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Effective Glycemic
Control Outside of the
Critical Care Unit
Christopher A. Newton, MD, FACE
[email protected]
Division of Endocrinology
Grady Memorial Hospital
Emory University
November 3, 2012
Dallas, TX • November 2–4, 2012
Objectives
• Describe acute care populations that
are at high risk for hyperglycemia
• Identify essential components to
achieving glycemic control in the acute
care setting
Dallas, TX • November 2–4, 2012
DEFINITIONS
Dallas, TX • November 2–4, 2012
Accepted Glycemic Ranges
Dallas, TX • November 2–4, 2012
Glycemic Thresholds
• In-hospital hyperglycemia is defined as
an admission or in-hospital blood
glucose >140 mg/dL
• Hypoglycemia is defined as any blood
glucose <70 mg/dL
• A patient with an HbA1c >6.5% can be
identified as having diabetes
Dallas, TX • November 2–4, 2012
• Comparison of sensitivity and
specificity achieved for the diagnosis
of diabetes based on fasting plasma
glucose at various levels of HbA1c
from data in NHANES III and 19992004 NHANES
Dallas, TX • November 2–4, 2012
J Clin Endocrinol Metab, July 2008, 93(7):2447–2453
INCIDENCE OF HYPERGLYCEMIA
Dallas, TX • November 2–4, 2012
Distribution of Patient-DayWeighted Mean POC BG Values
ICU
Non-ICU
DATA from ~49
million POC-BG
testing (12 M ICU;
37 M non-ICU) from
3.5 million patients
(653,359 ICU;
2,831,436 nonICU). The mean
POC-BG was 167
mg/dL for ICU
patients and 166
mg/dL for non-ICU
patients.
Dallas, TX • November 2–4, 2012
Swanson et al. Endocrine Practice, October 2011
Distribution of Patient-DayWeighted Mean POC BG Values
• Data from ~37 million BG readings from
2,831,436 non-ICU patients - mean
POC-BG: 166 mg/dL
Dallas, TX • November 2–4, 2012
Swanson et al. Endocrine Practice, October 2011
Hyperglycemia Is Common
50
Patients, %
40
Diabetes
No Diabetes
50
40
78%
30
30
20
20
10
10
0
0
<110 110-140 140-170 170-200 >200
26%
<110 110-140 140-170 170-200 >200
Mean BG, mg/dL
Dallas, TX • November 2–4, 2012
Kosiborod M, et al. J Am Coll Cardiol. 2007;49(9):1018-183:283A-284A.
IGT and Undiagnosed T2DM Are
Common in Acute MI and Stroke
2-hour OGTT
Norhammar A, et al. Lancet 2002;359:2140−4.
Matz K, et al. Diabetes Care 2006;792−7.
Dallas, TX • November 2–4, 2012
CLINICAL OUTCOMES ASSOCIATED
WITH HYPERGLYCEMIA
Dallas, TX • November 2–4, 2012
Hyperglycemia: Independent
Marker of In-Hospital Mortality
*
* P < 0.01
Dallas, TX • November 2–4, 2012
Umpierrez GE et al, J Clin Endocrinol Metabol 87:978, 2002
Hyperglycemia and
Pneumonia Outcomes
*
*
*
*
* P<0.05 vs
BG<198 mg/dL
N=2471 patients
with community
acquired
pneumonia
Dallas, TX • November 2–4, 2012
McAllister et al, Diabetes Crae 28:810-815, 2005
30 Day Mortality and In-hospital
Complications among Non-cardiac
Surgery Patients
*
*
†
*
*
*
#
† p = 0.1
* p = 0.001
# p =0.017
Dallas, TX • November 2–4, 2012
A Frisch et al. Diabetes Care, May 2010
INSULIN PROTOCOL DEVELOPMENT
Dallas, TX • November 2–4, 2012
Key Elements – BG Targets
• Glucose Target in non-ICU setting:
– Premeal glucose targets <140 mg/dL
– Random glucose <180 mg/dL
– To avoid hypoglycemia, reassess insulin
regimen if glucose levels fall below 100 mg/dL
– Occasional patients may be maintained with a
glucose range below and/or above these cutpoints
Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control
Dallas, TX • November 2–4, 2012
Consensus Panel. Endocr Pract. 2009;15(4).
http://www.aace.com/pub/pdf/guidelines/InpatientGlycemicControlConsensusStatement.pdf
Key Elements - Monitoring
• Glucose monitoring is an obvious, but
crucial, element of success
• Monitoring glucoses:
– Provides assessment of current glucose
– Are interpreted for adjusting medications
based upon the trends in the glucoses
• Frequency depends upon treatment
regimen utilized
– Quicker interventions need more frequent
Dallas, TX • November 2–4, 2012
assessments
Key Elements - Personnel
• Physician / Physician Assistant / Nurse
Practitioner
• Nurses
• Pharmacy Staff
• Laboratory Staff
• Administration
• Many other people
– Patients?
Dallas, TX • November 2–4, 2012
Key Elements - Medication
Antihyperglycemic Therapy
SC Insulin
Recommended for most
medical-surgical
patients
ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care. 2006 & 2009
Diabetes Care. 2009;31(suppl 1):S1-S110..
OADs
Not Generally
Recommended
Dallas, TX • November 2–4, 2012
Key Elements - Medication
• AACE/ADA Consensus Statement: Noninsulin therapies in the hospital?
– Sulfonylureas are a major cause of hypoglycemia
– Metformin contraindicated in setting of decreased renal
blood flow and with use of iodinated contrast dye
– Tyiazolidinediones associated with edema and CHF
– Alpha-glucosidase inhibitors are weak glucose
lowering agents
– GLP1-directed therapies can cause nausea and have
a greater effect on postprandial glucose
Dallas, TX • November 2–4, 2012
Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009
Key Elements - Insulin
• Sliding scale short-acting insulin (SubQ)
• Subcutaneous basal/bolus therapy
– NPH and Regular
– Long-acting and Rapid-acting analogs
• Subcutaneous continuous infusion
• Intravenous insulin
Dallas, TX • November 2–4, 2012
Key Elements - Insulin
• Study Type: Prospective, multicenter RCT
• Population: 130 subjects insulin naïve T2DM
• Basal-Bolus Protocol:
– Starting total daily dose (TDD):
• 0.4 unit/kg/day for BG between 140-200 mg/dL
• 0.5 unit/kg/day for BG between 201-400 mg/dL
– ½ TDD as insulin glargine and ½ as glulisine
• Glargine – once daily at same time each day
• Glulisine – three equally divided doses with meals
Dallas, TX • November 2–4, 2012
Umpierrez et al, Diabetes Care 30:2181–2186, 2007
Sliding Scale Insulin
• Before meal: Supplemental Sliding Scale Insulin (# of units)
• Bedtime: Give ½ of Supplemental Sliding Scale Insulin
Blood Glucose
(mg/dL)
Insulin Sensitive
Usual
Insulin Resistant
>141-180
2
4
6
181-220
4
6
8
221-260
6
8
10
261-300
8
10
12
301-350
10
12
14
351-400
12
14
16
>400
14
16
18
Dallas, TX • November 2–4, 2012
Umpierrez GE et al. Diabetes Care. 2007;30:2181-2186.
BG, mg/dL
Rabbit 2 Trial: Changes in Glucose Levels
With Basal-Bolus vs. Sliding Scale Insulin
aP<.05.
240
220
200
180
160
140
120
100
Admit 1
a
a
a
b
b
b
b
Sliding-scale
Basal-bolus
2
3
4
5
6
7
8
9
10
Days of Therapy
bP<.05.
• Sliding scale regular insulin (SSRI) was given 4 times daily
• Basal-bolus regimen: glargine was given once daily; glulisine was given before meals.
0.4 U/kg/d x BG between 140-200 mg/dL
0.5 U/kg/d x BG between 201-400 mg/dL
Dallas, TX • November 2–4, 2012
Umpierrez GE, et al. Diabetes Care. 2007;30(9):2181-2186.
BG, mg/dL
Rabbit 2 Trial: Treatment Success With
Basal-Bolus vs. Sliding Scale Insulin
300
280
260
240
220
200
180
160
140
120
100
Slidingscale
Basalbolus
Hypoglycemia rate:
 Basal Bolus Group:
 BG < 60 mg/dL: 3%
 BG < 40 mg/dL: none
Admit1 2 3 4 1 2 3 4 5 6 7
Days of Therapy
 Sliding Scale Group:
 BG < 60 mg/dL: 3%
 BG < 40 mg/dL: none
Persistent hyperglycemia (BG>240 mg/dl)
is common (15%) during SSI therapy
Dallas, TX • November 2–4, 2012
Umpierrez GE, et al. Diabetes Care. 2007;30(9):2181-2186.
Basal-Bolus vs Sliding Scale Insulin in
Hospitalized Patients with T2DM
• The mean insulin daily dose was significantly
higher in the basal-bolus group than in the
sliding scale group
Insulin Type
Mean Insulin Dose, units / day
Basal-Bolus Group
SSI Group
Basal insulin
22 ± 2
-
Rapid-acting insulin
20 ± 1
-
-
12.5 ± 2
Regular insulin
Dallas, TX • November 2–4, 2012
Umpierrez GE, et al. Diabetes Care. 2007;30(9):2181-2186.
• Study Type: Prospective, multicenter, randomized,
open-label trial in general surgery (non-ICU)
• Population: 211 subjects with T2DM on diet and/or
oral hypoglycemic agents or low dose insulin (<0.4
units/kg/day)
• Primary Outcomes: Differences between groups
in mean daily blood glucose and composite of
hospital complications (wound infection, pneumonia,
respiratory failure, acute renal failure, bacteremia
Dallas, TX • November 2–4, 2012
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
RABBIT 2 Surgery
Treatment on Admission
All
SSI
Glar+Glu
P-value
Diet alone, n
17
11
6
NS
Oral antidiabetic agents, n
153
80
73
NS
Insulin + oral antidiabetic agents, n
20
11
9
NS
Type of surgery
All
SSI
Glar+Glu
P-value
Cancer
76
40
36
NS
GI-GU benign
59
28
31
NS
Vascular
31
15
16
NS
Trauma
38
20
18
NS
Others
7
5
2
NS
Dallas, TX • November 2–4, 2012
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
RABBIT 2 Surgery:
Basal-Bolus Regimen
• D/C oral anti-diabetic drugs on admission
• Starting total daily dose (TDD): 0.5 unit/kg/day
• TDD reduced to 0.3 unit/kg/day in patients >70
years old or with creatinine >2 mg/dL
• ½ TDD as glargine and ½ TDD as glulisine
– Glargine – once daily at same time of day
– Glulisine – three equally divided doses with meals
• Goal glucoses: 100-140 mg/dL
Dallas, TX • November 2–4, 2012
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
Basal-Bolus Dose Adjustment
Blood glucose levels
Change in Daily
Insulin Dose*
Fasting and pre-meal BG between 100-140 mg/dl in
the absence of hypoglycemia
no change
Fasting and pre-meal BG between 141-180 mg/dl in
the absence of hypoglycemia
Increase by 10%
Fasting and pre-meal BG between >181 mg/dl in the
absence of hypoglycemia
Increase by 20%
Fasting and pre-meal BG between 70-99 mg/dl in the
absence of hypoglycemia
Decrease by 10%
Fasting and pre-meal BG between <70 mg/dl
Decrease by 20%
* Daily insulin adjustment was primarily focused on glargine dose.
* The treating physicians were allowed to adjust prandial (glulisine) insulin
dose, and to use the total supplemental dose, patient’s nutritional intake,
and results of BG testing to adjust insulin regimen. Dallas, TX • November 2–4, 2012
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
RABBIT 2 Surgery:
Glucoses During Therapy
*
*
†
R = Randomization
‡
†
†
* p<0.001
† p=0.01
‡ p=0.02
Dallas, TX • November 2–4, 2012
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
RABBIT 2 Surgery:
Mean Glucose During Day
*
*
*
*
*p<0.001
Dallas, TX • November 2–4, 2012
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
RABBIT 2 Surgery:
Postoperative Complications
P=0.003
P=0.05
P=NS
P=0.10
P=0.24
* Composite of hospital complications: wound infection, pneumonia, respiratory failure, acute
renal failure, and bacteremia.
Dallas, TX • November 2–4, 2012
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
RABBIT 2 Surgery:
Impact on Need for ICU
Post-surgical ICU Admission
ICU Length of Stay
P=0.003
P=0.16
Dallas, TX • November 2–4, 2012
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
RABBIT 2 Surgery:
Hypoglycemia
p<0.001
p<0.001
There were no differences in
hypoglycemia between
patients treated with insulin
prior to admission compared
to insulin-naïve patients.
p=0.057
Dallas, TX • November 2–4, 2012
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
RABBIT 2 Surgery:
Insulin Doses
Insulin Type
Mean Insulin Dose, units / day
Basal-Bolus Group
SSI Group
33.4
12.3
Basal insulin
21.8 ± 8.6
-
Rapid-acting insulin
14.8 ± 7.6
-
-
12.3 ± 6.5
Total daily dose
Regular insulin
SSI: range of daily regular insulin= 9.7 to 14.4 units after 24hr treatment
88.5% of patients received <20 units and 39.4% <10 units per day.
Dallas, TX • November 2–4, 2012
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
• Study Type: Prospective, randomized,
open-label trial
• Population: 130 subjects with T2DM on oral
hypoglycemic agents or insulin therapy
• Study Sites:
– Grady Memorial Hospital, Atlanta, GA
– Rush University Medical Center, Chicago, IL
Dallas, TX • November 2–4, 2012
Umpierrez et al, J Clin Endocrinol Metab 94: 564–569, 2009
DEAN Trial: Changes in Mean Daily
Blood Glucose Concentration
240
Detemir + aspart
NPH + regular
BG, mg/dL
220
200
P=NS
180
160
140
120
100
Pre-Rx
BG
0
1
2
3
4
5
6-10
Duration of Therapy, d
Data are means SEM.
Basal-bolus regimen: detemir was given once daily; aspart was given before meals.
NPH/regular regimen: NPH and regular insulin were given twice daily, 2/3 in AM, 1/3 in PM.
Dallas, TX • November 2–4, 2012
Umpierrez GE, et al. J Clin Endocrinol Metab. 2009;94(2):564-569.
DEAN Trial
Blood glucose (mg/dL)
Detemir + Novolog
NPH + Regular
Dallas, TX • November 2–4, 2012
Umpierrez GE, et al. J Clin Endocrinol Metab. 2009;94(2):564-569.
DEAN Trial: Insulin Doses
• The mean total daily insulin dose was not
significantly different between treatment
groups
Insulin Type
Total Units/day
Basal insulin/day
Rapid-acting insulin
Mean Insulin Dose, units / day
Detemir-Novolog
NPH-Regular
56 ± 45
45 ± 32
Detemir: 30 ± 28
NPH: 27 ± 20
Novolog: 27 ± 20*
Regular: 18 ± 14
* P < 0.05
Dallas, TX • November 2–4, 2012
Umpierrez GE, et al. J Clin Endocrinol Metab. 2009;94(2):564-569.
DEAN Trial: Hypogylcemia
• NPH/Regular
– BG <40 mg/dL: 1.6%
– BG <60 mg/dL: 25.4%
• Detemir/Aspart
– BG <40 mg/dL: 4.5%
– BG <60 mg/dL: 32.8%
To determine risk
factors for
hypoglycemic events
during SC insulin
therapy
Dallas, TX • November 2–4, 2012
Umpierrez GE, et al. J Clin Endocrinol Metab. 2009;94(2):564-569.
Interim Summary
• Treatment with basal bolus improved
glycemic control and reduced hospital
complications compared to SSI in
medicine and surgery patients with T2DM
• Basal-bolus insulin regimen is preferred
insulin regimen over Sliding Scale Insulin
in the hospital management of non-ICU
patients with T2DM
Dallas, TX • November 2–4, 2012
Hypoglycemia Risk Factors
p-value
Variable (univariate)
BG <60 mg/dL
BG <70 mg/dL
Age
0.036
0.001
Weight
0.027
0.001
HbA1c
0.521
0.658
Creatinine
0.011
0.002
Enrollment BG
0.166
0.319
Previous treatment
0.005
<0.001
Previous insulin treatment
<0.001
<0.001
Treatment group
<0.001
<0.001
*p-values are from Wilcoxon Two-Sample Test
Dallas, TX • November 2–4, 2012
Umpierrez et al, ADA Scientific Meeting, Poster #516, 2009
CAN HYPOGLYCEMIA FROM INSULIN BE
AVOIDED?
Dallas, TX • November 2–4, 2012
Hypoglycemia:
Triggering Events
• Transportation off ward, causing meal delay
• Failure to measure blood glucose before
insulin doses
• New NPO status
• Interruption of
–
–
–
–
IV dextrose therapy
TPN
Enteral feedings
Continuous venovenous hemodialysis
Dallas, TX • November 2–4, 2012
SubQ Basal Insulin Action
sc insulin
n=20 T1DM
Mean ± SEM
4.0
24
3.0
16
2.0
12
8
1.0
Glargine
0
4
8
12
16
Time (hours)
Adapted from Lepore M. et al., Diabetes 49:2142-8, 2000
20
4
0
NPH
0
µ mol/Kg/min
mg/Kg/min
20
24
Dallas, TX • November 2–4, 2012
Intravenous Insulin
• By-passes the delay associated with
subcutaneous insulin administration
• Insulin from an IV infusion or IV bolus will
disappear from bloodstream in 7 minutes
– With sufficiently frequent monitoring, can
decrease the insulin dose prior to onset of
hypoglycemia
• Majority of medical centers limit this option
to intensive/critical care settings
Dallas, TX • November 2–4, 2012
IV versus SubQ Insulin
• Long-acting subcutaneous insulin
– Slow steady release of insulin into blood
stream
– Can be mimicked by continuous infusion
• Rapid-acting subcutaneous insulin
– Faster absorption of insulin from
subcutaneous space (doesn’t last)
– Similar to a temporary increased infusion
rate (not the same as IV bolus)
Dallas, TX • November 2–4, 2012
Successful Insulin
Infusion Protocols
• Reaches and maintains BG successfully within a
prespecified target range
• Includes a clear algorithm for making temporary
corrective changes in the IV insulin rate as patient
requirements change
• Incorporates the “rate of change” in BG, not just the
absolute values
• Incorporates the current IV insulin rate
• Minimizes hypoglycemia; provides specific directions
for its treatment when it occurs
• Provides specific guidelines for timing and selection of
Dallas, TX • November 2–4, 2012
doses for the transition to SC insulin
IV Insulin in Non-ICU
• Retrospective review in 200 patients
– 90 General Medicine /110 General Surgery
– Mean glucose 322 mg/dL
• Targeted glucose <150 mg/dL for 85%
– 67% achieved glucose <150 by day 2
– Mean glucose during infusion: 170 mg/dL
Dallas, TX • November 2–4, 2012
Smiley D, et al. J Hosp Med. 2010;5:212-217.
Hypoglycemia on IV Insulin
Dallas, TX • November 2–4, 2012
Smiley D, et al. J Hosp Med. 2010;5:212-217.
Transition from IV Continuous Insulin
Infusion to SC Insulin Therapy
 We recommend that all patients with type 1 and type
2 diabetes be transitioned to scheduled sc insulin
therapy at least 1–2 h before discontinuation of CII.
 We recommend that sc insulin be administered
before discontinuation of CII for patients without a
history of diabetes who have hyperglycemia requiring
more than 2 unit/h.
 We recommend POC testing with daily adjustment of
the insulin regimen after discontinuation of CII.
Dallas, TX • November 2–4, 2012
Transition From Intravenous
to Subcutaneous Insulin
Known Diabetics:

Calculate total daily insulin requirement:
based on insulin rate during the last 4-hours of
infusion, (e.g., 2 units/hour = 48 U/day)

Start SC insulin as follow:
 ½ dose as basal (Glargine, Detemir)
 ½ dose as prandial (Lispro, Aspart, Glulisine)
 If patient not able to eat: give basal but hold
prandial insulin
Dallas, TX • November 2–4, 2012
Smiley et al. Ann. N.Y. Acad. Sci 1212:1-11, 2010
Transition From Intravenous
to Subcutaneous Insulin
No History of Diabetes (stress hyperglycemia):
 If HbA1c >7%, treat as diabetes
 If HbA1c <6.4%

If insulin requirements during CII is <2 U/hr, stop
infusion and use correction doses for BG >140 mg/dl
 If requirements >2 U/hr during CII, start SC insulin:
 ½ dose as basal (Glargine, Detemir)
 ½ dose as prandial (Lispro, Aspart, Glulisine)
Dallas, TX • November 2–4, 2012
Smiley et al. Ann. N.Y. Acad. Sci 1212:1-11, 2010
CONTINUOUS SUBCUTANEOUS INSULIN
INFUSION
Dallas, TX • November 2–4, 2012
Keys to CSII Use in the
Hospital
• AACE/ADA Inpatient Hyperglycemia
– Candidates for inpatient CSII use are those
using CSII as outpatients
• Must have mental and physical capacity to do so
– Nursing personnel must document basal
rates and bolus doses on regular basis
– Hospital personnel with expertise in CSII
therapy is essential
Dallas, TX • November 2–4, 2012
Potential Issues with CSII
Use
• Many nurses (and physicians) are unfamiliar
with the technology and thus uncomfortable
with allowing its continued use
– Knowledge scores 67% for those with prior
experience with CSII user vs 17% (p<0.01)
– Agreed CSII effective strategy for managing
diabetes in the hospital
– Only 27% thought they could safely care for a
patient using CSII
Dallas, TX • November 2–4, 2012
Noschese et al. Diabetes. 2006;55:846-P.
Policy for Continued CSII
Use
• List of suggested contraindications
– Altered state of consciousness
– Critically ill
– Risk of suicide
– “other reason” deemed appropriate by MD
• Set of rules to guide medical staff
• Requirement of signed informed
consent detailing conditions for CSII use
Dallas, TX • November 2–4, 2012
Bailon et al. Endocr Pract. 2009;15:24-29.
Procedures for Patients
Admitted to Hospital on CSII
•
•
•
•
•
•
•
•
Presence of insulin pump, brand of pump and insulin type are identified
Blood or capillary glucose level is determined
Contraindications for continued use of insulin pump are assessed
Physician order for alternate insulin therapy is obtained if CSII must be
discontinued
Patient’s consent for CSII is obtained
Admitting physician writes initial order for insulin pump therapy using the
preprinted order form
Endocrinology, diabetes education, and nutrition consultations are ordered
by admitting physician
Insulin pump basal-bolus blood glucose record flow sheet is placed at the
patient’s bedside
Dallas, TX • November 2–4, 2012
Bailon et al. Endocr Pract. 2009;15:24-29.
Insulin Pump Therapy:
One Institution’s Experience
• Frequency of hypoglycemic and
hyperglycemic events among hospitalized
patients receiving continuous subcutaneous
insulin infusion (insulin pump) therapy
Dallas, TX • November 2–4, 2012
Leonhardi BJ, et al. J Diabetes Sci Technol. 2008;2(6):948-962
Pump “On” vs Pump “Off”
BG > 200 mg/dL
BG < 70 mg/dL
Dallas, TX • November 2–4, 2012
Bailon et al. Endocr Pract. 2009;15:24-29.
Hypo and Hyperglycemia
With and Without CSII
Dallas, TX • November 2–4, 2012
Bailon et al. Endocr Pract. 2009;15:24-29.
Pitfalls to Continued CSII Use
• Limited experience
– Published reports suggest 1-2 patients/mo
• Supplies
– Tubing needs to be changed at most Q3days
– Different pumps need different reservoirs
• Determining who is “in charge” and tracking
the insulin dosing
• Pumps and MRI’s don’t mix
• Note, this is “continued” not “initiating”…
Dallas, TX • November 2–4, 2012
CONCLUSIONS
Dallas, TX • November 2–4, 2012
Summary
• Hyperglycemia is common in hospitals
• Evidence on the management of
hyperglycemia in non-ICU settings is
increasing
– Vast majority of studies utilize subQ insulin
• Intravenous insulin can be implemented
in non-ICU’s
– Has been most often studied in ICU’s
• SubQ insulin infusion can be continued
Dallas, TX • November 2–4, 2012