Treatment of diabetes mellitus

in hospitals

Done by:

Fatimah Al-ShehriPharm.D Candidate

King Abdulaziz university

Supervised by:

Dr.Hani Hassan

Clinical pharmacist/internal medicine.

Outline

-Introduction.

-Goals in the hospital settings.

-Prevention of hyperglycemia and hypoglycemia.

-Treatment.

Introduction:

Glycemic control is unstable

in hospitalized patients because of:

-Stress of the illness or procedure .

-Concomitant changes in dietary intake

-Physical activity .

- Frequent interruption of the patient's usual antihyperglycemic regimen.

Goals in hospitals:

-Avoid hypoglycemia.

-Avoid severe hyperglycemia.

-Avoid volume depletion--Avoid electrolyte abnormalities.

-Ensure adequate nutrition.

Avoidance of hypoglycemia: 

Hypoglycemia (ie, serum glucose conc <70 mg/dL [3.9 mmol/L]) 

Hospitalized patients are particularly

vulnerable to severe, prolonged hypoglycemia.???

Consequences of hypoglycemia:

-It effects the counter-regulatory hormones, especially catecholamines, which may possibly induce arrhythmias and other cardiac events .

-If the blood glucose falls to 50 mg/dL (2.8 mmol/L), transient cognitive deficits ..

Avoidance of hyperglycemia: 

 It is a long-standing clinical observation when blood glucose

sugar is above 110mg/dl.

Hyperglycemia consequences :

-Volume and electrolyte disturbances mediated by osmotic diuresis.

-caloric and protein loss in under-insulinized patients .

-Immune and neutrophil function is impaired.

Glycemic targets in hospitals:

Target of the blood sugar deepens on the severity of the illness.

A-Critically ill patients.

B-Non-critically ill patients.

:Non-critically ill

Glycemic goals in non-critically ill patients : <140 mg/dL (7.8 mmol/L) for general hospitalized patients, with all random glucose <180 mg/dL (10.0 mmol/L) 

To avoid hypoglycemia : FBG concentrations : 90 to 100 mg/dL (5.0 to 5.6 mmol/L) .

In general, all glucose levels should be kept below 180 mg/dL (10.0 mmol/L) to avoid dehydration, caloric loss, glycosuria, and to reduce the risk of infection and, although rare, ketoacidosis.

Treatment

Treatment of hyperglycemia in hospital:

1 -The type of diabetes.

2-The patient's current BG concentrations .

3-Prior treatment .

4-The severity of illness .

5 -The expected caloric intake during the acute episode.

.

Treatment options:

-Insulin .

-Oral hypoglycemic.

1-Insulin: Types of insulin :

1-long-acting insulin: such as glargine or detemir.

2-Intermediate-acting insulin:such as NPH .

3 -Premeal rapid or short-acting insulin such as :regular insulin, aspart , lispro.

Insulin analogs:

Insulin regimen used in hospitalized patients:

1-Fixed dose regimen :-Basal –bolus insulin regmin (BBI).

-Regular regimen.(

2-Sliding scale insulin regimen .( SSI)

3-Insulin correction.

3-Insulin infusion.

1-Basal bolus insulin regimen:

1-Basal –bolus regimen:Basal Insulin: Prevents between meal and overnight hyperglycemia

Bolus insulin: Limits hyperglycemia after meals.

1-Basal bolus insulin regimen:Proactive Approach :

Anticipate major change in blood

glucose levels and prevent them from occurring

Insulin therapies that mimic

physiological release of insulin.

Individualized basal-bolus

insulin therapies (BBI)

:2-Sliding-scale insulin

SSI: involves use of regular insulin or a rapid-acting insulin analogue provided without any other scheduled short-acting or long-acting insulin.

2-Sliding scale insulin:

Urine glucose monitoring.

Boil urine sample with solution containing copper sulfate.

1934 Sliding Scale by Elliot Joslin.

3-Today’s Insulin Sliding Scale:

Blood glucose monitoring, Use of glucometer.

Regimens for rapid-acting or short-acting insulin .

Schedule:TID-QID.

Units: Blood glucose level :

0 Unit. <6mmol/L

2 Units. 6.1-8 mmol/L

4 Units. 8.1-10 mmol/L

6 Units. 10.1-12 mmol/L

8 Units. 12.1-14 mmol /L

10 Units. 14.1-16mmol/L

12 Units. 16.1-18 mmol/L

14 Units. 18.1-20 mmol/L

Call MD. <20

Which sliding scale:

Advantages & Disadvantages of ISS:

Advantages Disadvantages

Not individualized

Creates a “roller coaster” effect

“Reactive Approach”

Not evidence based practice

Can initiate right away

Simple

Convenient

Umpierrez GE, Palacio A, Smiley D. Sliding scale insulin use: myth or insanity? Am J Med 2007; 120: 563– 567

2-Insulin sliding scale:

SSI -Traditional Insulin Sliding Scales:

No basal insulin.

-Supplemental Scale or Correction Scale:ISS + (basal insulin +/- bolus insulin)

Primarily used AS :

dose-finding strategy (bolus insulin dosage)

-As a supplement when rapid changes in insulin requirements (i.e. stress or illness)

ISS vs. BBI?

Evidence against SSI :

Rabbit trial 2:

Evidence against the SSI:

Evidence against the SSI:

Although sliding scale insulin regimens are prescribed for the majority of inpatients with diabetes, they appear to provide no

Benefit..

in fact, when used without a standing dose of intermediate-acting insulin, they are associated with an increased rate of hyperglycemic episodes.

Evidence against SSI:

MJA 2012; 196: 266–269 doi: 10.5694/mja11.10853

Mean change in BGL from baseline in the two insulin therapy groups.

MJA 2012; 196: 266–269 doi: 10.5694/mja11.10853

Conclusion: under routine clinical conditions, implementation of a BBI protocol to manage hyperglycaemia in hospitalised patients resulted in a lower mean daily BGL than did SSI .

BBI is associated with an increase in mild, but not severe, hypoglycaemia. We recommend that protocols for inpatient glycaemic control based around BBI be widely implemented.

Time to stop SSI:

1-Unaware of problems associated with ISS

2- Unwilling to make changes to therapies initiated by another physician

3 -Lack of evidenceLong-term care (LTC) setting

QUESTION: AS clinical pharmacist , When making your recommendation to

the physician, what information might you want to include about SSI and BBI?

A-Basal-bolus is a proactive approach to management, preventing hyperglycemia without increasing the risk of hypoglycemia.

B-The use of insulin sliding scale is not evidence-based practice.

C-Insulin sliding scale is most likely the medication causing the patient to fall and affecting patient’s ability to focus.

D- All of the above.

:3 -Correction insulin

The dose of correction insulin should be individualized based upon relevant patient characteristics such as:

-Previous level of glucose control.

-Previous insulin requirements .

- The carbohydrate content of meals .

Correctional insulin needs: -1800 rule: 1800/TDI=number of mg/dl of glucose lowering per 1 unit of

rapid acting insulin .

))1 unit of rapid actin insukin will reduce the BG concentration by x mg/dl.

-1500 rule :1500/TDI .

:3 -Correction insulin

Correction insulin alone may also be used :

- As initial insulin therapy in patients with type 2 diabetes previously treated at home with diet or an oral agent, who will not be eating regularly during hospitalization.

It is typically administered every six hours as regular insulin . 

 However, if the patient is eating and finger stick glucoses are consistently elevated (<180mg/dL [10.0 mmol/L]) :

)basal-bolus regimen.(

Insulin requirements:

50 % of the total daily dose can be given as BI.

The remaining 50% can be given in equally divided doses prior to meals (1/3 prior to each meal).

2-Regular insulin: 1-Basal –bolus regimen:

70%)2/3 (of the dose given in the morning.

30%)1/3 (of the dose given in the evening.

50% basal insulin .

50% bolus insulin .

e.g: 25 units/day (NPH). -16 units in the morning.

-9 units in the evening.

e.g: 25 units/day. -Glargin:12.5 unit as basal

-Lispro: 12.5 ( 4.4.4 ) as bolus.

http://diabetesmanager.pbworks.com/w/page/17680263/Management%20of%20the%20Hospitalized%20Diabetic%20Patient

4-Insulin infusion: 

Insulin infusions are typically

used in critically ill ICU patients, rather

than in patients on the general medical

wards of the hospital.

Oral hypoglycemic agents: 

References:

http://diabetes.niddk.nih.gov/dm/pubs/causes.

http://care.diabetesjournals.org/content/29/suppl_1/s43.full