Some Factors Destabilizing Glucose Control during Hospitalization

Internal Medicine Resident’s Fundamentals of Medicine Lecture Series

Managing Diabetes Mellitus in Hospitalized Patients

Steven Ing, MD MSCEDivision of Endocrinology, Diabetes and Metabolism

7/26/2010

Some Factors Destabilizing Glucose Control during Hospitalization

Stress of illness, surgeryGlucocorticoid therapyIV dextrose, TPNDecreased physical activityStopping DM medications

Decreased caloric intakeContinued sulfonylureaInappropriate “sliding scale” insulin“Tight” control

Glucose ↑ ↓ Glucose

Nuts & Bolts: 10 Ten List

1. Diet-controlled T2DM2. T2DM: what to do with oral DM meds3. What are the Glycemic Targets in Hospitalized

Patients?4. When to Consider IV Insulin Therapy5. How to Calculate an Initial Basal Insulin Dose

(and transitioning from IV insulin)

6. How to Manage Basal Insulin Dosing in Patients Already on Insulin

7. How to Calculate an Initial Prandial Insulin Dose8. How to Individualize the Premeal “Correction

Dose”9. When and Which Diabetes Consultant 10. Discharge Orders

1. Diet-controlled T2DM

• Who have minor surgery, imaging, procedure, or non-critical acute illness that is expected to be short-lived– will not usually need specific anti-hyperglycemic

therapy• Monitor glucose to detect serious

hyperglycemia (e.g. steroids in COPD exacerbation)

• Insulin therapy should be instituted if the preprandial blood glucose concentration >200 mg/dL

• Inform patient that insulin may not be necessary after the episode is over

2. T2DM: What to do with oral meds• Sulfonylureas

– glipizide (Glucotrol)– glyburide (Diabeta, Micronase, Glynase PresTab)– glimepiride (Amaryl)

• Meglitinides – repaglinide (Prandin)– netaglinide (Starlix)

• Biguanide– metformin (Glucophage, Glucophage XR, Fortamet, Glumetza,

Riomet)– Metaglip, Glucovance

• Thiazoladinediones– rosiglitazone (Avandia): Avandaryl, Avandamet– pioglitazone (Actos): Duetact, Actoplus Met

• Alpha-glucosidase inhibitors– acarbose (Precose)– miglitol (Glyset)

• Contraindicated if hemodynamic status or renal function is impaired or threatened– Acute cardiac or pulmonary decompensation – Surgery (with potential compromise of circulation) – Acute renal failure– IV iodinated contrast studies (with potential for

contrast-induced ARF)– Dehydration– Sepsis

• Should be held at least temporarily in most hospitalized acutely ill patient until renal function and circulation can be established, e.g. 48 hours after IV contrast

Metformin

Thiazoladinedione (TZD)

• Associated with edema, fluid retention– Contraindicated in advanced heart failure (NYH

class III, IV)– If there is question of ventricular dysfunction

during hospitalization, hold TZD until the situation is clarified

– Since the anti-hyperglycemic effect extends for several weeks after discontinuation, temporary interruption should have little effect on glucose lowering effect

Sulfonylureas

• Associated with hypoglycemia that may be severe and prolonged

• Changes in renal function may increase the risk for hypoglycemia (decreased clearance)

• Consider discontinuation during the hospitalization in the patient with erratic meal schedules and missed meals to lower the likelihood of hypoglycemia

Meglitinides

– repaglinide (Prandin)– netaglinide (Starlix)– Non-sulfonylurea insulin secretagogues– Prandial administration– Shorter duration of action – Theoretical advantage in hospitalized

patients, but should also be used cautiously

Newer Diabetic Meds• exenatide (Byetta)

– GLP-1 analog – ↑ insulin, ↓ gastric emptying, ↓ appetite, ↓ glucagon– Nonformulary, SQ injection– Hold as inpatient

• sitagliptan (Januvia) – DPP4 inhibitor, oral– OK to continue except in ARF– Janumet = Januvia + metformin– Saxagliptan (Onglyza)

• pramlintide (Symlin)– Amylin analog – ↓ gastric emptying, ↓ appetite, ↓ glucagon– Nonformulary, SQ injection– Hold as inpatient

3. What are the Glycemic Targets in Hospitalized Patients?

AACE Guidelines• ICU: 140-180 mg/dL • Noncritical care:

< 140 mg/dl preprandial< 180 mg/dL postprandial

• Values > 180 mg/dL indicate need to monitor glucose levels more frequently to determine the direction of any glucose trend and the need for more intensive intervention

American Association of Clinical Endocrinologists. Available at:

http://www.aace.com/pub/ICC/inpatientStatement.php.

OSUICU: 110-150Noncritical care: 110-180

Insulin Therapy in Managing Hospitalized Persons With Diabetes

• Intravenous insulin– continuous variable-rate infusion– regular insulin

• Subcutaneous Insulin– basal/bolus therapy– long-acting and rapid-acting insulin

4. When to Consider IV Insulin Therapy

• Diabetic ketoacidosis (DKA)• Hyperglycemia hyperosmolar state (HHS)• Critical care illness • Myocardial infarction (MI) or cardiogenic shock• Postoperative period following heart surgery• Labor and delivery• NPO status in Type 1 diabetes• General pre-, intra-, and postoperative care• Organ transplantation• Total parenteral nutrition• Exacerbated hyperglycemia during high-dose glucocorticoid

therapy• Dose-determining strategy prior to initiation of subcutaneous

insulin

American Association of Clinical Endocrinologists. Available at:http://www.aace.com/pub/ICC/inpatientStatement.php.

IV Insulin Protocol

• When to initiate: – consider initiating if 3 consecutive accuchecks or

blood glucose values > 200 mg/dL and if NPO >24 hours

• Insulin solution: – regular insulin 100 units in 100 ml of 0.9% saline– piggy-backed with D5W– If initial glucose > 250 mg/dl: start D5W @ 25

ml/hr and increase to 100 ml/hr after glucose drops below 250 mg/dl.

– If initial glucose < 250 mg/dl: start D5W @ 100 ml/hr

IV Insulin Protocol

• OSU target glucose range: 110 -150• Assessment:

– Serum or capillary glucose q1 hour– May transition to q 2 hours if glucose

values are within goal range x 3 consecutive measurements

– Convert back to q1 hour for major change in clinical condition or with any measurement out of goal range

• For patient who is eating, provide prandial rapid-acting insulin

IV Insulin Protocol

• STEP 1: Consider consulting the Diabetes Team 292-3800• STEP 2: Patient must receive dextrose CONTINUOUSLY

during insulin infusion • STEP 3: Measure the patient's serum or capillary glucose

q1 hour.• STEP 4: Initiate insulin infusion at 2 units/hr• STEP 5: Monitor glucose and adjust the insulin infusion

rate as directed in following table • STEP 6: Frequency of glucose checks can be reduced to

q2 hours. Convert back to q1 hour for major change in clinical condition or with any measurement out of goal range

• STEP 7: Rate of decline of glucose should not be > 100 mg/dl/hour

Insulin Drip Guideline

OSU IV Insulin Protocol: Doctor-initiated and Nurse-driven

Current Glucose

Δ in Glucose from Prior Measure

Decreased by≥ 50 mg/dl

Change <50 mg/dl (↑ or ↓) Increased by ≥50 mg/dl

400 mg/dl Contact the Prescriber

301-400 mg/dl

↑ infusion rate by 2 units/hr ↑ infusion rate by 2-4 units/hr ↑ infusion to 2x current rate

201-300 mg/dl

↑infusion rate by 1 unit/hr ↑ infusion rate by 1-2 units/hr ↑ infusion rate by 1-3 units/hr

151-200 mg/dl

No Change ↑ infusion rate by 0-1 units/hr ↑ infusion rate by 1-2 units/hr

110-150 mg/dl

↓infusion rate by 2units/hr [minimum rate=0.5-1unit/hr]

If blood glucose is increasing then ↑ infusion rate by 0-1 units/hr.

If blood glucose is decreasing then ↓ infusion rate by 0-2 units/hr

[minimum rate=0.5 unit/hour]

↑ infusion by 0-1 units/hr

65-109 mg/dl Stop infusion of insulin and contact the Prescriber

If rate is < 3 units/hr, ↓infusion by 1-2 units/hrIf infusion stopped, contact the Prescriber

If rate 3-7 units/hr ↓ by 1-3 units/hr.If rate >7 units/hr ↓ rate by ≤50%

[minimum rate=0.5-1 unit/hr]

No Change

< 65 mg/dl

Stop infusion of insulin and contact the PrescriberDouble current infusion rate of dextrose solution. If not receiving dextrose IV infusion, start D5W at 50 ml/hr.

Consider giving 12.5g D50% x 1 (1/2 ampule). Recheck glucose in 15 minutes. When glucose > 150mg/dl, reduce the dextrose infusion back to previous rate

and resume drip at 0.5-1unit/hr. Resume drip protocol

1. If patient is eating on IV insulin, cover mealtime carbohydrates

• On order set for CHO:insulin ratio, delete the correction factor

2.When transitioning off IV to basal insulin, overlap by 6 hours

• E.g. 9 PM give lantus, 3AM stop insulin drip

• Lantus typically but not necessarily at HS

3.Lowering insulin rate @ 0/hr ≠ stop insulin protocol

IV Insulin: Miscellaneous

Take 80% of insulin drip rate in fasting patient with stable glucose

e.g. IV insulin rate @ 2 units/hr for past 8 hours

2 Units/hr x 24 hr x 0.8 = 38 Units glargine

5. How to Calculate an Initial Basal Insulin Dose: Converting from insulin drip

Example: IV to SQ Insulin

Time Gluc U/hr11:20 342 2

12:30 298 23

13:30 288 3

14:30 279 3

15:30 244 34

16:30 219 45

17:30 155 54

18:30 138 43

19:30 161 3

20:30 196 34

22:00 173 43

Time Gluc U/hr00:00 114 32

01:00 130 2

02:00 97 21

03:00 96 1

04:00 97 1

05:00 155 13

06:30 189 34

07:30 145 41

08:30 144 1

09:30 179 2

10:30 272 24

Insulin Glargine

6. How to Manage Basal Insulin Dosing in Patients Already on Insulin

• Patients already on basal insulin, continue some basal insulin

• Food intake is diminished or stopped completely,– if glucose is well controlled in hospital, continue Rx– If hyperglycemic, can increase basal– if you suspect patient is on too much basal and too little

bolus, decrease lantus 20%, decrease NPH 50%

• NPO for test/procedure– Decrease prior PM glargine, detemir or NPH by 20%– Decrease AM NPH by 50%– After test/procedure, resume usual evening if eating

6. How to Manage Basal Insulin Dosing in Patients Already on Insulin (cont’d)

• Insulin requirements often higher due to illness: infection, MI, steroids

• Consider IV insulin, until glucose reasonably stable– If basal insulin requirement was high (e.g. 100 U/day),

IV insulin rate should be higher (e.g. 5 U/hr)• Adjust basal insulin (often upwards) based on prior

day’s glucose data• Basal insulin requirement changes with improvement

of stress state, caloric intake, steroid dose, etc.

7. How to Calculate an Initial Bolus Insulin Dose

1. Prandial dose • Insulin:carbohydrate ratio

– E.g. 1:15 = 1 unit lispro per 15 gm carbs, or 1:10, 1:20, etc.– Pro: flexible– Con: requires carbohydrate counting and calculation

• Fixed dose insulin– E.g. 5 units each meal– Ideally accompanied by fixed carbs each meal

(essentially same as insulin:carb ratio)

2. Correction factor– needed for either method– corrects for current glucose level, i.e. “Sliding Scale”

10 Carbs(grams) = 1 unit insulin

Std: 10 Carbs(grams) = 1 unit insulinLow: 20 Carbs(grams) = 1 unit insulinHigh: 5 Carbs(grams) = 1 unit insulin

“Sliding Scale” Insulin Alone Is Discouraged (in insulin-requiring diabetic)

• “Sliding Scale” is considered anti-intellectual

• Sliding scale only without basal insulin results in high rates of hyperglycemia, hypoglycemia, or iatrogenic diabetic ketoacidosis in hospitalized patients with T1DM

American Association of Clinical Endocrinologists. Available at:http://www.aace.com/pub/ICC/inpatientStatement.php.

Carbohydrate Counting

• Grams of carbohydrates are listed on the menu tray ticket

• PCA/Nurse– calculate total carbs eaten – calculates prandial insulin dose– determines correction factor insulin dose– gives insulin as soon as possible post-meal

• At home patients take insulin pre-meal

8. How to Individualize a Premeal “Correction Factor”?

Premeal BG Additional

Insulin

150-199 1 unit

200-249

2 units

250-299 3 units

300-349 4 units

>349 5 units

“Standard Dose” Algorithm Individualized Dose Algorithm

Premeal BG Additional Insulin

150-199 ___ units

200-249 ___ units

250-299 ___ units

300-349 ___ units

> 349 ___ units

Must document against all occurrences regardless of whether product given or not given.

Insulin I:Cho+Cfact Lispro Sub Q Qachs

Nursing Documentation

2) In “VS/Lab info” document grams of carbs eaten and premeal glucose e.g. 30:151

Cho(grams): B.S.(mg/dl)I:Cho(unit)+Cfact(Unit)

Insulin I:Cho+Cfact Lispro Sub Q Qachs 1) Document administration time/date

3) In “Rate/Dose” document units given for carb intake and units given per Correction factor. e.g. 3+1

Insulin I:Cho+Cfact Lispro Sub Q Qachs Insulin I:Cho+Cfact Lispro Sub Q Qachs Insulin I:Cho+Cfact Lispro Sub Q Qachs

RN # 1 (user id = RNCHEM) documents administration 3+1 = units given for I:Cho and Correction factor30:151 = Cho (grams) and B.S. (mg/dl)Select F12 Save

Cho(grams): B.S.(mg/dl)Ins:Cho(unit)+Cfactor(Unit)

Document actual Admin Tm/Dt blood sugar checked• In VS/Lab info document Cho intake in grams and Correction factor (Blood Glucose in mg/dl) i.e. 0:100• In Rate/Dose document units given per I:Cho intake and units given per Correction factor. i.e. 0+0•Select F5 Not Admin


* Indicates Not Admin0+0 = units given for I:Cho and Cfactor0:100 = Cho (grams) and Cfactor (mg/dl)Select F12 Save


Adjusting Insulin Doses

Breakfast Lunch Dinner Bedtime

Date BS

(mg/dl)

Carbs

(g)

Insulin

(Units)

BS

(mg/dl)

Carbs

(g)

Insulin

(Units)

BS

(mg/dl)

Carbs

(g)

Insulin

(Units)

BS

(mg/dl)

Carbs

(g)

Insulin

(Units)

7/22

7/23

7/24

Organize data into table: glucose, carbs, insulin by meal each day

9. When and Which Diabetes Consult?

1. Staff Nurse– Review insulin self-administration: syringe and pen devices– Provide basic survival skills: video, written materials– Review DM regimen and insulins– CAPI: #15 Patient Care Teaching/Educate Self Injections or

Diabetic Teaching (enter specific info into comments field, e.g. “video/book review”

2. Nutritionist:– Provide carbohydrate counting education– Review ADA diet– CAPI: #13 Anc Services

3. Diabetes Clinical Nurse Specialist (C.N.S.)– Complex patient– Newly diagnosed diabetic– Needle phobia– Insulin pump– Review blood glucose monitoring technique– CAPI: #13 Anc Services

INSULIN PENS Quick, Discreet, and

Convenient

10. Discharge Orders: Basics• Insulin plus Supplies

• Ketostix• BD Ultra-Fine Insulin Syringes

size: 1 ml (100 units), 0.5 ml (50 units), 0.3 ml (30 units)100-count box, refills x ___

• BD Ultra-Fine Syringe Needles, 31 gauge x 5/16” (8 mm), 100-count box, refills x ___

• Pen insulin: 1 box of 5 cartridges (300 ml per cartridge)• BD Ultra-Fine Pen Needles, 100-count box, refills x ___

– 31 gauge x 5/16” (8 mm) - short– 31 gauge x 3/16” (5mm) - mini

• Glucometer• Lancets: BD Ultra-Fine Lancets, 33 gauge, 100-count box, refills x ___• Test strips for glucometer: sig, #, refills

Diabetes Med Set: ease of use for DI

At discharge generate prescription/med list

Select “Add/Modify Discharge Meds”

Diabetes Med Set: Ease of Use at Discharge

Select “New Med”


Select “Med Sets”


Select “Diabetes: Insulin And Supplies”


You may select specific dosing of “Insulin Products” without Sliding Scales Here.

Page down for more options!


You may select “Insulin Products” with “STD”, “HI”, or “LO” Sliding Scales Here.

You can choose just CF or CF with Carb Counting (I:CHO) based on patient needs.



You may select patient “Diabetic Supplies” for Insulin Administration at home.



Be sure to take advantage of the “DIABETES MED SET”

Saves time

Provides instructions to transition diabetic care to home

Customize the basal insulin, prandial insulin, and diabetic supplies that are specific to your patient

Insulin Cost10 ml Vial 5 Pens (1500ml)

Lantus $114.99 $237.99

Levemir $132.99 $231.99

Humalog $122.99 $245.99

Novolog $132.99 $259.99

Humulin R $54.99 NA

Novolin R $62.99 $107.99

Humalog 75/25 $122.99 $245.99

Novolog 70/30 $132.99 $245.99

Humulin 70/30 $54.99 $172.99

Novolin 70/30 $62.99 $93.98

Syringe (10) $3.39 NA

Pen Tips (100) NA $38.99

Glucometer Strip Cost

Pharmacy FreeStyle Lite 50 Count

FreeStyle Lite Promise Program

True Track

50 Count

CVS $67.99 $42.99 $31.99

Walgreen’s $69.99 $44.99 $31.99

CostCo $63.09 $38.09 $34.00Discount Drug Mart $59.99 $34.99 $29.99

Kroger $62.99 $37.99 $31.59

Target $59.99 $34.99 $$26.49

Giant Eagle $62.99 $37.99 $31.59

Wal-Mart $57.99 $32.99 $26.22

Freestyle Lite Promise Program

• For extra $5 the patient can accurately dose their insulin

• Never need to code strips (wastes a strip)• Receive other perks:

– Free Batteries– Free Meter Upgrades– Free Access to Certified Diabetes Educators– Patient Education Materials– Insurance Help Line– Meter Tech Support

Conclusion: Some Recommendations • Don’t be afraid of IV insulin

• Provide basal insulin (glargine, detemir, or NPH)

• Provide bolus insulin (rapid acting insulin) based on – carbohydrate intake (prandial dose)– premeal glucose (correction factor)

• Individualized dietary management

– fixed insulin (fixed carbs) vs. insulin:carb ratio

• Involve: Staff Nurse, Nutritionist, Diabetes CNS

• Schedule procedures and surgery in early AM

–insulin and food can simply be shifted later in the day

• Use the Med Sets

END

???

Management with Subcutaneous Insulin

Basal/Bolus Concept

InsulinInsulin(µU/mL)(µU/mL)

GlucoseGlucose(mg/dL)(mg/dL)

Physiologic Insulin Secretion

24-Hour Profile

150150

100100

5050

0077 88 99 1010 1111 1212 11 22 33 44 55 66 77 88 99

A.M.A.M. P.M.P.M.

Basal GlucoseBasal Glucose

Time of DayTime of Day

5050

2525

00 Basal InsulinBasal Insulin

Breakfast Lunch DinnerBreakfast Lunch Dinner

Bolus Insulin

Basal Insulins

Insulin Onset of Action Peak Action

Duration of Action

NPH

Formulary

1-2 hours 4-8 hours 10-20 hours

glargine (Lantus)

Formulary

1-2 hours Flat ~ 24 hours

detemir (Levemir)

Formulary 7/07

? Flat ~ 14 hours

Lente

Ultralente

2-4 hours Unpredictable 16-20 hours

Bolus InsulinsInsulin Onset of Action Peak Action Duration of Action

Regular

Short-acting

Formulary - vial

30-60 minutes 2-4 hours 6-10 hours

lispro (Humalog)

Rapid-acting

Formulary - pen


aspart (Novolog)

Rapid-acting

Formulary - pen


glulisine (Apidra)

Rapid-acting

Nonformulary


NPH/regular 70/30 Nonformulary

50/50 Nonformulary

NPH/lispro 75/25 Nonformulary

NPH/aspart 70/30 Formulary

Premixed Insulins

Twice-daily Split-mixed Regimens

Regular

NPH

B SL HS

Insu

lin E

ffec

t

B

Multiple Daily Injections:NPH + Regular

Regular NPH

NPH at breakfast and HS + Regular breakfast and dinner

NPH at HS + Regular qAC

Insu

lin

Eff

ect

B SL HS B

Insu

lin

Eff

ect

B SL HS B

Regular NPH

Multiple Daily Injections:NPH + Lispro

NPH at breakfast and HS + Regular breakfast and dinner

NPH at HS + Lispro qAC

Insu

lin

Eff

ect

B SL HS B

Insu

lin

Eff

ect

B SL HS B

LisproNPH

LisproNPH

Pros:Pros:• Postprandial control at each mealPostprandial control at each meal• Improve fasting glucoseImprove fasting glucose• Provides basal coverage Provides basal coverage

throughout the daythroughout the day

Cons:Cons:• Inconvenient, multiple dosingInconvenient, multiple dosing• Cannot mix glargine (or Cannot mix glargine (or

detemir) with other type of detemir) with other type of insulininsulin

B B LL SS HsHs BBMealsMeals

GlargineGlargineInsulin EffectInsulin Effect

Multiple Daily Injections:Glargine + Premeal Rapid Acting Insulin

Locating “ADM 72 HOUR FAST”Order Set in CAPI

1. After selecting a patient from any service go to ordering screen above.

2. Select Order Sets button.


1. If patient is on a service other than Diabetes…..

2. Select another service….


1. Select Diabetes Service …..


1. Select “ADM 72 Hour Fast” Order Set …..

Documents

Some Factors Destabilizing Glucose Control during Hospitalization