1. Management of Inpatient Blood Glucose at Temple Housestaff Orientation 2014

2. 2 Hyperglycemia is Associated with Morbidity and Mortality in Inpatients ICU ICU Ward Ward Surgical Surgical Medical Medical Endocarditis Pneumonia Renal transplantation COPD exacerbation Post-MI Stroke Infection Wound healing

3. 3 Glycemic Control Targets in Non–ICU Patients Premeal BG <140 mg/dL Premeal BG <140 mg/dL Random BG <180 mg/dL Random BG <180 mg/dL To avoid hypoglycemia (BG <70 mg/dl), reassess insulin if BG levels fall below 100 mg/dL To avoid hypoglycemia (BG <70 mg/dl), reassess insulin if BG levels fall below 100 mg/dL

4. Estimating Insulin Requirement Home insulin regimen Home insulin regimen Weight-based dose Weight-based dose Recent insulin given (as inpatient) Recent insulin given (as inpatient) Clinical status (hypoglycemia and insulin resistance factors) Clinical status (hypoglycemia and insulin resistance factors) 4

5. Hypoglycemia and insulin resistance factors Hypoglycemia risk factors Type 1 diabetes Renal dysfunction Severe cardiac dysfunction Severe hepatic dysfunction Advanced age Insulin resistance factors Obesity Infection Open wounds Steroids Glucotoxicity BG > ~300 mg/dl A1c > ~10% 5

6. Continuing home insulin program in hospital Must fully assess Must fully assess Glucose control at home Glucose control at home Hypoglycemia, hyperglycemia, A1c Hypoglycemia, hyperglycemia, A1c Compliance (confirm meds/doses) Compliance (confirm meds/doses) Does the regimen make sense? Does the regimen make sense? Consider along with weight-based estimate to calculate dose: use clinical judgment Consider along with weight-based estimate to calculate dose: use clinical judgment 6

7. 7 Weight-based SC insulin dosing 1. Estimate Total Daily Dose (TDD, U/kg) 0.3 U/kg if high risk of hypoglycemia 0.3 U/kg if high risk of hypoglycemia 0.4 – 0.5 U/kg average type 2 diabetes 0.4 – 0.5 U/kg average type 2 diabetes 0.6 U/kg if insulin resistant 0.6 U/kg if insulin resistant

8. 8 How to dose SC insulin 2. TDD = 50% basal insulin + 50% bolus insulin 3. Basal insulin = Lantus (glargine) qHS or NPH q12 h  Do not hold for NPO (give 50-80%) 4. Bolus (nutritional, prandial) insulin = Humalog (lispro) qAC  Given with meal (or tube feeds)  Given as long as premeal BG >70 mg/dl

9. 9 Hypoglycemia risk factors: age, Cr 1.6 Hypoglycemia risk factors: age, Cr 1.6 Insulin resistance factors: steroids, hyperglycemia Insulin resistance factors: steroids, hyperglycemia Estimated TDD = 0.5 units/kg/day Estimated TDD = 0.5 units/kg/day TDD = 66 kg x 0.5 U/kg = 33 units TDD = 66 kg x 0.5 U/kg = 33 units 50% basal = 33/2 = 16 units glargine qHS 50% basal = 33/2 = 16 units glargine qHS 50% bolus = 16/3 meals = 5 units lispro qAC 50% bolus = 16/3 meals = 5 units lispro qAC STOP all oral diabetes meds STOP all oral diabetes meds Assess glucose and titrate daily Assess glucose and titrate daily Case: 78 yo woman, type 2 DM on metformin 1000mg BID + glargine 20units qHS admitted for COPD, BG is 320 mg/dl, A1c is 9%

10. 10 What about correction insulin? 150-200 2U 201-250 4U 251-300 6U…

11. 11 The expected drop in glucose after administering 1 unit of insulin The expected drop in glucose after administering 1 unit of insulin HIS SF= 10 HER SF = 50 HIS SF= 10 HER SF = 50 AVERAGE SF= 30 AVERAGE SF= 30 This scale assumes SF=25 This scale assumes SF=25 2 units for 50 mg/dl intervals 2 units for 50 mg/dl intervals Sensitivity Factor 150-200 2U 201-250 4U 251-300 6U…

12. 12 Correction Scales at TUH Insulin Correction Scale BG mg/dl #1#2#3#4 151-2001234 201-2502468 251-30036912 301-350481216 351-4005101520 SF50251712.5

13. 13 Rule of 1500 SF = 1500/TDD SF = 1500/TDD From prior ex., TDD = 33 From prior ex., TDD = 33 SF = 1500/33 = 45 SF = 1500/33 = 45 Use correction scale #1 Use correction scale #1 Better to use lower-dose scale if SF is between scales Better to use lower-dose scale if SF is between scales Rubin DJ, Golden SH. Hypoglycemia in non-critically ill, hospitalized patients with diabetes: evaluation, prevention, and management. Hosp Pract (1995). 2013

14. A complete insulin program Basal + Bolus + Correction Basal + Bolus + Correction Correction is given regardless of nutrition status (NPO) Correction is given regardless of nutrition status (NPO) Should be ordered for: Should be ordered for: All type 1 diabetes All type 1 diabetes Most type 2 diabetes Most type 2 diabetes Except diet-controlled and BGs <140 mg/dL Except diet-controlled and BGs <140 mg/dL 14

15. 15 Key Points Inpatient blood glucose is important Inpatient blood glucose is important Non-ICU BG targets: <140 premeal, <180 random Non-ICU BG targets: <140 premeal, <180 random Do not use sliding scale alone Do not use sliding scale alone Stop oral diabetes meds Stop oral diabetes meds Order a complete SC insulin program Order a complete SC insulin program Check A1c on every diabetic or BG >140 Check A1c on every diabetic or BG >140

17. TUH Diabetes Protocols  Located in SharePoint  Hypoglycemia protocol  MIS Diabetes orderset instructions  Prandial insulin hold Guideline  DKA/HHS Guideline  Critical Care IV Insulin Guideline  Transitioning IV to SC insulin  Insulin instructions for discharge

18. How to access SharePoint  From any TUH computer, type “diabetes” in web browser

20. How to access SharePoint  From any TUHS network computer or via Citrix, use SharePoint directory

21. Select “SharePoint site directory”

22. Select “TUH Glycemic Control”

24. Hypoglycemia algorithm

25. Diabetes Orderset

31. Prandial Insulin Hold Guideline “Hold” parameters for Prandial/nutritional/bolus insulin, i.e., Humalog (lispro) or Regular insulin Do not give dose if blood glucose <70 mg/dL Do not give dose if blood glucose <70 mg/dL Give ½ the ordered dose if blood glucose is 70-99 mg/dL Give ½ the ordered dose if blood glucose is 70-99 mg/dL Give all of the ordered dose if blood glucose is ≥100 mg/dl Give all of the ordered dose if blood glucose is ≥100 mg/dl

32. DKA/HHS Guideline

34. Critical Care Insulin Infusion  Applies to all patients in all ICUs except DKA or HHS or expected transfer out of unit within 24 hrs  Start when 2 BG >160 mg/dl within 24-48 hr  Target 120-160 mg/dl  Nurses titrate  Give SC insulin (usually glargine) 2 hrs before stopping insulin drip

35. Transitioning IV to SC Insulin

38. Insulin Discharge Instructions

39. Order HBA1C in Common Lab Tests Menu