Download Management of Diabetes and Hyperglycemia in the Hospital Patient

Management of Diabetes and
Hyperglycemia in the Hospital Patient:
Focus on subcutaneous insulin use in the
non-critically ill, adult patient
Lead authors: Gregory Maynard MD, MS
David H. Wesorick MD
For the SHM Glycemic Control Task Force
The SHM Glycemic Control Task
Force
Hospitalists
Representing The Society of Hospital Medicine:
Gregory Maynard, MD
Alpesh Amin, MD, MBA, FACP
Lakshmi Halasyamani, MD
Kevin Larsen, MD
Cheryl O'Malley, MD
Jeffrey L. Schnipper, MD, MPH
David H. Wesorick, MD
Mitchell J. Wilson, MD
Education
Marcia D. Draheim, RN, CDE
Sharon Mahowald, RN, CDE
Pharmacy
Stuart T. Haines, Pharm.D., FASHP, FCCP, BCPS
Representing the American Society of Consultant
Pharmacists:
Donald K Zettervall, RPh, CDE, CDM
Case Management
Endocrinologists
Representing the American Diabetes Association:
Andrew J. Ahmann, MD
Michelle F. Magee, MD
Representing the American Association of Clinical
Endocrinologists:
Richard Hellman, MD, FACP, FACE
Representing the American College of Physicians
Doron Schneider, MD
Endocrinology Expert Panel:
Susan Shapiro Braithwaite, MD, FACP, FACE
Mary Ann Emanuele, MD, FACP
Irl B. Hirsch, M.D.
Robert Rushakoff, MD
Representing the Case Management Society of America
Cheri Lattimer, RN, BSN
Nancy Skinner, RN, CCM
Dietetics
Carrie Swift, MS, RD, BC-ADM
Visit the Society of Hospital Medicine’s Glycemic Control
Resource Room at www.hospitalmedicine.org for more
Information on the Task Force Members.
Objectives For This Exercise
• Appreciate the obstacles to achieving good glycemic control
in hospital patients
• Understand and apply the best practice of inpatient
hyperglycemia/diabetes management using subcutaneous
insulin, including the use of anticipatory, physiologic insulin
dosing in a variety of clinical situations
• Understand the common deviations from the best practices
of insulin management in the hospital
• Learn how to prevent and manage hyperglycemia and
hypoglycemia
Managing Diabetes in the Hospital Presents
Different Challenges than Managing
Diabetes in the Outpatient Arena!
The hospital is associated with:
-
Nutritional and clinical instability
The need for changes from the home diabetes medical regimen
Acute illness, “stress-related” hyperglycemia
Use of medications that impact glycemic control
Why Should We Care?
• Hyperglycemia occurs frequently in hospital patients, and is
associated with poor outcomes
• Hypoglycemia occurs frequently in hospital patients, and is
unpleasant and dangerous
• Adequate metabolic control is an attainable goal for hospital
patients
Hyperglycemia is Undesirable!
Umpierrez et al. Journal of Clinical Endocrinology and Metabolism 2002; 87: 978-82.
• Hyperglycemia in the hospital is associated with adverse
outcomes
• Hyperglycemia can occur in patients without a known
diagnosis of diabetes
– Undiagnosed diabetes
– Illness-related hyperglycemia
• Patients with hyperglycemia without a known diagnosis of
diabetes experienced even worse outcomes than the known
diabetes patients in this study
Hyperglycemia and Poor Hospital Outcome
Metabolic stress response
 stress hormones and peptides
 Glucose
 Insulin
 Reactive O2 species
Immune dysfunction
Infection dissemination
 FFA
 Ketones
 Lactate
 Secondary mediators
Cellular injury/apoptosis
Inflammation
Tissue damage
Altered tissue wound repair
Clement et al,
Diabetes Care 27:553-591, 2004
 Transcription factors
Prolonged hospital stay
Disability / Death
Hyperglycemia is Undesirable!
• Epidemiologic and uncontrolled observational studies
suggest that hyperglycemia is associated with adverse
outcomes in a wide range of hospital patients
• Interventional trials have shown that improved glycemic
control is associated with improved outcomes in several
different patient populations, including those with:
– Acute myocardial infarction
– Cardiac surgery
– Critical illness
• The evidence supporting metabolic control in inpatients has
been reviewed (Diabetes Care 2004; 27: 553-91, Endocrine Practice 2004; 10: 77-82, and
Diabetes Care 2006; 29: 1955-62)
How Can Diabetes and Hyperglycemia
be Controlled in the Hospital?
• Oral agents = often inappropriate for hospital patients
• IV insulin = most often used in the intensive care unit setting
(or in other defined populations)
• Subcutaneous insulin = the drug of choice for controlling
hyperglycemia in the majority of non-critically ill patients
Oral Antidiabetes Agents in the Hospital
• Oral agents can be continued in stable patients with normal nutritional
intake, normal blood glucose levels, and stable renal and cardiac
function. However, there are several potential disadvantages to using
these medications in hospital patients:
– Disadvantages of most oral agents:
• Slow-acting/difficult to titrate
– Disadvantages of insulin secretagogues (e.g. sulfonylureas and
meglitinides such as glyburide, glypizide, repaglinide, etc.):
• Hypoglycemia if caloric intake is reduced
• Some are long-acting (hypoglycemia may be prolonged)
– Disadvantages of metformin:
• Lactic acidosis can occur when used in the setting of renal dysfunction,
circulatory compromise, or hypoxemia
• Slow onset of action
• GI complications: Nausea, diarrhea
Oral Antidiabetes Agents in the
Hospital, continued…
– Disadvantages of thiazoladinediones (e.g. rosiglitazone, pioglitazone):
• Slow onset of action (2-3 weeks)
• Can cause fluid retention (particularly when used with insulin), and increase risk
for CHF
– Disadvantages of alpha-glucosidase inhibitors (e.g. acarbose, miglitol)
• Abdominal bloating and flatus
• Need pure glucose to treat hypoglycemia
– Disadvantages of GLP-1 mimetics (e.g. exenatide)
• Newer agents without data to support use in the hospital
• Abdominal bloating and nausea secondary to delayed gastric emptying
Diabetes and Hyperglycemia Require
Proactive Management
• Diabetes requires proactive management in all hospital
patients. There are no “autopilot” insulin regimens
• Insulin is a “high alert” medication that is frequently
associated with medication errors in the hospital, and
JCAHO considers insulin to be one of the highest risk
medications in the hospital (JCAHO Website, 2006)
The Issue of Hypoglycemia
• Fear of hypoglycemia often results in the use of nonphysiologic insulin regimens (e.g. sliding scale insulin,
alone)
• Using too little insulin and purposefully allowing
hyperglycemia would only be appropriate if hyperglycemia
were entirely benign or if adequate metabolic control were
an unattainable goal
• It has been demonstrated that rates of hypoglycemia in the
hospital can be reduced by using standardized, physiologic
insulin regimens
What is the Appropriate Glycemic
Control Target for Inpatients?
• Controversial!
ICU
Non-ICU,
Preprandial
Non-ICU,
Maximum
ACCE/ACE
110 mg/dl
110 mg/dl
180 mg/dl
ADA
110 mg/dl
90-130 mg/dl
180 mg/dl
Selecting a Non-ICU Glycemic Target
For Your Practice/Institution
• Examples of target ranges set by some institutions:
– 90-150 mg/dL
– Pre-prandial target 90-130 mg/dL; Random glucose < 180
mg/dL
– Pre-prandial target 80-130 mg/dL for most patients; preprandial target 90-150 mg/dL for patients with hypoglycemia
risk factors
Current Practice ≠ “Best Practice”
• Dependence on non-physiologic insulin prescribing (as opposed
to insulin that mimics physiologic insulin secretion)
• Dependence on reactive strategies (e.g. sliding-scale insulin)
• Overemphasis on simplicity (particularly simplicity from the
perspective of the ordering physician)
• Overemphasis on avoidance of hypoglycemia
• Lack of standardization of insulin use in the hospital
What is the “Best Practice” for Managing
Diabetes and Hyperglycemia in the Hospital?
• The answer is anticipatory, physiologic insulin dosing,
prescribed as a basal/bolus insulin regimen
• This means giving the right type of insulin, in the right
amount, at the right time, to meet the insulin needs of the
patient
The Components of a
Physiologic Insulin Regimen
• Basal insulin
• Nutritional insulin
• Correctional insulin
Physiologic Insulin Secretion:
Basal/Bolus Concept
Nutritional (Prandial) Insulin
Insulin
(µU/mL)
50
25
Basal Insulin
0
Breakfast
Glucose
(mg/dL)
150
Lunch
Supper
Nutritional Glucose
100
50
0
Suppresses Glucose
Production Between
Meals & Overnight
Basal Glucose
7 8 9 101112 1 2 3 4 5 6 7 8 9
A.M.
P.M.
Time of Day
The 50/50 Rule
Providing Exogenous Basal Insulin
• Long-acting, non-peaking insulin is preferred as it provides
continuous insulin action, even when the patient is fasting
• Required in ALL patients with type 1 diabetes
• Many patients with type 2 diabetes will require basal insulin
in the hospital
• Can be estimated to be about 1/2 of the total daily dose of
insulin (TDD)
Which Insulins are Best for
Basal Coverage?
Insulin Effect
NPH
Detemir (Levemir)
Glargine (Lantus)
Regular
Lispro (Humalog)
Aspart (Novolog)
Glulisine (Apidra)
Inhaled insulin
0
6
12
Time (hours)
18
24
Providing Exogenous Nutritional Insulin
• Usually given as rapid-acting analogue (preferred in most
cases) or regular insulin, for those patients who are eating
meals
• Must be matched to the patient’s nutrition
• Should not be given to patients who are not receiving
nutrition (e.g. NPO)
• Can be estimated to be about ½ of the total daily dose of
insulin (TDD)
Which Insulins are Best for
Nutritional Coverage?
Insulin Effect
NPH
Detemir (Levemir)
Glargine (Lantus)
Regular
Lispro (Humalog)
Aspart (Novolog)
Glulisine (Apidra)
Inhaled insulin
0
6
12
Time (hours)
18
24
Providing Exogenous Correctional Insulin
• Correctional insulin is extra insulin that is given to correct
hyperglycemia
• Usually rapid-acting or regular insulin (usually the same as the
nutritional insulin)
• Often written in a “stepped” format that is used in addition to
basal and nutritional insulin
• Customized to the patient using an estimate of the patient’s
insulin sensitivity
• If correctional insulin is required consistently, or in high doses, it
suggests a need to modify the basal and/or nutritional insulin
doses
Using Exogenous Insulin to Imitate
Physiologic Insulin Secretion: Summary
• Basal insulin: Use non-peaking, longer acting insulins
– Glargine or detemir are preferred
– NPH also possible
• Nutritional insulin: Depends on the type of nutrition
– Rapid-acting insulin is preferred when patients are eating meals
– Regular insulin also possible
• Correctional insulin: Use rapid-acting (or regular) insulin
– Usually the same as the nutritional insulin
Which Patients Should be Treated with
a Physiologic Insulin Regimen?
During hospitalization
• Any patient with blood glucose levels consistently above the
target range
Immediately at the time of admission
• All patients with type 1 diabetes
• Patients with type 2 diabetes if…
– They are known to be insulin-requiring
– They are known to be poorly controlled despite treatment with
significant doses of oral agents
– They are known to require high doses of oral agents that will
be held in the hospital
A Stepwise Approach to Physiologic
Insulin Dosing in the Hospital
1.
Estimate the amount of insulin the patient would need
over one day, if getting adequate nutrition = Total Daily
Dose (TDD)
2.
Assess the patient’s nutritional situation
3.
Decide which components of insulin the patient will
require, and which percentage of the TDD each should
represent
4.
Assess blood glucoses at least daily, adjusting insulin
doses as appropriate
STEP 1: Estimate the Amount of Insulin the
Patient Would Need Over One Day, If Getting
Adequate Nutrition = Total Daily Dose (TDD)
• Insulin drip-based estimate (for patients treated with an insulin
infusion- see below)
• For patients already treated with insulin, consider the patient’s
preadmission subcutaneous regimen and glycemic control on that
regimen
• Weight-based estimate:
– TDD = 0.4 units x Wt in Kg
– Adjust down to 0.3 units x Wt in Kg for those with hypoglycemia risk factors,
including kidney failure, type 1 diabetes (especially if lean), frail/low body
weight/ malnourished elderly, or insulin naïve patients
– Adjust up to 0.5-0.6 units (or more) x Wt in Kg for those with hyperglycemia
risk factors, including obesity and high-dose glucocorticoid treatment
Conditions Associated with
Hypoglycemia in Hospitalized Patients
•
Known sensitivity to insulin recognized as low TDD of insulin (e.g. type 1
diabetes) or lean body habitus
•
Malnutrition or low body weight
•
Specific medical conditions, including renal failure (ESRD), liver disease, heart
failure, malignancy, circulatory failure (shock), adrenal insufficiency, burns,
alcoholism
•
Prior hypoglycemia or labile blood glucose control
•
Medications: sulfonylureas, pentamidine, quinine, or lowering of the doses of
glucocorticoids
•
Decreases in nutritional intake (e.g. those related to physician orders, delays in
food delivery, sudden discontinuation of parenteral or enteral nutrition, or patientspecific factors such as nausea, etc)
•
Advanced age
Conditions Associated with
Hyperglycemia in Hospitalized Patients
• Known insulin resistance recognized by high TDD of insulin
or obesity
• Medications: glucocorticoids, catecholamines, tacrolimus,
cyclosporine
• Significant illness: “Stress response” related to the release
of counter-regulatory hormones
• Increases in nutritional intake (e.g. restarting a diet, starting
enteral or parenteral nutrition)
STEP 2: Assess the Patient’s
Nutritional Situation
• Eating meals or receiving bolus tube feeds
• Eating meals but with unpredictable intake
• Getting continuous tube feeds
• Getting tube feeds for only part of the day
• Getting parenteral nutrition
• NPO
STEP 3: Decide Which Components of
Insulin the Patient Will Require, and Which
Percentage of the TDD Each Should Represent
• Basal insulin can generally be estimated to be 1/2 of the
TDD
• Nutritional insulin makes up the remaining 1/2 of the TDD
STEP 3: Decide Which Components of
Insulin the Patient Will Require, and Which
Percentage of the TDD Each Should
Represent, Continued…
• In most cases, basal insulin should be provided
• In most cases, well-designed corrective insulin regimens
should be provided
• When a patient is not receiving nutrition, nutritional insulin
should not be given
• Nutritional insulin needs must be matched to the actual
nutritional intake
STEP 4: Assess Blood Glucoses at Least
Daily, Adjusting Insulin Doses as Appropriate
• Blood glucose targets can only be achieved via continuous
management of the insulin program
• There is no “autopilot” insulin regimen for a
hospitalized patient!
Example Cases
• Introduction to the Cases
Case 1
56 year old woman with DM2 admitted with a diabetes-related
foot infection which may require surgical debridement in the
near future, eating regular meals.
- Weight: 100 kg
- Home medical regimen: Glipizide 10 mg po qd, Metformin
1000 mg po bid, and 20 units of NPH q HS
- Control: A recent HbA1c is 10%, POC glucose in ED 240
mg/dL
What are your initial orders for basal and nutritional insulin?
How would you manage the oral agents?
Case 1: Solution
• Bedside glucose testing AC and HS
• Discontinue oral agents
• Total daily dose 100 kg x 0.6 units/kg/day = 60
• Basal: Glargine 30 units q HS
• Nutritional: Rapid-acting analogue 10 units q ac at the first bite of
each meal
• Correction: Rapid-acting analogue per scale q ac and HS (Note:
Use correctional insulin with caution at HS, reduce the daytime
correction by up to 50% to avoid nocturnal hypoglycemia)
Case 1 Continued…
The patient is made NPO after midnight for a test, but is
expected to be able to resume her diet at lunch or dinner the
next day. What changes would you make to her management
program regarding glucose monitoring and her insulin
program? Would you provide dextrose in her IV fluids?
Case 1 continued: Solution
• Change bedside glucose checks to q 6 hours, as the patient will
not be eating meals
• Continue basal insulin: If using glargine, continue as is. If using
NPH, continue in equal twice daily doses with a dose reduction of
1/3-1/2 while NPO.
• Hold nutritional insulin while NPO
• Provide a low level of intravenous dextrose (e.g. 75-125 cc/hr of a
D5 containing solution)
• Continue appropriate correctional insulin for hyperglycemia
Case 2
56 year old woman with type 1 diabetes admitted with a diabetesrelated foot infection. The wound is an infected ulcer on the fifth digit
with necrosis. The plan is for amputation first thing in the morning,
so the patient will be NPO after midnight. However, she is expected
to resume a regular diet at lunch the following day after surgery.
- Weight: 70 kg
- Home medical regimen: 70/30 insulin 14 units BID
- Control: A recent HbA1c is 9%, POC glucose in ED is 240 mg/dL
It is now dinner time, and the patient took her last dose of insulin
before breakfast. What insulin would you give her now (before
dinner) and how would you modify her regimen given the plan for
NPO after midnight?
Case 2: Solution
• Bedside glucose testing AC and HS while eating, and q 6 hours when
NPO
• TDD by weight = 70 kg x 0.4 units/kg/day = 28 units
• Her home TDD is 28, but patient has very poor control on this regimen,
so increase (arbitrarily) by 20% = 34 units
• IV dextrose infusion while NPO (e.g. D5 at 75-150 cc/hr)
• Basal: Glargine 17 units q HS
• Nutritional: Rapid-acting insulin 6 units q ac at the first bite of each meal
•
Correction: Rapid-acting insulin per scale q ac and HS
Case 3
A 54 yo m with DM2 presents with acute pancreatitis (1
Ranson criteria). You make him NPO as part of your plan.
- Weight: 100 kg (BMI 35)
- Home medical regimen: 70/30 insulin 15 units at
breakfast and 15 units at dinner
- Control: A recent HbA1c was 9.2%, admission glucose is
166
What insulin orders would you write?
Case 3: Solution
• Bedside glucose checks Q6 hrs
• TDD = 100kg x 0.5 = 50
• Basal: Glargine 25 units HS
• Nutritional: None (NPO)
• Appropriate correctional insulin scale
• D5 ½ NS at 100 cc/hr continuous
Case 3 Continued…
Hospital day 3, the patient’s abdominal pain is worse, although
he is otherwise stable. You decide to start TPN. The patients
blood glucoses have been in the mid to high 100’s on the initial
insulin regimen described above (see next slide). How would
you manipulate this patient’s insulin as you initiate TPN?
Prior Day
Glucose
8 AM
Noon
Supper
Bedtime
150
195
172
198
Insulin
Totals
Lispro
Mealtime
Lispro
Correctional
Glargine
TDD
2u
2u
2u
6u
25 u
25 u
31 u
Case 3 Continued: Solution
• Parenteral nutrition often causes hyperglycemia and often
requires insulin treatment, even in patients who would not
require insulin otherwise
• An intravenous insulin infusion, separate from the nutritional
infusion, is a rational way of managing this patient that will
allow good initial control of the patient’s blood glucose, and
accurate insulin dose-finding
• Stop SC insulin when starting the insulin infusion
Case 3 Continued…
Initially the insulin drip is adjusted frequently but, after 6 hours,
stabilizes to a steady state, using 2-3 units per hour. Over the
subsequent 12 hours the patient uses 31 units of insulin total
(see next slide). You want to try to discontinue the separate
intravenous infusion. How much insulin do you put in the TPN
bag for the subsequent day? What other orders do you write to
assure that hyperglycemia does not ensue?
8 AM
Prior Day
Glucose
Noon
Supper
Bedtime
Glucoses averaging 130 over last 12 hours
Insulin
totals
Lispro
Mealtime
Lispro
Correctional
Glargine
Infusion
TDD
2-3 units per hour for a total of 31 units
over the last 12 hours
62 u
62 u
Case 3 Continued: Solution
• Add the majority (e.g. 80%) of the patients daily insulin to
the next 24 hour bag = 48 units regular insulin (31 units in
12 hours x 2 = 62 x 0.8 = 48)
• In addition, appropriately dosed correctional insulin, given
SC, with glucose checks every 4-6 hours would be
appropriate
Case 4
A 62 y/o woman with a history of type 2 diabetes was admitted to the
ICU with urosepsis. Her admission glucose was 311 and her
admission systolic blood pressure was 60. Over the first day, she
was treated with IV fluids, antibiotics, an IV insulin infusion, and
pressors (which were weaned off after a few hours). She stabilized
and was able to eat a small amount of dinner that evening. On the
morning of the second hospital day, she remains stable and the ICU
team calls you to transfer this patient out of the ICU to your service.
You decide to change her to a subcutaneous insulin program.
- Weight: 90 kg
- Home medical regimen: 70/30 NPH/regular insulin 10 units BID
- Control: She says that her outpatient blood glucoses are usually in
the 200’s, but she does not know her HbA1c level. Her insulin and
glycemic data for the prior day are shown on the next slide.
What subcutaneous insulin orders would you write?
Time
10
Events
Admit
Glucose
311
201
154
134
118
98
112
Insulin
Drip Rate
6u
4u
3u
2u
2u
1u
2u
Time
11
12
13
14
15
16
17
18
19
20
108
188
211
155
1u
3u
4u
3u
Dinner
21
22
23
00
1
2
3
4
5
6
7
Glucose
119
X
110
98
X
109
119
104
98
110
120
Insulin Drip
Rate
2u
2u
1u
1u
1u
1u
2u
1u
1u
1u
2u
Meals
Stepwise Approach to Moving from IV
to SC Insulin
• Calculate how much IV insulin the patient has been
requiring
• Recognize which component of the physiologic insulin
requirement the IV insulin represents, and translate that to a
SC regimen
• Consider any nutritional changes that may be implemented
at the time of the transition off of the drip
• Make sure SC insulin is given before discontinuation of the
IV insulin
Case 4 Solution
•
TDD prior to admission = 20 (Poor control)
•
Weight-based TDD = 45 (90 x 0.5)
•
Drip-based estimate: 1 unit/hr estimate of basal needs while fasting overnight x
20 = 20 units basal insulin. Therefore, TDD estimate = 40 units
•
Her condition is improving, therefore her insulin requirements may decrease
•
Glucose check AC and HS
•
Basal: Glargine 20 units daily
•
Nutritional: rapid-acting analogue 7 units with meals
•
DC the insulin drip an appropriate time after the subcutaneous insulin is
administered
Case 4 Continued…
The patient receives basal insulin at bedtime and the insulin
infusion is discontinued. She is scheduled to receive 7 units of
a rapid-acting insulin with each meal. The next morning her
breakfast tray arrives, and the bedside glucose is 112. The
nurse calls you because the patient says she does not feel like
can eat much of the food that is being provided. The nurse
asks if you still want the patient to receive the 7 units of rapidacting insulin. What is your response?
Case 4 Continued:
Solution = Post-Meal Rapid Acting Analogue
• The ideal solution in this case is to have the nurse give the
patient a chance to eat, and then reassess her caloric
intake. The rapid-acting insulin can then be given
immediately after the patient eats, in a dose proportional to
the amount of carbohydrates consumed.
Case 5
You are consulted by the neurology service for diabetes
management on a 79 y/o M who suffered a large stroke, leaving him
with severe dysphagia. He has type 2 diabetes, on maximum doses
of metformin, glipizide, and rosiglitazone at home. A PEG was
placed and he is up to his goal of 60 cc/hr on continuous tube feeds,
but is now hyperglycemic (see next slide).
- Weight: 100 kg (BMI 35)
- Current medical regimen: “High” sliding-scale (orals all held)
- Control: Glucoses consistently in the mid to high 200’s, a recent
HbA1c is 9.6%
What insulin regimen will you choose? Does the distinction between
basal and nutritional insulin still make sense with continuous
feeding?
Prior Day
Glucose
8 AM
Noon
Supper
Bedtime
254
295
238
291
Insulin
Total
Lispro
Mealtime
Lispro
Correctional
8u
8u
6u
8u
30 u
Glargine
TDD
?
Case 5: Solution
• TDD = 100 x 0.6 units/kg/day = 60 units
• Provide this TDD to meet basal and continuous nutritional insulin
requirements
• There is no scientific evidence suggesting one way is better than
another
• Examples:
–
–
–
–
–
–
–
Glargine 60 units daily
Glargine 24 units daily (basal) + rapid-acting insulin 6 units q4 hrs (nutritional)
Glargine 24 units daily (basal) + regular 9 units q6 hrs (nutritional)
70/30 20 units q8 hrs
Regular insulin 15 units q6 hrs
Rapid-acting insulin 10 units q 4 hrs
Other combinations
Transitioning to the Outpatient Arena
• Deciding on a home regimen
– HbA1c
– Anticipating clinical improvement
– Patient factors: Financial, social, abilities, wishes
• Patient education
– Changes made in the hospital
– Diabetes/insulin survival skills
• Communication with outpatient physicians
Systems for Improving the Quality of
Insulin Use in Inpatients
• Protocols
• Standardized order sets
• Physician, midlevel provider, and nurse education
Summary
Understanding these basic principles of physiologic,
anticipatory insulin will allow clinicians to formulate rational
insulin regimens in virtually any clinical situation! A printable
summary sheet can be accessed via a link located in the
“Teaching and Learning” section of the Glycemic Control
Resource Room, just below the link you used to access this
presentation.
Key Review Articles
• Clement and colleagues. Diabetes Care 2004; 27: 553-91.
• American College of Endocrinology Position Statement on
Inpatient Diabetes and Metabolic Control. Endocrine
Practice 2004; 10: 77-82.
• American College of Endocrinology and American Diabetes
Association Consensus Statement on Inpatient Diabetes
and Glycemic Control. Diabetes Care 2006; 29: 1955-62.