Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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???