In Patient Diabetes r 1 Lecture

8/8/2019 In Patient Diabetes r 1 Lecture

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What to Do When Your Patient

Has Diabetes

Karen A. McDonough MD

Inpatient Medical ServiceUWMC


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Stress Hyperglycemia Increases

Morbidity/Mortality in:

Acute MI Acute stroke

Medical and surgical admits to an

inner city hospital


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Hyperglycemia and Infection Abnormal leukocyte function in patients

with diabetes

Improves with control

Risk of surgical site infection correlates

with severity of perioperative

hyperglycemia


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Hyperglycemia and Infection

1548 patients admitted to a surgicalintensive care unit, almost all post-op

13% diabetic

Randomized to intensive insulin therapy tomaintain blood glucose 80-110 mg/dLversus usual care

Mean blood glucose in experimental group103 mg/dL versus 153 mg/dLfor controlgroup

Van den Berghe NEJM 2001;345:1359


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In hospital death

11%

7%

8%

5%

Death in ICU

8%

4%

ICU sepsis

Intensiveinsulin

Control


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Other benefits of glucose control

Less critical illness polyneuropathy

Less renal failure requiring dialysis

Less antibiotic use

Less osmotic diuresis/electrolyte

abnormalities Less gastric dysmotility/vomiting

Van den Berghe NEJM 2001;345:1359


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Goal for inpatienttherapy

ICU: 80-120

Floor: CBG 100-180


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Normal Physiologic Insulin

Release

Prandial

Basal

B L D


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Insulin Action - Hours

Onset Peak Duration

NPH 1-2 4-8 12-20

Glargine 2-3 None ~24

Regular -1 2-4 6-10Lispro,

aspart

1 4-6


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Case # 1A 58 year old woman with well controlled

type 2 diabetes is admitted with community

acquired pneumonia. Although she has felt

ill for 2 days, she has been able to eat and

has continued her usual insulin - glargine

15U at hs and lispro 5 U before each meal.Her admission blood glucose is 280.

.


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Sliding Scale??


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Roller-coaster glucose control

50

150

250

350

10U

1 amp D50

6 U


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Insulin order

Basal insulin

Prandial insulin

OPTION AT UW AND HMC

Supplemental insulin (for pre-mealhyperglycemia)

150-200 1 U lispro

201-250 2 U lispro

251-300 3 U lispro ...


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jAdditional prandial insulin for premeal

hyperglycemia

jLispro and aspart are ideal

jrapid onset of action controls hyperglycemia

jrapid offset makes later hypoglycemia less likely

jNO doses less than 4 hours apart to avoid

STACKING and hypoglycemiajGREAT CAUTION with regular insulin

Supplemental Insulin


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But how is this different from a

sliding scale?

Patients get basal insulin, just like at home

Patients get prandial insulin even if CBG isnormal

Supplemental insulin is given IN

ADDITIONto usual diabetes regimen (not

instead of it) to correct premeal

hyperglycemia


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What if my patient is not eating

as much as usual?

Reduce prandial insulin

May need to reduce basal insulin by about a

third

If stressed by illness, may not need to

reduce usual basal doses


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What if my patient is not eating

at all?

Stop prandial insulin

For Type 1 patients on glargine - continueat usual dose

For all others - decrease other basal insulin

by 1/3


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Case #2

A 41 year old man with type 1 diabetes

presents with a 12 hour history of nausea

and LLQ discomfort. He is diagnosed withdiverticulitis and admitted. Although he has

been unable to eat, his blood glucose is 234.

His outpatient insulin regimen consists of

NPH and regular insulin before breakfast

and dinner. How should he be managed?


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NPO Type 1 Patient

MUST have insulin to prevent DKA, death OPTIONS:

Insulin drip

Preferred treatment at UWMC Available on any floor

More restrictions at HMC

Only in ICU at VA (but VERY few Type 1 patients)

Long acting subQ insulin with close monitoringand supplemental insulin prn (but no more

frequently than lispro/aspart q 4 hours)


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Insulin Drips Variable rate IV infusion of insulin

Adjusted per protocol

Chemsticks q 1 hour until stable

Daily Chem 7

Dextrose containing IV fluids - D51/2NS at100 cc/hour


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Pitfalls with Insulin Drips Turning off dextrose while insulin still

running hypoglycemia

Failing to notice when blood glucose is

falling too fast

Stopping an insulin drip without having

given subQ insulin this causes patients todevelop (orRE-develop DKA)


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Transition to SubQ Insulin

When able to eat

Best time to stop is when a dose of basal

and prandial insulin would usually be given

Strategies for glargine

Continue the drip as basal insulin,

giving mealtime prandial insulin subq,

until glargine due that evening

give 1/2 usual glargine dose as NPH in

the morning before stopping the drip


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Case #3

A 77 year old woman with type 2 diabetes,

treated with rosiglitazone and metformin, is

admitted to the hospital with unstableangina. Her diabetes is well controlled, and

blood glucose is132 at admit. She will

undergo cardiac cath at 11 am tomorrow.

How should she be managed?


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Drink plenty of fluids and stay out of the sun


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Contraindications to Metformin

Renal insufficiency (Cru 1.5 in men, 1.4 in

women)

Congestive heart failure requiring drugtherapy

Acute or chronic acidosis

Iodinated contrast (until Cr documented tobe normal 48 hours after contrast)

Relative liver disease, hypoxia


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Other oral agents

Glitazones contraindicated in NYHA Class

3 or4 CHF

Sulfonylureas cause hypoglycemia,

especially in the elderly and those with

renal failure


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Case #4

A 22 y.o. man presented 36 hours ago with

DKA and was diagnosed with type 1

diabetes. He has been managed with aninsulin drip, at 0.5 units per hour for the

past 10 hours, and is doing well. He has

been able to tolerate clears without nausea,

and this morning is ready to eat breakfast.

What insulin order will you write?


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Starting insulin in type 1 patients

Start with 0.2-0.4 units per kg per day

Divide into basal and prandial insulin

Basal options:NPH

Glargine

Prandial options: Regular

Lispro or aspart


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Insulin Analogues in T1DM

Rapid acting

Less postprandial hyperglycemia

Greater flexibility in meal timing/amount

Require patient commitment

No clear improvement in HgbA1c

Long acting

Less hypoglycemia

Improved HbA1c in some studies

Hirsch I NEJM 2004; 352:174


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Case #5

A 62 year old man with a 12 year history of

type 2 diabetes is admitted for IV antibioticsfor hand cellulitis. He is on maximal doses

of glyburide and metformin, and recent

HgbA1c was 10.2%.


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Triple Oral Therapy

Patients with HgbA1c u8.5% despite

sulfonylurea plus metformin randomized to

addition of troglitazone vs placebo

At 6 months, 43% of troglitazone patients

had HgbA1c e8%, vs 6% with placebo

15% had HgbA1c e7%

Annals of Internal Medicine 2001;134:737


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TripleO

ral Therapy

Glipizide $19.99

Generic metformin $55.99

Rosiglitazone $77.99

$153.97


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Bedtime Basal Insulin

NPH or glargine

Patients with HgbA1c u 7.5% on 1 or 2 oral

agents

NPH or glargine started at 10 U at bedtime,

and titrated according to a weekly titration

schedule based on self monitored FPG

Oral agents continued

Goal FPG e 100

Diabetes Care 2003;26:3080


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Bedtime Basal Insulin

Mean HgbA1c at baseline = 8.6%

Mean Hgb A1c at end = 7%;60% achieved

HgbA1c e 7%

Mean daily insulin doses 47 U with

glargine, 42 U with NPH

Less symptomatic hypoglycemia with

glargine than NPH (13.9 vs 17.7 perpatient/year)

Diabetes Care 2003;26:3080


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Starting Bedtime Basal Insulin

10-20 units, or0.1-0.2 U/kg (can starthigher if very poorly controlled)

Measure CBG before breakfast

Increase by 4 units if CBG is over140 on 3consecutive measures

Increase by 2 units if CBG is 110-140 on 3

consecutive measures Dont increase if hypoglycemia has

occurred in the past week

JAMA 2003;289:2265


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Teaching opportunities Diet review

Medication teaching

Review of insulin injection technique

Review of glucometer use

Initiation of insulin (in consultation withPMD)

Review of foot care


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Case #6A 52 year old man with diabetes will be

having an EGD/colonoscopy tomorrow. His

diabetes is well controlled with NPH insulin10 units at 7 AM and 8 units at 9 PM, and

insulin lispro before meals. His AM glucoses

run 90-110 mg/dL.

What is the best approach to diabetes

management for this patient?


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Periprocedural ManagementPeriprocedural Management

of T1DMof T1DM

Must have basal insulin to prevent ketosis

even if not eating Ideally minor procedures that require NPO

status should be done first in am


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Periprocedural Management of

Type 1 PatientOPTIONS:

Long acting subQ insulin with close monitoring

and supplemental insulin prn

Insulin drip

Preferred therapy for major procedures at

UWMCNursing staff must be trained


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Type 2 Insulin treated

First thing in am for minor procedures

Insulin drip for major procedures

Begin when CBG > 120 if theyvetaken insulin night before or am

Basal insulin plus supplemental lispro or

aspart


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Type 2 Diet or Oral Agents

May not require insulin

For major surgery, start insulin drip when

CBG above goal range

For minor procedures, correction doses of

rapid acting insulin for hyperglycemia

Hold metformin for48 hours post op,with normal Cr

Hold other oral agents til PO intake good


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Case #7A 22 year old man with type 1 diabetes is

admitted with severe odynophagia due to

HSV esophagitis. He uses an insulin pumpwith a basal rate of1 U per hour, and uses

mealtime boluses of1 U of insulin per10

grams of carbohydrate. Oral intake islimited. How will you manage him?


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Insulin Pumps Can continue IF patient with it enough to

manage

Continue basal rate only if NPO

Patient may need to increase basal rate if

stressed or on steroids

Patients managed with pumps are usually

pretty sophisticated listen to them


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Take home points

Controlling hyperglycemia is important

Sliding scale insulin is not the way to do it

Insulin drips for type 1 patients who are not

eating Supplemental insulin in addition to usual

insulin regimen to control stresshyperglycemia

Help with diabetes management is alwaysavailable Endocrine Consult Service at allhospitals, nurse specialist at UWMC and

HMC

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In Patient Diabetes r 1 Lecture