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Glycemic Control in theHospitalized Patient

How do you do it?


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Hospitalization of the Patient With

Diabetes

Acute metabolic complications

Chronically poor metabolic control Acute or chronic complications of diabetes

Newly diagnosed diabetes (children)

Uncontrolled diabetes during pregnancy

Acute or chronic problems unrelated to

diabetes


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Barriers to Inpatient Diabetes

Management

Increased insulin requirement due to illness

Exaggerated variability in subcutaneous insulinabsorption

NPO status; inconsistent oral intake; interruptionof meals by procedures

Unpredictable arrival of meals Inability of patient to participate in management

decisions

Medication errors


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Why be concerned about short-termglycemic control in hospital?

Critical illness

Acute myocardial infarction

Post-operative infection/wound healing

In-hospital mortality

Stroke


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NEJM 2001;345:1359


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BMJ 1997;314:1512


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Mortality in DIGAMI 2

European Heart Journal 2005;26:650


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Fasting Blood Glucose in DIGAMI 2



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HbA1c in DIGAMI 2



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Ann Thorac Surg 1999;67:352-62


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J Clin Endocrinol Metab 2002;87:978


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Stroke 2001;32:2426


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Glucose: the 6thvital sign

Measure blood glucose in all patients

admitted with acute illnessAll patients with type 1 diabetes will require

at least basal insulin replacement

Most insulin treated patients will require

continued insulin therapy

Consider insulin therapy in any patient with

random blood glucose > 180 mg/dl


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Key Concepts of Insulin Therapy

Basalinsulin

Controls hepatic glucose production Food(prandial) insulin

Based on meal carbohydrate content

Correction(supplemental) insulin Treats acute elevation in blood glucose


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Basal

Bolus


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Indications for IV Insulin Therapy

DKA/ HHS

Critical illness Major surgery

Cardiopulmonary bypass surgery

Transplantation surgeryAbdominal surgery (NPO post-op)


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IV Insulin Therapy- Considerations

Define target blood glucose.

Define threshold for initiating therapy.

Determine starting dose (& bolus) based onglucose level.

Adjust infusion rate based on rate of change in

blood glucose. Infusion rates will vary depending

on individual patients insulin sensitivity.

Define when to interrupt therapy for low blood

glucose.


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IV to SC Insulin

Begin subcutaneous basal insulin while the patientcontinues to receive iv insulin.

Add prandial insulin when the patient is able to resumeoral intake.

Taper iv insulin, maintaining predetermined targets. IVinsulin can be discontinued when: IV insulin requirements are


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Use of Subcutaneous Insulin in

Hospital

Unpredictable

Best choice for insulin treated patient who

is able to eat

Options:

Once daily NPH insulin (type 2 diabetes only)

Twice daily split-mix insulin/pre-mix insulin

MDI or CSII

Listen to the experienced patient


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Starting Insulin in the Newly Diagnosed

Patient

Calculate the total daily dose

Determine basal insulin requirement

40 to 50% of total daily dose

Determine the mealtime insulin

requirement

50 to 60% of total daily dose

Determine the correction dose

Based on estimate of insulin sensitivity


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Daily Insulin Requirements

Patient Description Insulin (units/kg.day)

Trained athlete 0.5

Mod. active man 0.6

Sedentary man; 1st trimesterof pregnancy

0.7

Mod. stressed man; 2ndtrimester of pregnancy

0.8

Severely stressed man; 3rd

trimester of pregnancy 0.9

Systemic bacterial infection;full term pregnancy

1.0

Severely ill man 1.5-2.0


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Oral Agents in the Hospital

Classes

Insulin secretagogues (sulfonylureas; meglitinides)

Alpha-glucosidase inhibitors (acarbose; miglitol) Biguanides (metformin)

Thiazolidinediones (pioglitazone; rosiglitazone)

Limitations

Mild glucose elevations

Able to eat and ingest medicines

No comorbid conditions that contraindicate use


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Challenging Clinical Situations

The NPO patient

The patient receiving corticosteroids The patient receiving TPN

The patient on enteral nutritional support

Continuous

Intermittent


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The NPO Patient with Diabetes

Basal insulin as insulin glargine

Previous insulin: TDD

Insulin nave: 0.4 units/kg

(if on iv insulin, taper after insulin glargine is

added)

Regularinsulin supplement q4-6 hours


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Corticosteroid Therapy and

Diabetes

Minimal elevation of fasting glucose

Exaggeration of postprandial hyperglycemia

Lack of sensitivity to exogenous insulin

Consider:

Prandial insulin in patients without prior history

of diabetes 70% prandial insulin, 30% basal insulin in

patients with established diabetes history


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TPN and Diabetes

TPN commonly leads to hyperglycemia inthe absence of diabetes.

Insulin requirements are increased inpatients with diabetes; 75% of patientswith type 2 diabetes not previously treatedwith insulin will require insulin with TPN.

IV insulin should be infused separatelyuntil requirements are known; insulin canthen be added to the TPN solution.


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Enteral Nutrition and Diabetes

Enteral nutritional support can result inhyperglycemia, even in the absence of diabetes. Inpatients with established diabetes, insulin

requirements increase substantially. High fat formulas (monounsaturated fats) achieve

better metabolic control that traditional highcarbohydrate preparations.

Blood glucose control may be attainable with longacting subcutaneous insulin preparations- insulinglargine (with constant nutrition). Previous diabetes: TDD



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Intermittent Enteral Nutrition

Basal insulin as NPH at the start of

nutritional support Previous diabetes: TDD


Regular insulin usually required at start offeeding

25 to 50% of NPH dose


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Summary

Aggressive glycemic control in hospitalizedpatients improves clinical outcomes.

Management of diabetes in an inpatient settingrequires familiarity with the use of both iv and scinsulin, both in intensive care units and ongeneral nursing units.

The time-honored traditions of sliding scaleinsulin, and of withholding insulin for proceduresand euglycemia should be buried along withfractional urine testing.


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Remember

Most hospitalized patients are discharged

Inpatient diabetes treatment should

transition smoothly to outpatientmanagement

Think ahead; plan early

? Dietary consultation

? Diabetes education consultation

? Endocrinology consultation

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