Diabetes Management in the Wards - Home - WSLHD

Prescribing Insulin in the Wards

N Wah Cheung Dept of Diabetes & Endocrinology

Why is glucose management important? Insulins and regimens How to chart insulin Supplemental Insulin How to get a diabetes consult Treatment targets and how to adjust insulin Hypos and hyperglycaeima

Diabetes in Hospital 20-40% of inpatients have diabetes Illness, medications, feeds and procedures cause

unstable diabetes or stress hyperglycaemia Increased risk of hypoglycaemia Poor diabetes control affects patient outcomes - impaired wound healing - lower resistance to infection - worse outcomes from AMI - longer LOS - increased mortality

General Principles Identify patients with diabetes: Distinguish T1 from T2 Identify the patients’ usual diabetes medication Ascertain usual level of diabetes control: HbA1c Anticipate problems with BSL control - fasting - infection - medication (eg steroids) Expect that things will change - be proactive rather than reactive Ensure BGLs are measured (minimum fasting and 2 hrs

post meals. Before meals and 0200-0300 also helpful)

Insulin Errors NSW IIMS Reports Jan-Jun 2009

33% of the medical errors that caused death within 48 hours of the error involved insulin Hellman Endo Pract 2004

Current Anti-Diabetes Agents Oral Agents

Metformin Sulphonylureas (eg Gliclazide MR, Glimeperide)

Glitazones (eg Pioglitazone)

α-glucosidase inhibitors (eg Acarbose)

DPP IV inhibitors (eg Sitagliptin, Vildagliptin, Linagliptin, Saxagliptin)

SGLT2 inhibitors (eg Dapagliflozin, Empagliflozin, Ertugliflozin)

Combinations

Non-insulin injectables GLP1 Analogues (eg Exenatide, Dulaglutide, Liraglutide)

Insulin

Insulin Pharmacokinetics

Rapid Analogues Novorapid, Humalog, Apidra

Short Acting Actrapid, Humulin R

Intermediate Acting Protaphane, Humulin NPH

Long Acting Levemir, Lantus

Ultra Long Acting Degludec

1 2 3 4 6 8 24 42

Usually given before meals: PRANDIAL or BOLUS

Usually given at bedtime or bd: BASAL

Pre-mixed Insulins Rapid/short acting + intermediate acting

Rapid + Intermediate Rapid + Intermediate 25-30 : 75-70 50 : 50 Eg Novomix 30, Humalog Mix 25

Mixtard 30/70

Humalog Mix 50

Usually given twice daily

Rapid/short acting + ultra long acting Ryzodeg (Aspart + Degludec, 30 : 70)

Usually once or twice daily

Insulin Regimens Basal bolus insulin [preferred in hospital]

NOT sliding scale insulin Insulin infusions [preferred for fasting, mandatory for

T1DM when fasting or DKA]

Bd Premixed insulin- OK if is usual regimen + satisfactory BGs

Basal Insulin only – often with OHAs

Insulin pumps (T1 Diabetes)

Unstable or Stable Patients

Stable Patients

Need Endo team involvement

MN 0600 1200 1800

BSL

Rapid Rapid Rapid Basal

Principles of Basal Bolus Insulin

Basal Bolus Insulin Initiation

Total daily dose 0.5 units/kg/day Reduce to 0.2-0.4 units/kg /day if kidney disease, liver disease, elderly, poor intake, metformin, recurrent hypoglycemia, or other risk factors for hypoglycemia

50% basal + 50% prandial Add supplemental rapid acting insulin TDS ONLY ie at same time as standard prandial insulin May continue Metformin but generally stop other oral agents

If on premixed insulin Adjust from premixed dosage

Adjust from daily dosage If on insulin infusion

Bedtime Long acting Lantus

Rapid acting in 3 divided meal doses Novorapid

If new to insulin

Preferred regimen for unstable patients

Do the following insulin regimens make sense?

i) Protaphane and Novorapid TDS with meals ii) Novorapid TDS with meals and Lantus at

bedtime Mixtard 30/70 TDS iii) Humalog BD iv) Lantus at bedtime with gliclazide BD v) Novomix 30 BD

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x

x x √

Subcutaneous Insulin And Blood Glucose Chart

Subcutaneous Insulin Chart The Subcutaneous Insulin Chart is a separate chart

to the National Inpatient Medication Chart. All subcutaneous insulin to be prescribed on SIC IV insulin on iv orders chart Oral anti-hyperglycaemic drugs on the NIMC Glucose monitoring on SIC if patient on insulin, on

BG monitoring chart if not, SAGO chart if not diabetic

https://www.aci.health.nsw.gov.au/resources/endocrine/subcut-insulin/subcut-insulin

REGULAR DOSE

Chart insulin dose daily

“Units” preprinted

BG Monitoring

Order BG Monitoring

Mrs Annie Smith 53 year old woman admitted with cellulitis Type 2 diabetes 74 kgs Medications: Novorapid 8 units tds Lantus 16 units nocte Metformin 1g bd

No allergies

Chart the regular insulin for her

Annie Smith MRN 0950099 DOB 15/6/1965 12 John St, Westmead 2145

What do we do with unexpected high readings?

Sliding Scale Insulin

Adjust usual insulin and add

Supplemental Insulin

Used in addition to regular subcutaneous insulin to correct and prevent hyperglycaemia.

Not to be used alone.

The MO must prescribe the type of insulin and the Administration Time (Usually given before meals)

Supplemental Scale

Supplemental Scale Use Rapid Acting (Novorapid, Humalog, Apidra)

Standard Insulin Resistant BSLs 10.1-12mmol/l 2 Units 4 Units BSLs 12.1-18mmol/l 4 6 BSL 18.1-20mmol/l 6 8 >20 mmol/l Call RMO

in addition to usual sc insulin ideally before meals.

Mrs Annie Smith You review her recent BGs and they have

intermittently been in the mid teens.

Concerned about possibility of high BGs this evening, you chart a supplemental scale

Chart supplemental insulin for her

Diabetes Consult

Diabetes Consult

Diabetes Consult

Resources Inpatient Diabetes Management Service (surgical patients): Diabetes Registrar Others: Endocrine Registrar Consult early, not on the day of discharge Diabetes Educators - BSL monitoring - insulin administration - general education & support Subcutaneous Insulin Chart My Health Learning Thinksulin

My Health learning

Thinksulin

Treatment targets A high BGL is not normal for a person with diabetes “Normal” glucose 4 - 8 mmol/L

In hospital Aim for BGL <10 mmol/L Do not aim to get BG below 5 mmol/L As a general target aim for 5-10 mmol/L. Not hypo until <4 mmol/L

Patients on oral agents may require insulin in hospital Patients on b.d. insulin may require basal bolus insulin

Adjusting insulin doses - 1

Novorapidac breakfast

Novorapid ac lunch

Novorapid ac dinner

Lantus bedtime

fasting pc breakfast

ac lunch

pc lunch

ac dinner

pc dinner

8 8 8 16 10 12.1 9.5 8 8.6 12.4

12 9.8 15.2

Novorapidac breakfast

Novorapid ac lunch

Novorapid ac dinner

Lantus bedtime

fasting pc breakfast

ac lunch

pc lunch

ac dinner

pc dinner

8 8 8 16 10 12.1 9.5 8 8.6 13.4

12 8 12 20 10.8 15.2

16

Novorapidac breakfast

Novorapid ac lunch

Novorapid ac dinner

Lantus bedtime

fasting pc breakfast

ac lunch

pc lunch

ac dinner

pc dinner

8 8 8 16 10 12.1 9.5 8 8.6 13.4

12 8 12 20 10.8 15.2 13.3 12.8 8.9 9.2

16 12 13

Novorapidac breakfast

Novorapid ac lunch

Novorapid ac dinner

Lantus bedtime

fasting pc breakfast

ac lunch

pc lunch

ac dinner

pc dinner

8 8 8 16 10 12.1 9.5 8 8.6 13.4

12 8 12 20 10.8 15.2 13.3 12.8 8.9 9.2

16 8 12 24 12 13

16

Novorapidac breakfast

Novorapid ac lunch

Novorapid ac dinner

Lantus bedtime

fasting pc breakfast

ac lunch

pc lunch

ac dinner

pc dinner

8 8 8 16 10 12.1 9.5 8 8.6 13.4

12 8 12 20 10.8 15.2 13.3 12.8 8.9 9.2

16 8 12 24 12 13 10.1 9.5 7.6 8.0

16 8.2 4.1

Novorapidac breakfast

Novorapid ac lunch

Novorapid ac dinner

Lantus bedtime

fasting pc breakfast

ac lunch

pc lunch

ac dinner

pc dinner

8 8 8 16 10 12.1 9.5 8 8.6 13.4

12 8 12 20 10.8 15.2 13.3 12.8 8.9 9.2

16 8 12 24 12 13 10.1 9.5 7.6 8.0

16 8 12 24 8.2 4.1

14

The fasting patient

Diet alone or on small doses of anti-hyperglycaemia tablets may require no specific treatment

Patients on large doses of oral agents or insulin Brief procedures (eg gastroscopy, D&C): schedule first in

morning – may require no specific treatment Longer procedures or later in day – insulin/dextrose infusion Prolonged NBM (eg abdominal surgery): generally maintain

insulin/dextrose infusion

Annie Smith MRN 0950099 DOB 15/6/1965 12 John St, Westmead 2145

Chart Annie’s iv insulin

Upon Discharge Revert back to pre-admission diabetes

medication and doses if patient was previously well controlled and returned to pre-morbid state.

Needs follow-up if control previously poor and/or changed treatment to be continued.

Insulin doses usually need reducing if tight control established in hospital.

Mrs Annie Smith Patient now ready for discharge She has been on Novorapid 12 units mane, 8 units midi, 14 units nocte

(before meals) Lantus 20 units bedtime

Because she will be more active on discharge, you decide to

reduce her Novorapid by 2 units for each dose. She will be using a flexpen.

Write her discharge script, and an external prescription

Annie Smith MRN 0950099 DOB 15/6/1965 12 John St, Westmead 2145

Hypoglycaemia

Sudden severe hyperglycaemia (eg >20) Immediate management Type 1 diabetes: check for ketones Can prescribe supplemental insulin But Is there a pattern of high BGL?

- if so, fix the regular treatment

Why has it occurred? Possible reasons: - missed dose - sugar intake - infection

SGLT-2 Inhibitors and Surgery Recent reports of DKA As precaution, cease 3 days prior to surgery Ensure insulin dextrose infusion for surgery Check ketones pre-op post-op If ketones ≥1.5, check VBGs (HCO3 and pH) Resume SGLT-2 inhibitor only when eating

normally again In meantime need alternative means of

controlling hyperglycaemia