PowerPoint Presentation

Management of Inpatient Diabetes and Hyperglycemia

Kendall Rogers MD CPE FACP SFHMAssociate ProfessorChief Division of Hospital Medicine

Thursday School 201311Objectives For This LectureRecognize the importance of good glycemic control for hospital inpatientsAppreciate the obstacles to achieving good glycemic control in hospital patientsUnderstand 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 situationsReview special cases including steroids and discharge

Case 156 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 kgHome medical regimen: Glipizide 10 mg po qd, Metformin 1000 mg po bid, and 20 units of NPH q HSControl: A recent HbA1c is 10%, POC glucose in ED 240 mg/dL

What are your initial orders?3Note that the HbA1c is available on this patient, and can be used to help you estimate both the immediate and long-term (e.g. discharge) insulin requirements of the patient. We recommend that providers order HbA1c in inpatients with hyperglycemia if a recent value is not already available in the medical record. (Note: HbA1c values may be inaccurate in patients who have been recently transfused red blood cells.)You put the patient on the Insulin Order Set with the reg diet checked, moderate dose option with nutritional and basal insulin orderedWrite down:When will the CBGs be checked?Exactly what insulin is scheduled and at what times?If the patient is hypoglycemic, what will happen? Managing Diabetes in the Hospital Presents Different Challenges than Managing Diabetes in the Outpatient Arena! The hospital is associated with:

Nutritional and clinical instabilityThe need for changes from the home diabetes medical regimen Acute illness, stress-related hyperglycemiaUse of medications that impact glycemic control5Much of the management of diabetes in outpatients is predicated on stability in the lifestyle regimen. Diabetes patients are generally instructed to eat consistent amounts of carbohydrate, take the prescribed doses of insulin, and do regular exercise, each day. The hospital, however, results in a high level of instability in these and other variables that impact blood glucose. For example, a patients nutrition becomes varied, as s/he goes from NPO status to parenteral nutrition. The patients home diabetes medication regimen must often be altered for a variety of reasons. Also, the patient may experience hyperglycemia as a response to the stress of acute illness (release of counter-regulatory hormones such as cortisol and catecholamines) or the addition of medications that adversely affect glycemic control.

Managing diabetes and hyperglycemia in this labile environment requires a flexible management strategy. 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 patientsInpatient Glycemic GoalsBAD

BAD

GOODHypoglycemiaHyperglycemiaSomewhere in the Middle

200

7The point the goal is somewhere in the middle exactly where is not clear but too high and too low are definitely not good.7Recommended Inpatient Glycemic TargetsMaintain fasting and preprandial BG