1. MANAGEMENT OF THE HOSPITALIZED TYPE I DIABETIC PATIENT Riverside Methodist Hospital January 23, 2014 Rundsarah Tahboub, MD

2. CASE  A 44 year old male is transferred from an outside hospital with low back pain and hyperglycemia after recent spinal surgery. The patient uses an insulin pump at home and it is unclear if he has Type I or II Diabetes. He was initiated on an intravenous insulin infusion at the outside facility for glucose of 300 and his pump was removed.  On admission the patient was not able to state how much insulin he gets through pump on a daily bases  The admitting hospitalist discontinued the insulin drip and began sliding scale insulin.  The patient became severely hyperglycemic shortly afterward and developed ketoacidosis  He was found to have an epidural abscess

3. QUESTIONS I  What is the best insulin regimen for this patient ? 1. Aggressive corrective sliding scale insulin since he has a severe infection 2. Glargine insulin and standard corrective sliding scale insulin 3. Variable intravenous insulin infusion 4. Have him put his pump back on

4. QUESTION II  What would you do if patient became hypoglycemic while NPO on your insulin regimen? 1. Discontinue insulin altogether 2. Reduce insulin doses 3. Correct hypoglycemia with IV dextrose 50 once 4. Initiate IV dextrose infusion

5. QUESTION III  All the following are appropriate criteria for reinitiating of insulin pump except one: 1. Will only resume at home after discharge 2. Hemodynamically stable and AOX3 3. Able to tolerate diet 4. Has insulin pump supplies and able to fill pump and administer boluses

6. HOSPITALIZED TYPE I DM PATIENT  High risk patient  Completely dependent on exogenous insulin  Insulin sensitive usually requires <0.5 units/kg/day  Frequent use of insulin pumps  Will develop ketoacidosis in absence of sufficient basal insulin:  SSI monotherapy  Holding basal insulin when NPO  Delay in responding to stress hyperglycemia DKA occurring after admission in a hospitalized patient is a result of medical error until proven otherwise

7. COMMON ERRORS IN MANAGEMENT OF INPATIENT TYPE I DM  Holding basal insulin for NPO status or hypoglycemia severe hyperglycemia or DKA  Omitting mealtime insulin for low premeal BG (60-80 )  Using SSI only  Assuming Type I patient is as insulin resistant as Type II patients when correcting hyperglycemia

8. RECOMMENDED GLYCEMIC TARGETS  Targets Must be: Achievable Reasonable Safe Critically IllNon critically Ill 140-180 mg/dL Premeal <140 mg/dL Random <180 mg/dL NOT recommended BG <110 mg/dL Consider changing regimen for BG <100 mg/dL

9. NON CRITICALLY ILL TYPE I DM  Continue to require an insulin regimen similar to home regimen but modified for being inpatient with potential less PO intake  Regimen consists of:  Basal insulin  long acting glargine or detemir  intermediate acting NPH  Mealtime insulin (analog) must be scheduled if patient is eating  Corrective insulin for premeal glucose above target of 150 typically

10. NON CRITICALLY ILL TYPE I DM & NPO STATUS  Must always continue exogenous basal insulin  Long or intermediate acting insulin  Basal rate of insulin pump if suitable  Initiation of IV insulin especially in critical care setting  May use corrective insulin in addition to basal

11. PERIOPERATIVE MANAGEMENT OF TYPE I DM  Basal insulin should always be continued  Using glargine or detemir  If well controlled give 80% of dose  Uncontrolled may give the full dose  Using NPH  Give full evening dose  Give 50% of AM dose  Avoid use of mixed insulin 70/30, 75/25  Hold scheduled mealtime insulin but may continue to use corrective doses  If undergoing high risk surgery such as CABG or prolonged procedures initiate IV insulin infusion the night before

12. Insulin Pump Therapy Electronic device that delivers insulin through a SC catheter Can be programmed to deliver variable basal rates throughout the day Delivers bolus /mealtime coverage based on carbohydrate intake with meals : insulin to carbohydrate ratio programmed into pump. Example 1 unit per 15 gm of carb per meal correction factor : example 1 unit of insulin drops BG by 50mg/dl

13. CHALLENGES OF INSULIN PUMP THERAPY IN HOSPITAL SETTING  Patient may be unfamiliar with the pump settings but know how to use pump otherwise ( fill with insulin, insert SC catheter, bolus for meals and give correction doses )  Hospital Staff usually unfamiliar with pumps  Safety issues with pumps (kinked catheter, overbolused, discontinued by staff without alternate insulin orders)  Technical concerns (safety with radiological testing, intraopertively)

14. REQUIREMENTS FOR SAFE INPATIENT USE OF INSULIN PUMP THERAPY  Insulin pump order set  Patient contract  Nursing documentation of basal rates and boluses administered by patient & evaluation of insertion site  Pharmacy overview of pump & patients insulin supply  Endocrine consult

15. INPATIENT INSULIN PUMP THERAPY  Criteria for maintaining pump  The patient is alert and oriented  Not critically ill  Able to administer boluses and suspend pump when needed  Cooperation with staff and signs patient contract  Patient has own supplies

16. INSULIN PUMP THERAPY IN PERIOPERTAIVE PERIOD  May continue use of pump for short procedures <2 hours and insulin insertion site away from surgical site  Reduce basal rate by 20% of usual  For procedures >2 hours  Initiate IV insulin infusion the night before at same rate as the insulin pump infusion rate  Discontinue insulin pump

17. CRITICALLY ILL TYPE I DM & NPO STATUS  IV insulin infusion is the method of choice until condition is stabilized  Often need D5 IVF initiated also if  expected to be NPO for prolonged periods  BGs trending <150  IV insulin infusion rates may be titrated down as low as 0.1 units/hour to avoid hypoglycemia while still providing IV insulin without interruption

18. CRITICALLY ILL TYPE I DM & NPO STATUS  If enteral nutrition is going to be initiated IV insulin infusion is the safest and most flexible method of achieving control  IV insulin should be maintained until the patient is tolerating enteral nutrition and at goal rate

19. WHEN IS PATIENT READY TO BE TRANSITIONED FROM IV TO SC INSULIN?  Hemodynamically stable  DKA or HHS resolved  Insulin infusion rate has been stable for 6-8 hours  Insulin infusion rate < 5 units/hour  Insulin infusion rates are similar to patient prior insulin requirements  Medications that effect BG have not been recently changed  Inotropes  Glucocorticoids

20. CONSIDERATIONS WHEN TRANSITIONING FROM IV TO SQ INSULIN  Continue IV insulin until patient is able to tolerate PO intake (diabetic clear liquids) if not on EN or PN  Continue IV insulin at least 2 h after the first SC basal insulin injection is given or pump is started (Overlap is essential)  Is patient receiving Dextrose in IVF or have they eaten on Insulin Infusion?  Do not use the total insulin IV amount given in previous 24 hours  Don’t switch to SSI only !

21. FEEDING WHILE ON INSULIN INFUSION  The insulin infusion will not prevent hyperglycemia associated with ingestion of carbohydrates  Insulin infusion is reactive  Interferes with our ability to calculate insulin requirements when transitioning off of infusion  If you are going to feed on insulin give a SC dose of short acting insulin before the meal  Giving a IV bolus is not going to cover the meal..its effect only lasts 5- 10mins

22. HOW TO TRANSITION FROM IV TO SQ INSULIN  Type I DM on IV insulin and D5 IVF (such as DKA)  Use stable insulin infusion rate in past 6 hours to calculate total daily dose (TDD)  Example:  Stable average infusion rate 2 units/hour  2 units/hour x 24 hours =48 units (TDD)

23. HOW TO TRANSITION FROM IV TO SQ INSULIN  Type I DM on IV insulin and D5 IVF (DKA)  Divide the new TDD as follows:  50% Basal ( to be given 2-3 hours before discontinuation of insulin IV)  50% as premeal divided into 3 doses  Example : TDD 48 units calculated from IV insulin  24 units glargine  24/3 units as premeal analog insulin = Lispro 8 units with each meal

24. HOW TO TRANSITION FROM IV TO SQ INSULIN  Type I on TPN or continuous tube feeds  Use stable insulin infusion rate in past 6 hours to calculate TDD  Divide the new TDD as follows:  50% Basal either glargine every 24 hours or equal dose of NPH q 12 hours  50% as nutritional given as regular insulin scheduled Q 6 hours

25. HOW TO TRANSITION FROM IV TO SQ INSULIN  Type I on TPN or continuous tube feeds  Example average hourly rate over previous 6 hours while on goal tube feeds = 3.5 units/hour  3.5 x 24 hours = 84 units  Give 50% as basal = 42 units of glargine  even if TF discontinued this dose should be continued  Give 50% as nutritional = 42 units ÷ 4 ~ 10 units q 6 hours while on TF  this is to be held if TF interrupted  Also start correctional SSI

26. HOW TO TRANSITION FROM IV TO SQ INSULIN  Type I DM (Not receiving dextrose, TPN or Tube feed)  Use stable insulin infusion rate in past 6 hours to calculate total basal dose  Example:  infusion rate 2 units/hour  2 x 24 hours =48 units  Give 80% as the Total basal dose for next 24 hours  0.8 x 48=40 units  Give all of this as basal insulin  Give premeal insulin roughly 0.05 - 0.1 unit/kg with each meal when patient starts eating

27. TRANSITIONING FROM IV TO INSULIN PUMP  Insulin pump should be placed and started at least 1-2 hours before IV infusion is discontinued

28. QUESTIONS ??

29. REFERENCES  Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97:16-38.  American Diabetes Association. Standards of medical care in diabetes— 2013. Diabetes Care. 2013;36(suppl 1):S11-S66.  Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15:353-369.