurements in the first 6 hours range between 200-275 mg/dL. What is the best treatment for hyperglycemia? A 70F is admitted to ICU for ARDS and hooked to a mechanical ventilator. She has no history of DM but glucose measurements in the first 6 hours range between 200-275 mg/dL. What is the best treatment for hyperglycemia? A. Start insulin infusion. A. Start insulin infusion. B. Start basal insulin + regular insulin SS Q6 B. Start basal insulin + regular insulin SS Q6 C. Start basal insulin + pre-prandial insulin + regular insulin SS C. Start basal insulin + pre-prandial insulin + regular insulin SS D. Check glucose Q6 and correct with regular insulin SS only D. Check glucose Q6 and correct with regular insulin SS only E. Insert a nasogastric tube and pass metformin E. Insert a nasogastric tube and pass metformin

15. Answer In the ICU, optimal glycemic control may be achieved by continuous infusion with frequent hourly monitoring. In the ICU, optimal glycemic control may be achieved by continuous infusion with frequent hourly monitoring. Use the last 24 hour requirement to approximate total daily dose and divide into basal and pre- prandial accordingly. Use the last 24 hour requirement to approximate total daily dose and divide into basal and pre- prandial accordingly.

16. Take Home Points Know goals. Know goals. Get adequate BASAL insulin on board. Get adequate BASAL insulin on board. Sliding scale ALONE is usually insufficient. Sliding scale ALONE is usually insufficient. Monitor and adjust continuously. Monitor and adjust continuously.

17. Thank you