1. MANAGEMENT OF HYPOGLYCEMIA A Nimalasuriya

2. INSULIN ACTIONS

3. Subcutaneous Insulin Maintaining Physiologic Insulin Delivery in the Hospital BE THE PANCREAS!

4. Which insulins are best for basal coverage? Insulin Effect Time (hours) 06121824 NPH Glargine (Lantus) Regular Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) Detemir (Levemir) Inhaled insulin 

5. Which insulins are best for nutritional coverage? Insulin Effect NPH Glargine (Lantus) Regular 06121824 Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) Time (hours) Detemir (Levemir) 

6. Dose in reaction to a single retrospective blood glucose measurement Does not provide basal insulin coverage Provides supplemental insulin after hyperglycemia occurs Does not consider nutritional changes or diurnal insulin requirements Nonphysiologic dosing places patients at risk of large fluctuations in blood glucose levels – Increased incidence of hyperglycemic and hypoglycemic episodes 1 1. Queale et al. Arch Intern Med. 1997;157:545-552.  The of Diabetes Management

7. RABBIT 2 Trial Prospective randomized trial of 130 insulin naïve T2DM non-ICU inpatients Admission blood glucose b/w 140-400 mg Basal- bolus insulin with glargine and glulisine vs Regular insulin SS

8. RABBIT 2 Trial Mean Blood glucose mg/dl DAYS Umpierrez, et al Diabetes Care 30;2181-86,2007

9. RABBIT 2 TRIAL n=9 SSI Failures Mean Blood glucose mg/dl DAYS

10. WHAT ARE THE RANGE FOR CRITICAL CARE CRITICAL CARE BLOOD SUGARS 140-180

11. NON CRITICAL HOSPITALIZED PATIENTS PRE MEAL LESS THAN 140 RANDOM 180 OR LESS

12. HOW DO WE DEFINE SEVERE HYPOGLYCEMIA 1. REQUIRES ASSISTANCE OF ANOTHER PERSON TO ADMINISTER CHO 2. NEUROGLYCOPENIA- SEIZURE OR COMA

13. DOCUMENTED SYMPTOMATIC HYPOGLYCMIA TYPICAL SYMPTOMS PLASMA GLUCOSE EQUAL OR LESS THAN 70 mg/dl

14. ASYMPTOMATIC HYPOGLYCEMIA MAY HAVE HYPOGLYCEMIC UNAWARENESS ANTECEDENT HYPOGLYCEMIA

15. RELATIVE HYPOGLYCEMIA TYPICAL SYMPTOMS WHEN BLOOD SUGAR IS GREATER 70 mg/dl PATIENT WITH CHRONIC HYPERGLYCEMIA DUE TO UNCONTROLLED HYPERGLYCEMIA

16. NEW GUIDELINE HOSPITAL PRACTICE BLOOD SUGAR LESS THAN OR EQUAL TO 40 mg THE NURSE WILL INFORM THE PHYSICIAN AND THE PHARMACIST – PHARMACIST TO REVIEW MEDICATION TO HELP THE PHYSICIAN AND WILL ALSO BE ACCOUNTABLE – PLEASE DOCUMENT ACTION TAKEN TO PREVENT RECURRENCE

17. NEW GUIDELINES FOR RECURRENT HYPOGLYCEMIA OVER THREE EPISODES OF HYPOGLYCEMIA OVER A 2 DAY PERIOD ENDOCRINE CONSULT –MANDATORY – COULD BE TELEPHONIC

18. KAISER RIVERSIDE HYPOGLYCEMIA MULTIFACTORIAL AND ABOUT EQUALLY 1. GLIPIZIDE - 70/30 insulin NPO STATUS INSULIN GIVEN WITHOUT ADEQUATE FOOD INTAKE SLIDING SCALE ONLY

19. ADMISSION - PREVENTION HIGH RISK PATIENTS – TYPE 1 – INSULIN DEFICIENT TYPE 2 – RENAL DISEASE – PATIENTS LESS THAN 100 lb – PATIENT DEMENTED CONFUSED ON VENTILATORS

20. ADMISSION MEDICATIONS GLIPIZIDE STOP GLIPIZIDE BASAL INSULIN RECOMMENDED total average patient 0.4 units /kg daily 50 percent basal 0.2 mg/kg daily divided for am and bedtime

21. Calculating Initial MDI* Doses for Insulin-naïve Patients *Give after meals as rapid-acting analog if food intake is in doubt *MDI = Multiple daily injection Thompson et al. Diabetes Spectrum. 2005;18:20-27. Starting dose = 0.4 × weight in kg Basal dose = 40%- 50% of starting dose at bedtime Total prandial dose = 50%- 60% of starting dose, 1/3 at each meal* Do not skip correction dose even if no food eaten  Adjust upwards daily by adding 50% of correction doses to basal and bolus doses

22. PATIENT EXAMPLE- BASAL WEIGHT 100 kg total dose 40 units (0.4 units/kg) Basal NPH 20 units- 10 units in am and 10 units bedtime

23. BOLUS INSULIN PATIENT IS EATING 0.2 UNITS/kg = 20 unit for three meals approx 6 units per meal

24. CORRECTION SCALE LOW DOSE---NPO ELDERLY GFR LESS THAN 30 THIN BMI <23 OUTPATIENT INSULIN <20 UNITS/DAY MEDIUM DOSE-- AVERAGE WT BMI 23-38- OUTPATIENT INSULIN 20-60 UNITS HIGH --STEROIDS, BMI OVER 38, OUTPATIENT INSULIN UNITS OVER 60 UNITS INCREASE THE SCALES IF BS GREATER 200 MG

25. INSULIN ADMINSTRATION FOR PATIENTS NOT EATING BASAL-NPH EVERY 12 HR FSBG TESTING EVERY 6 HR USE REGULAR INSULIN - LOW DOSE SLIDING SCALE

26. INSULIN ADMINISTRATION- EATING PATIENT BASAL PRANDIAL- RAPID - PRIOR TO OR WITH MEALS CORRECTION OR SUPPLEMENTAL INSULIN – RAPID ACTING ADDED TO PRANDIAL INSULIN

27. NPO PROCEDURE NEVER GIVE AN ORDER” FROM MIDNIGHT” STATE THAT NPO 4 HR BEFORE THE PROCEDURE CONSIDER 5% D5 IV IF THE PATIENT HAD BEEN ON DIABETES MEDICATION CORRECTION SCALE ONLY NO MEAL BOLUS BASAL INSULIN MAY REDUCE BUT DO NOT HOLD THE BASAL INSULIN

28. PROCEDURES NPO –BLOOD SUGARS Q 4 HR RADIOLOGY PROCEDURES RN AGREED TO CHECK BLOOD SUGARS Q 4HRLY DURING PROCEDURES AND BEFORE LEAVING

29. INSULIN – FOOD MISMATCH BOLUS INSULIN SHOULD BE ONLY GIVEN AFTER THE FOOD TRAY REACHES PATIENT NURSING WILL WORK ON THIS MEAL BOLUS SHOULD NOT BE GIVEN IF PATIENT IS NOT EATING

30. OUR DATA A DIABETIC PATIENT ADMITTED HAS A 17 PERCENT CHANCE OF GETTING AN EPISODE OF HYPOGLYCEMIA WE ARE CHANGING OUR SYSTEM

31. HYPOGLYCEMIA PROTOCOL This protocol does not need a physician ’ s order to implement it. The hypoglycemia protocols are based on the FSBG (finger stick blood glucose) number and the signs/symptoms the patient may be experiencing! For any suspected hypoglycemia, do a FSBG immediately AND treat

32. HYPOGLYCEMIA PROTOCOL This protocol has the following definitions: Mild/Moderate Hypoglycemia is defined as: FSBG 41 – 69mg/dl whether symptomatic or not Severe Hypoglycemia is defined as: FSBG is 40mg/dl or less

33. MILD/MODERATE HYPOGLYCEMIA TREATMENT Treatment for patients who are eating: Give the patient 15-30 grams of carbohydrate using one of the following:  3 to 4 glucose tablets  one Glucose gel tube (squeeze tube contents into patient ’ s mouth and have them swallow)  one-half cup juice (Do Not add extra sugar) Again keep treating the hypoglycemia every 15 minutes until the FSBG is >70-80mg/dl

34. MILD/MODERATE HYPOGLYCEMIA TREATMENT Gel are preferred treatment since they are a purer form of glucose and exact dose of glucose is given and documented in the MAR Apple juice is preferred over orange juice since orange juice may be contraindicated in many patients (as renal or cardiac patients).

35. MILD/MODERATE HYPOGLYCEMIA TREATMENT Re-testing the FSBG and treating EVERY 15 minutes with 15 to 30 grams carbohydrate is very important!

36. MILD/MODERATE HYPOGLYCEMIA TREATMENT THE LAST STEP THE SNACK OR MEAL Once the hypoglycemia is resolved AND if it is more than an hour before next meal, give one of the following: 6 crackers and 1ounce cheese, OR, 6 crackers and 2 Tbsp. peanut butter, OR, 1 slice bread and 1 ounce meat/cheese, OR, 1 carton of skim milk with 1 box (serving) of cereal

37. MILD/MODERATE HYPOGLYCEMIA TREATMENT If after 45 minutes of treatment and hypoglycemia is not resolved, Consider iv glucose glucagon or octeotride.

38. MILD/MODERATE HYPOGLYCEMIA TREATMENT Special notes: If the patient is being treated with Acarbose (Precose) or Miglitol (Glyset) treat with only tablets or gel (a purer form of glucose has to be used since these drugs effect the digestive system). Avoid use of Glucose e gel if patient has a decreased swallowing reflex (on aspiration precautions). Intubated patients should be treated intravenously.

39. SEVERE HYPOGLYCEMIA TREATMENT Now let ’ s discuss Severe Hypoglycemia treatment. Definition: FSBG of 41-69mg/dl with mental status changes, or, Unconscious, or, FSBG of 40mg/dl or less (whether symptomatic or not) Patients who are NPO and have hypoglycemia will be treated as if in severe hypoglycemia if FSBG is less than 70mg/dl. Now, let ’ s look at IV available versus IV not available.

40. SEVERE HYPOGLYCEMIA TREATMENT If an IV is available, follow these steps: 1.Give one (1) amp of D50 (50ml) 2.Retest FSBG 15 minutes after treatment 3.If adult remains unconscious, give additional one (1) amp (50ml) of D50 slowly 4.When patient is conscious, follow up with a snack (as discussed earlier)

41. SEVERE HYPOGLYCEMIA TREATMENT If an IV is not available: (or if the patient is not willing or able to swallow) 1.Give Glucagon IM (1mg) Retest FSBG 15 minutes after treatment 2.Give one (1) amp D50 slowly 3.Start D5W at 100ml/hour 4.Notify physician KEY POINT: Glucagon comes in a kit from the Pharmacy. It has to be reconstituted by the nurse right before giving it.

42. SEVERE HYPOGLYCEMIA TREATMENT Glucagon is given for severe hypoglycemia as an IM injection which helps to quickly raise the blood glucose. When Glucagon is used, place the unconscious patient on his/her side, supporting the head, give the IM injection, and closely observe the patient. The patient may wake up vomiting and/or feeling sick.

43. SEVERE HYPOGLYCEMIA TREATMENT REMINDER: Implement seizure precautions (observe for seizures) when patient is experiencing severe hypoglycemia. KEY POINTS: Plan ahead!!! For any patient on insulin, always keep a watch out for hypoglycemia. Treat immediately and re- treat!!! Teach!!! Document, document, document!!!

44. HYPOGLYCEMIA OTHER POINTS OF INTEREST: Some patients may have ‘ hypoglycemia unawareness ’. This is when the patient loses the ability to feel the symptoms of low blood glucose. Frequent monitoring helps to identify that condition and treatment is initiated sooner. This helps the body to recognize the low blood glucose sooner. KEY POINT: It is important to treat the FSBG number whether symptomatic or not. Another point of interest is the timing of FSBGs, Insulin Administration and meals.

45. HYPOGLYCEMIA DETERMINE CAUSE AND MAKE CHANGES: 1.SLIDING SCALE INSULIN 2.INADEQUATE INTAKE 3.NPO STATUS AND DIABETES AGENTS NOT DISCONTINUED 4.INSULIN AND MEAL NOT SYNCHRONOUS 5.WRONG TYPE ISULIN 70/30 6.GLIPIZIDE NOT DISCONTINUED

46. TIMING OF FSBG, INSULIN, AND MEALS The timing of checking a patient ’ s blood glucose is important in relation to the meal. It ’ s important to check it right before the meal (which is why the order needs to be ac & hs). Then it can be determined whether insulin is needed or not. And depending on the type of insulin, it may be given right before the meal (as Novolog or Humalog insulin) or up to about 30 minutes before the meal (as Regular insulin).

47. TIMING OF FSBG, INSULIN, AND MEALS Therefore, we often need to encourage the patient to eat especially if he/she is receiving insulin. Sometimes if the patient does not eat enough and insulin is given, then low blood glucose could occur. Monitoring, recognizing hypoglycemia symptoms, and providing replacement foods will help to prevent it!!! A consult to the Dietitian may need to be considered.

48. SIMPLE PRINCIPLES PRIMARY PREVENTION – WHAT WE D0- CHANGING SYSTEM – Stop glipizide 70/30 insulins – Stop the sliding scale SECONDARY PREVENTION – make changes after one episode of hypoglycemia – Look at the blood sugars DAILY – Reduce insulin dose if the blood sugars is less than 100mg since our target has changed