1. Intensive insulin therapy for managing diabetic foot Dr. Bipin Kumar Sethi

2. Intensified insulin therapy..myths Costly ! Costly ! Not for this patient ! Not for this patient ! Not yet..not so soon ! Not yet..not so soon ! Why this headache? Why this headache? Why another specialist ? Why another specialist ? Patient won’t accept ! Patient won’t accept !

3. Glycemic control is one of the important facets of management of diabetic foot & is complimentary to the general care, antimicrobial therapy and surgery Glycemic control is one of the important facets of management of diabetic foot & is complimentary to the general care, antimicrobial therapy and surgery Most hospitalised patients require insulin and the regimens depend upon Most hospitalised patients require insulin and the regimens depend upon Route of nutritional delivery/sensorium Route of nutritional delivery/sensorium Hemodynamic status Hemodynamic status Co-morbid conditions esp. hepatic and renal insufficiency Co-morbid conditions esp. hepatic and renal insufficiency Monitoring facilities Monitoring facilities Degree of hyperglycemia/ decompensation Degree of hyperglycemia/ decompensation Hyperglycemia in a hemodynamically stable patient should not be a deterrent to delivery of adequate foot care (debridement, desloughing, amputation) Hyperglycemia in a hemodynamically stable patient should not be a deterrent to delivery of adequate foot care (debridement, desloughing, amputation)

4. Why does glycemic control worsen ? Never checked before – natural course Never checked before – natural course Recumbency Recumbency Infection Infection Diet Diet Drugs- steroids Drugs- steroids Hospital “schedules/protocols” Hospital “schedules/protocols” Stress Stress

5. Benefits of intensified insulin regimens Quick(er) metabolic control Quick(er) metabolic control Anabolic effect Anabolic effect Better insulinisation Better insulinisation Lesser mismatch Lesser mismatch Lesser hypos Lesser hypos Others Others

6. For patients taking nutrients orally MSI MSI R + R + R + Basal (N/L/G/D) R + R + R + Basal (N/L/G/D) S + S + S + Basal (N/L/G/D) S + S + S + Basal (N/L/G/D) Premixed + S/R + Premixed Premixed + S/R + Premixed

7. International Diabetes Center Relative Insulin Effect Time (Hours) 0246810121416 Long (Glargine) 1820 Intermediate (NPH) Short (Regular) Rapid (Lispro, Aspart) Insulin Time Action Curves

8. 220 Blood sugar (mg%) 210 200 180 160 140 6 am 12 noon 6 pm 12 midnight 5 am BreakfastLunchDinner INSULIN Biphasic Rapid insulin Monophasic Blood sugar : Multiple Daily Insulin Injections

9. International Diabetes Center RA Physiologic Insulin S/R – S/R – S/R– G/D/N Serum insulin (mU/L) Hours S/R G/D/N Glargine

10. For patients not taking nutrients orally Insulin infusion Insulin infusion GIK GIK Non GIK Non GIK 1. Infusion pump 2. Neutralised 3. Pediatric drip

11. Short term NBM requiring procedure Insulin + Dextrose infusion Insulin + Dextrose infusion GIK GIK Non GIK Non GIK

12. Algorithms 1. Guidelines rather than sacrosanct rules 2. Go by antecedent responses, memory and current blood glucose 3. Revise if response is suboptimal Target BG 80-110mg/dl Monitoring key to success Don’t leave it to paramedics

13. Team approach Not just numbers but interacting dedicated members Not just numbers but interacting dedicated members Flexibility to change regimens Flexibility to change regimens Monitoring, record keeping Monitoring, record keeping

14. A chain is as strong as its weakest link Anonymous

15. Case scenario Mr. MRLS, 55y Mr. MRLS, 55y T2DM 10y, Gliclazide + Mixtard 30 & 20 units T2DM 10y, Gliclazide + Mixtard 30 & 20 units HTN HTN No CVA, PVD No CVA, PVD CAD ? CAD ? Cataract bilaterally Cataract bilaterally Neuropathy +, PVD + Neuropathy +, PVD + Admitted on 31.3.04 Admitted on 31.3.04

16. Foot infection on left side for 2 months, ulcer is located below the left great toe, redness, edema and tenderness extending up to forefoot. Foot infection on left side for 2 months, ulcer is located below the left great toe, redness, edema and tenderness extending up to forefoot. Disarticulation of 2 nd toe with wide local excision done on 9.4.04 Disarticulation of 2 nd toe with wide local excision done on 9.4.04 Continued to be febrile and hyperglycemic Continued to be febrile and hyperglycemic Wound remained unhealthy despite radical excision of all slough Wound remained unhealthy despite radical excision of all slough 15.4.04 endocrinology consultation taken, started on MSI with A20,20,20; M26units 15.4.04 endocrinology consultation taken, started on MSI with A20,20,20; M26units

17. DateFPGPPGRapidBasalMix 15.4.0429336420,20,2026 16.4.0416028,28,2816,30 18.4.0431438420,20,2426 19.4.0417622624,24,2424,24 20.4.045413615,15,1515 21.4.0418316,16,1618 25.4.047818624,24

18. Mid tarsal amputation done on 17.4.04, as his oral intake remained very poor after surgery he was given infusion of DNS with added insulin Mid tarsal amputation done on 17.4.04, as his oral intake remained very poor after surgery he was given infusion of DNS with added insulin He experienced hypoglycemia on 20.4.04 He experienced hypoglycemia on 20.4.04 Below knee amputation on 4.5.04 Below knee amputation on 4.5.04 Post surgery intake remained poor and had vomiting Post surgery intake remained poor and had vomiting Surgery team would change to insulin as per sliding scale, insulin would be stopped altogether whenever hypos occurred Surgery team would change to insulin as per sliding scale, insulin would be stopped altogether whenever hypos occurred Parenteral nutrition was also given with no provision of insulin Parenteral nutrition was also given with no provision of insulin Altered sensorium with hypotension on 11.5.04 Altered sensorium with hypotension on 11.5.04

19. DateFPGPPGRapidBasalComments 5.5.0420326410,10,1010 7.5.040781148,8,88 8.5.0412321212,12 Nil orally 9.5.0425332412,12,1212 10.5.0424316,16,1616 11.5.0465,6396

20. DateFPGPPGRapidBasal Pre Mixed 15.5.0413418410,10,1010 19.5.0411116115,15,1515 24.5.047410135,25

21. Hyponatremia (Na112),Hypokalemia (K 2.8) Hypotension 90/50 mmHg, Pyrexia, Metabolic alkalosis Hyponatremia (Na112),Hypokalemia (K 2.8) Hypotension 90/50 mmHg, Pyrexia, Metabolic alkalosis Blood culture grew Klebsiella,Enteococcus species Blood culture grew Klebsiella,Enteococcus species Was managed in AMC, received IV insulin infusion Was managed in AMC, received IV insulin infusion Discharged on 25.5.04 ! Discharged on 25.5.04 !

22. Intensified insulin regimens work but are introduced rather late Intensified insulin regimens work but are introduced rather late Insulin requirements fluctuate but hypos should not deter from achieving the goal Insulin requirements fluctuate but hypos should not deter from achieving the goal Shifting from oral to parenteral nutrition does occurs and needs closer monitoring and better insulinisation Shifting from oral to parenteral nutrition does occurs and needs closer monitoring and better insulinisation Unplanned procedures often result in interruption of insulin Unplanned procedures often result in interruption of insulin At all times provide for nutrient/fluid and insulin

23. Summary Most patients with diabetic foot ulcers have significant hyperglycemia necessitating insulin therapy Most patients with diabetic foot ulcers have significant hyperglycemia necessitating insulin therapy Glycemic control is an important though not the only management tool in the care of diabetic foot ulcers,sadly it is often neglected Glycemic control is an important though not the only management tool in the care of diabetic foot ulcers,sadly it is often neglected Regimens for glycemic control vary among other things with the severity of hyperglycemia,monitoring facilities, co-morbid conditions but are driven largely by the enthusiasm for euglycemia of treating team and must ensure continuity of insulin therapy Regimens for glycemic control vary among other things with the severity of hyperglycemia,monitoring facilities, co-morbid conditions but are driven largely by the enthusiasm for euglycemia of treating team and must ensure continuity of insulin therapy Admission for diabetic foot offers an opportunity for salvaging/protecting the individual against further ravages of micro/macrovascular disease Admission for diabetic foot offers an opportunity for salvaging/protecting the individual against further ravages of micro/macrovascular disease

24. Acknowledgement

25. Thanks…if at all you could keep awake!!