Download Inpatient Management of Diabetes

Inpatient Management of
Diabetes
Dona Gray, M.D.
September 20, 2012
Pre-test questions:
• Insulin pumps:
– A.
– B.
– C.
– D.
Infuse basal insulin only
Use rapid acting insulin
Are surgically inserted
Can not use U-500 insulin
Pre-test questions:
In a patient with Type 1 DM who is NPO:
A.
B.
C.
D.
Stop all insulin.
Use only sliding scale
Use only rapidly acting insulin
Continue basal insulin
Pre-test questions:
Basal insulin generally constitutes how much of
a total daily insulin usage:
A.
B.
C.
D.
10-20%
20-30%
40-50%
60-70%
Pre-test questions:
When converting from insulin drip to
subcutaneous insulin, start the subcutaneous
insulin:
A.
B.
C.
D.
2 hours before stopping the infusion
When you stop the insulin drip
1 hour after stopping the drip
6 hours after stopping the drip
Pre-test questions:
U-500 insulin:
A. Is four times more concentrated than regular
insulin.
B. Is supplied in a larger vial than U-100
insulin.
C. Has a peak in 60 minutes.
D. Has a duration of action of up to 4 hours
Discussion topics
• IV insulin
• Insulin pumps
• Examples of cases of special situations
(NPO, steroids, TPN)
• U-500 insulin
• Transition to outpatient care
Diabetes and Hospitalization
Scope of the Problem
• The total estimated cost of diabetes in 2007 was $174 billion, with
$116 billion attributed to excess medical expenditures1
– The largest component of medical expenditures attributed to
diabetes was hospital inpatient care (~50% of costs)
• Diabetes ranked #2, after circulatory diseases, as a hospital
discharge diagnosis in 20052
– Diabetes made up 11% of all first-listed diagnosis ICD-9-CM
Codes
– Discharges with diabetes as a first-listed diagnosis accounted
for about 2.8 million days of hospital stay
1. American Diabetes Association. Economic Costs of Diabetes in the U.S. in 2007. Diabetes Care 2008;31:1–20.
2. http://www.cdc.gov/diabetes/statistics/hosp/adulttable1.htm Accessed January 21, 2008.
Impact of Hyperglycemia
and Diabetes and the Hospital
• Hyperglycemia affects the body’s ability to heal,
resulting in increased lengths of stay and leading to
complications
• Mortality risk increases dramatically when diabetes is
not diagnosed and not effectively treated during a
hospital stay
• Diabetes causes a ~2-4 fold increase in rates of
hospitalizations and increases lengths of stay by 1-3
days
ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract. 2006;12:458-468.
Factors Affecting Blood Glucose
Levels in the Hospital Setting1
• Increased counter-regulatory hormones
• Changing IV glucose rates
• TPN and enteral feedings
• Lack of physical activity
• Unusual timing of insulin injections
• Use of glucocorticoids
• Unpredictable or inconsistent food intake
• Fear of hypoglycemia
• Cultural acceptance of hyperglycemia.
1
Carter, L. Oklahoma Nutrition Manual, Oklahoma Dietetic Association, 2006.
Inpatient Glycemic Management
Definition of terms:
• Hospital hyperglycemia: Any BG > 140 mg/dl (7.8 mmol/L)
• Stress hyperglycemia: Elevations in blood glucose levels
that occur in patients with no prior history of diabetes and
A1c levels that are not significantly elevated (<6.5%)
• A1c values above 6.5 in patients with hyperglycemia
suggests a prior history of diabetes
• Hypoglycemia: Any BG < 70 mg/dl (3.9 mmol/L)
• Severe hypoglycemia: Any BG < 40 mg/dl (2.2 mmol/L)
Recommended Inpatient
Glycemic Targets
• Maintain fasting and preprandial BG <140 mg/dL
(7.8 mmol/L)
• Modify therapy for BG < 100 mg/dl to avoid risk for
hypoglycemia
• Maintain random BG <180 mg/dL (10 mmol/L)
• More stringent targets may be appropriate in stable
patients with previous tight glycemic control.
• Less stringent targets may be appropriate in terminally
ill patients or in patients with severe co-morbidities.
Considerations with Non-insulin
therapies in the hospital
• Sulfonylureas are a major cause of prolonged hypoglycemia
• Metformin is contraindicated in patients with decrease renal
function, use of iodinated contrast dye, and any state
associated with poor tissue perfusion (CHF, sepsis)
• Thiazolidinediones associated with edema and CHF
• α glucosidase inhibitors are weak glucose lowering agents
• Amylin and GLP1 agonists can cause nausea and exert a
greater effect on postprandial glucose
• Time action profiles of oral agents can result in delayed
achievement of target glucose ranges in hospitalized
patients
Insulin Administration
Inpatient protocols use one or more of these
components to achieve glycemic goals:
Basal insulin doses - “background” or “baseline” insulin refers to the
amount of exogenous insulin necessary to prevent unchecked
glucogenesis and ketogenesis.
• Nutrition insulin doses are defined as the amount of insulin required
to prevent glucose excursions following a meal or other nutritional
source (TPN, enteral nutrition)
• Bolus correction doses is defined at the additional insulin required
to cover blood sugars that exceed the goal range. This is given in
addition to basal and nutritional insulin
Insulin Use in the Hospital Setting
Insulin Infusion Plans
IV Regular insulin is titrated to maintain target glucose levels. Regular
insulin is the basal insulin and is adjusted to correct for hyperglycemia.
• Give enough glucose IV infusion to prevent
hyperglycemia and starvation ketosis (typically 5-10g
each hour).
• Can be quickly adjusted for changes in enteral or
parenteral feedings.
• Safer than SC insulin in patients who are not eating or
who may suddenly switch to NPO status.
Hypoglycemia can be easily treated with additional IV
glucose.
1Moghissi,
ES, Hirsch, IB. “Hospital Management of Diabetes.” Endocrinology and Metabolism Clinics of North America 34 (2005)
Insulin Use in the Hospital Setting
Subcutaneous Basal/Bolus Insulin Plans1:
A combination of basal, “prandial/nutrition” and “correction/
supplemental” insulin doses are given to maintain target glucose levels.
• Nutritional/prandial bolus doses of rapid or shortacting insulin may be titrated based on the CHO
content of the meal, or fixed doses may be ordered if
consistent CHO meal plans are used.
• Correction bolus doses of rapid or short-acting insulin
may be added to the nutritional/prandial dose to
correct hyperglycemia.
1
Adapted from ediba® Diabetes Center of Excellence professional education materials. ©2003
Insulin Use in the Hospital Setting
Subcutaneous Basal/Bolus Insulin Plans1 (Cont.):
• Hypoglycemia is treated with oral CHO or D50 IV per
hypoglycemia guidelines or protocol.
• Protocols using algorithms for insulin adjustment can
help achieve target goals rapidly.
1
Adapted from ediba® Diabetes Center of Excellence professional education materials. ©2003
Physiologic Components of Insulin Therapy
Basal insulin
glargine (Lantus®) NPH detemir (Levemir®)
The amount of insulin necessary to regulate glucose levels between meals
and overnight
Nutritional insulin regular
(Humulin® Novolin®)
lispro (HumaLOG®) aspart (NovoLOG®) glulisine (Apidra®)
The amount of insulin required to cover meals, IV dextrose, enteral
nutrition, TPN or other nutritional supplements
Correctional insulin (Supplemental insulin)
• Refers to supplemental doses of rapid or short acting insulin given to
correct elevations in blood glucose that occur despite use of basal and
nutritional insulin.
• Usually administered before meals together with prandial insulin
Addressing the Challenges of Altered Intake
in Hospitalized Patients with Diabetes1
Issue: Delayed meals / inconsistent meal timing.
Key points to discuss with clinical staff:
• Meal (nutritional) insulin may be delayed until intake
resumes after tests or procedures.
• Basal insulin should not be routinely held.
• Patients taking secretagogues, may need a snack if a
meal delay is anticipated.
1
Swift, S, Boucher, JL. “Nutrition Care for Hospitalized Individuals with Diabetes.” Diabetes Spectrum 18 (2005)
Estimating a Starting Dose
• Use patient’s home regimen
– Adjust as clinically indicated
• Make a weight based estimate
– Start 0.4 units/kg for glucose 140-200
– Start 0.5 units/kg for glucose 201-400
– Consider lower starting dose with significant renal or hepatic
impairment
• Estimate basal insulin and carb count
– Difficult to achieve in the hospital
– If attempting, estimate basal insulin (.2-.25 units/kg/day)
• Type I: Give 1 unit per 15g carbohydrates
• Type II: Give 1 unit per 10g carbohydrates
Diabetes Care 30:2181-2186, 2007
Initiating Insulin Therapy in the Hospital
Obtain patient weight in kg
Calculate total daily dose (TDD)
as 0.2-0.4 units per kg/day
Choose the dosing schedule
Give 50-60% of TDD as basal insulin
Give 40-50% of TDD as bolus (premeal or nutritional) insulin
Use Correction Insulin for BG above goal range
Adjust according to results of BSGM
Adjust dose for NPO status or changes in clinical status
Insulin pumps
Specific Clinical Situations
Patients with insulin pumps
Patients who use CSII pump therapy in the
outpatient setting can continue to use these
devices as inpatients provided that they have the
mental and physical capacity to do so.
Availability of hospital personnel with expertise
in CSII therapy is recommended
Inpatient CSII Protocol
An insulin pump should NEVER be discontinued without
initiation of either subcutaneous or intravenous insulin.
If the pump is discontinued for any reason, additional insulin
(either IV or subcutaneous) MUST be given 30 minutes
prior to discontinuation.
Patient is to self-manage insulin pump and nurse is to verify
and document all basal rates and bolus doses
administered.
Insulin pumps must be discontinued for an MRI. If the pump
is interrupted for more than one hour, another insulin
source needs to be ordered.
Noschese ML et al Endocrine Practice 15:415 2009
IV insulin
Indications for Intravenous
Insulin Therapy
• Diabetic ketoacidosis
• Nonketotic
hyperosmolar state
• Critical care illness
(surgical, medical)
• Post-cardiac surgery
• Myocardial infarction
or cardiogenic shock
• NPO status in Type 1
diabetes
• Labor and delivery
• Glucose exacerbated by
high-dose glucocorticoid
therapy
• Perioperative period
• After organ transplant
• Total parenteral nutrition
therapy
American Association of Clinical Endocrinologists. Available at:
http://www.aace.com/pub/ICC/inpatientStatement.php. Accessed March 17, 2004.
General Guidelines for Transitioning
from IV to SubQ Insulin
1. Calculate daily insulin requirement based on
insulin infusion rate
2. Evaluate amount of glucose patient is receiving
a)
NPO with minimal dextrose (120 gm/24hr) – insulin infusion is
providing primarily basal with some stress correction

b)
Give 60-80% of calculated daily insulin requirement as basal insulin
(Detemir, Glargine, NPH)
Receiving 50% of estimated caloric needs – insulin infusion is
providing both basal and prandial coverage


Give 30-40% of calculated daily insulin requirement as basal
Give 30-40% of calculated daily insulin requirement as prandial
3. Determine the appropriate correction algorithm
4. Monitor blood glucose and adjust PRN
U-500 insulin
Can U500 Regular Insulin Be Used
in the Hospital?
General Guidelines
Inpatient use of U500 insulin is reserved for patients who use
this concentrated form of regular insulin as outpatients and
who demonstrate a similar or greater degree of insulin
resistance at time of hospital admission.
To avoid dosing errors that have potential for hypoglycemia,
many hospitals regulate the administration of U500 insulin by
requiring one or all of the following:
Order written as volume to be given using a TB syringe
All doses prepared in pharmacy
Alerts in patient room and on patient medicine
administration record
U-500 Indications
• Type 2 Diabetes and severe insulin
resistance
• High doses of insulin
• High doses of steroids
U-100 vs U-500
•
•
•
•
•
•
Both have onset of action of 30 minutes.
Peak insulin effect in 3 hours
However, U-100 has duration of 8 hours.
U-500 can have a duration up to 24 hours
Highly concentrated agent
There is no U-500 insulin syringe
Enteral feeding
What Is the Impact of Tube Feedings
on Blood Glucose Levels?
• Patients on tube feedings will usually receive a
continuous flow of carbohydrates via their feeding
• Blood glucose monitoring (usually q 4 hrs or Q 6 hrs) and
scheduled dose of insulin plus corrections are needed
• Interruption of feeding can cause hypoglycemia and IV
dextrose may be needed while the feeding is off
Notify physician for IV dextrose and adjustment of
insulin orders when there is interruption or change
in feeding rate
Glycemic Management of the Patient
Receiving Enteral Nutrition
Continuous enteral nutrition (EN)
Basal: 40-50% of TDD as long or intermediate acting
insulin given once twice a day
Short acting 50-60% of TDD given q6h
Cycled enteral nutrition
Intermediate acting insulin given together with a rapid or
short acting insulin with start of TF
Rapid or short acting insulin administered q4 to 6 hours
for duration of EN administration
Correctional insulin given for BG above goal range
Bolus enteral nutrition
Rapid acting analog or short acting insulin given prior to
each bolus
Treatment Algorithm For Patients
Receiving Continuous Enteral Nutrition
Patient with no prior history diabetes started on EN
BG < 130 mg/dl x 48 hrs
≥ 2 BG > 130 mg/dl
Discontinue BG Monitoring
Glargine 10 units + Correction Insulin q6h
All BG < 130 mg/dl
≥ 2 BG >180 mg/dl in prior 24 hours
Add 25-50% Correction Insulin to Glargine
Continue current regimen
Administer regular insulin q6h
Glycemic Management of the Patient
Receiving Enteral Nutrition
Suggested
Dose of short acting insulin can be based on anticipated
“dose” of carbohydrate
Example:
67 yo woman receiving Peptamin with calculated 188 G
of carbohydrate over 24 hrs
Insulin to carbohydrate ratio: 1 unit/10 G
Calculated total insulin dose 19 units
Administered total insulin dose over 24 h 20 units
BG over 1st 36 hours 90-135 mg/dl
Glycemic Management of the Patient
Receiving Enteral Nutrition
Patients who already have an underlying diagnosis of diabetes
are likely to experience further elevations in blood glucose
levels with the initiation of enteral nutrition1.
Patients receiving EN often have a higher severity of illness
that those who do not.
Unanticipated dislodgement of a feeding tube, temporary
discontinuation of the feedings, or changes in the rate of
administration can result in hypoglycemia.
Protocols for avoidance and early treatment of hypoglycemia
are recommended in case of abrupt discontinuation of EN.
For example: Keep order in place to start dextrose-containing
IVFs in event of abrupt discontinuation of EN
TPN and blood sugars
What Is the Impact of Total Parenteral
Nutrition (TPN) on Blood Glucose?
• Patients on total parenteral nutrition (TPN) may
have insulin in the TPN or may be on SC insulin
• Blood glucose monitoring q 4-6 hrs is needed
• Interruption of TPN can cause hypoglycemia
and initiation of IV dextrose may be needed
Notify physician for IV dextrose and adjustment
of insulin orders when there is interruption or
change in TPN
Glycemic Management of the Patient
Receiving TPN
Suggested
In patients with known type 2 diabetes, add 1 unit for each
10 Grams of carbohydrate in the solution
Initiate Correctional Insulin Scale for BG > 140 mg/dl
Add 60 to 100% of previous days correctional insulin dose
to next day’s TPN solution
Consider
Add basal long or intermediate acting insulin at a dose of
0.2 to 0.4 units per kg per day
Steroids and blood sugars
Steroids
• Stimulate hepatic glucose production
and inhibit peripheral glucose uptake
• Dexamethasone: Half life 48 hrs
• AM Prednisone:
 Effect usually seen post meals
 Peak effect on glycemia 2 PM to 8 PM
Leak, A, et al. Cl J Oncology Nurs. 13:205-10, 2009
How do Steroids Differ in their Effects?
Steroid Potency and Duration of Action
Glucocorticoid Potency Biologic Half Life
Hydrocortisone
Prednisone
Methylprednisolone
Dexamethasone
1
4
5
30-40
8-12 hours
18-36 hours
18-36 hours
36-54 hours
20mg/d of prednisone ~= 80mg/d of hydrocortisone ~= 16mg/d of
methylprednisolone ~= 3mg/d dexamethasone)
One Suggested Approach for Treatment
of Hyperglycemia in Patients Receiving
Glucocorticoid Therapy
Prednisone (mg/day)
NPH (units/kg/day)*
> 40
0.4
30
0.3
20
0.2
10
0.1
*Administered in AM at time of prednisone administration
Glargine preferred if dexamethasone used or Prednisone given twice a day
Clore JN, Thurber-Hay L. Endocrine Practice 15:469 2009
Tips for Glycemic Control with Steroids
• IV insulin infusion is often the easiest but if
patient will be eating the monitoring will be
intense.
• Steroids disproportionately affect prandial insulin
requirement
• Typically a patients daily insulin requirement is
equally divided between basal and prandial
• Steroid patients have much higher prandial
requirements 60-70% of total daily insulin
requirement
Steroid Therapy and Glycemic Control
General Guidelines
• The majority of patients (but not all) receiving high dose
glucocorticoid therapy will experience elevations in blood
glucose
• For patients without prior DM or hyperglycemia or those
with diabetes controlled with oral agents:
Initiate glucose monitoring with low dose correction
insulin scale administered prior to meals
• For patients previously treated with insulin
Increase total daily dose by 20 to 40% with start of
high dose steroid therapy
Increase correctional insulin by one step
(low to moderate dose)
• Adjust insulin as needed to maintain glycemic control
Surgery and Diabetes
Pre-Op Recommendations for Patients
Admitted Day of Surgery
Oral Hypoglycemic Agents
Withhold oral agents the morning of surgery
Insulin is necessary to control blood glucose in
patients with BG > 150 during surgery
Oral agents can be resumed postoperatively
when
• Patient is reliably taking PO
• Risk of liver, kidney and heart failure are minimized
Pre-op Recommendations for
Patients Admitted Day of Surgery
Insulin Treated Patients
Give at least 50 to 70 % of usual dose of NPH insulin
and 70 to 100 % of detemir or glargine insulin
For patients receiving premix insulin (70/30 or 75/25),
give 1/3 of total dose as NPH insulin prior to the procedure
For patients undergoing prolonged procedures (e.g. CABG)
hold SQ insulin and start IV insulin infusion
NPO Patients
A Typical Meal Tray in the Hospital Will Raise
Blood Glucose by About 200 mg/dL
• Breakfast-2 slices
toast, 1/2 banana, 4
oz. Juice, eggs &
sausage
• Lunch-sandwich, 8
oz. Milk, 1 small
cookie
• Dinner-roll, 1/4 cup
fruit, 2/3 cup rice, 8
oz. Milk, Pork-chop
What Is the Impact of NPO Status on
the Patient’s Blood Glucose Levels?
• Ideally, patients will have surgery early in
the morning to avoid a prolonged length
of time being NPO
• NPO patients need regular blood glucose
monitoring (q 4-6 hours) and may need
IV fluid
• NPO patients on oral diabetic medications
with long duration are at risk for
hypoglycemia
NPO Patients
• If the patient is made NPO
• Management is different for type 1 and type 2
type 1 patients still need basal insulin
• Transports with insulin on board
• Advocate for early test procedures so
pts do not miss too many meals
• Solution – use insulin analogs for basal/bolus

NPO Patients
• If the patient is made NPO:
Give ½ of the basal insulin dose and
hold the mealtime insulin, and continue
the correction dose
Monitor BG Q 6 hours and give corrective
insulin as needed
Resume the previous regimen once the
patient is eating again
Discharge planning
Discharge Considerations
•
•
•
•
What are your discharge plans for this patient?
Will they be discharged on insulin therapy?
When and where will follow-up take place?
What education do they need prior to discharge?
Effective Discharge Planning for
Continuity of Care
• A1C on admission for all diabetic patients, as well as
patients experiencing hyperglycemia prior to discharge
• Timely Referral to Inpatient Diabetes Educator if
applicable
• Post Hospital Plan of Care discussed with Patients
during Hospital stay – Nursing to reinforce
• Reconciliation of medications - If new to insulin, regime
discussed with patient prior to discharge. Insulin
Instruction Sheet given to patient to take home
• DME supplies – meter, syringes, lancet, needles etc.
• Referral for OP diabetes Self management If appropriate
• Follow-up care with PCP within 15-30 days, or if new to
insulin within 7-14 days
A1C is Helpful in Determining
Post Discharge Treatment
In those without previously diagnosed diabetes and an A1C level
of:
– 6.5% or higher: Indicates the incidence of diabetes and
referal to Inpatient Diabetes Educator is essential to begin
self-management education prior to discharge
– 5.7 – 6.4%: Indicates a category of increased risk for
diabetes. Lifestyle interventions that promotes weight loss
and increased activity should be addressed prior to
discharge
– Differentation between hospital-related hyperglycemia and
undiagnosed diabetes requires follow-up testing (FBG, 2H
OGTT) once metabolically stable using established criteria
DIABETES CARE, VOLUME 33, SUPPLEMENT 1, JANUARY 2010
Patients Newly Diagnosed with
Diabetes During Hospitalization
A diabetes education plan should be developed for each
patient prior to hospital discharge that address the
following:
•
•
•
•
•
•
•
Understanding related to the diagnosis of diabetes
SMBG and explanation of home blood glucose goals
Definition, recognition, treatment, and prevention of
hyperglycemia and hypoglycemia
Identification of healthcare provider who will provide diabetes care
after discharge
Information on consistent eating patterns
When and how to take medication including proper disposal of
needles and syringes
Sick day management
Diabetes Care, Volume 33, Supplement 1, January 2010
Recommended Treatment Strategies
for the Discharging Patient
In those with previously diagnosed diabetes and an elevated A1C
level
•
If HbA1C 7-8%: Increase dose of home oral agents, add third
agent or add basal insulin at bedtime
•
HbA1C > 8%: If already on two oral agents, add once daily
basal insuin at bedtime
•
If HbA1C 9-10%: Patient should be discharged home on
basal and bolus insulin regime. Use the amount of basal
insulin required in the hospital as once daily glargine/detimer
or bid NPH dose. Continue multiple daily dose as started in
the hospital if appropriate.
•
Twice daily premixed insulin should be considered for less
complex insulin regimens particularly in elderly patients.
Recommended Treatment Strategies
for the Discharging Patient
Journal of Hospital Medicine Vol 3/ Issue 5/ September/October 2008
Continuum of Care
• If new to insulin
1. Referral to an outpatient diabetes education
program shortly after discharge to discuss
ongoing diabetes control
2. Discharge Information on when to check BG and
timing of insulin administration. Information should
also include parameters for when to call PCP
3. Communication to patients PCP regarding
changes made to patients treatment regime during
hospitalization and a complete medication list
4. An assessment of the need for home health care
Thanks
• Questions???