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In-patient Management of Diabetes

In-patient Management of Diabetes. Armed Forces Academy of Medical Sciences. Learning Objectives. Review basic information about the hospitalized diabetic patient Identifying goals of treatment How to achieve goals of treatment Famous diabetics. Quiz.

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In-patient Management of Diabetes

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  1. In-patient Management of Diabetes Armed Forces Academy of Medical Sciences

  2. Learning Objectives • Review basic information about the hospitalized diabetic patient • Identifying goals of treatment • How to achieve goals of treatment • Famous diabetics

  3. Quiz • Who is international chairperson for JDRF?

  4. Will you see a diabetic patient in the hospital? • DM is primary diagnosis in approximately 8% of admissions • Prevalence of diabetes is estimated (conservatively) at 13-25% of hospitalized adults

  5. Is blood sugar control important? • Hyperglycemia: • Impairs immune function • Worsens heart attacks • Leads to thrombosis • Increases inflammation • Causes endothelial cell dysfunction

  6. Causes of hyperglycemia • Acute stress of illness • Poorly controlled as outpatient • Infection • Drugs- glucocorticoids, vasopressors, etc.

  7. Quiz – Name the person who is not a type 1 diabetic

  8. Goals of treatment • Pomposelli et al. found >220 on POD#1 predicted infection • In ICU, normoglycemic patients had lower rates of infection (8% vs 29% p<0.01) • Capes et al metaanalysis for AMI goal <180 • Bolk et al found mortality risk > 199

  9. Goals of treatment • ADA recommends preparandial between 90 -130 and max 180 for general patient • For critically ill, goal is 90 – 120. Based on 2001 (revised 2006) NEJ Van den Berghe study.

  10. Goals of treatment • Avoidance of hypoglycemia • <70 can have harmful counterregulatory effects • <50 has significant cognitive impairment

  11. Quiz – which dead musician was not diabetc?

  12. How to achieve goals? • First, consider . . . • Type of diabetes • Severity of illness • Length of stay • Previous regiment • Nutrition status/caloric intake

  13. Oral agents • Common agents are biguanides, sulfonylureas, and thiazolidinediones • No great studies on these agents in inpatient setting

  14. Sulfonylureas • Potential for cardiovascular effects • Predisposition to hypoglycemia • Difficult to rapidly adjust dose to meet changing inpatient needs

  15. Metformin • Lactic acidosis • Contraindicated in acute kidney injury, cardiac or pulmonary decompensation, sepsis, dehydration, surgery, urinary obstruction. • Caution if getting contrast

  16. TZDs • Increase intravascular volume • Caution for which patient population? • Long-lasting effects

  17. Quiz – which sports figure is not a diabetic?

  18. Insulin • Insulin vs normoglycemic; which is actually protective? • Type 1 diabetics • Type 2 diabetics controlled on insulin at home

  19. Sliding scale <60: hypoglycemic protocol and call 60-150: 0 units 151-200: 2 units 201-250: 4 units 251-300: 6 units 301-350: 8 unis >351: 10 units and call

  20. Lantus • Provides basal rate • Can titrate up based on insulin requirements

  21. Recommendations • Type 1: • Always have some insulin onboard • Never just sliding scale • Watch for hypoglycemia • Watch for sudden shifts in blood sugars

  22. Recommendations • Type 2: • If diet-treated alone: • No therapy, but frequent checks • If on orals • Omit day of surgery/procedure • If on insulin • Sliding scale plus lantus

  23. Special situations • ICU – different talk • NPO – depends if insulin deficient • TPN – Can add insulin to TPN bag • Steroids – No trials, but consider sliding scale

  24. Self administration • May be ok for patient who is intelligent, has stable blood sugar at home, and stable level of consciousness • Coordinate with nursing • Patients should log blood sugars for review

  25. Quiz – which author does not have diabetes?

  26. Summary • Fasting sugar > 90mg/dl – 130mg/dl • Postparandial < 180mg/dl - 200mg/dl • ICU goal 110mg/dl, usually with drip • Normoglycemic AMI patients, regardless of diabetes status

  27. Thank You • Any Questions?

  28. References • Antman, EM, Anbe, DT, Armstrong, PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation 2004; 110:588. • Clement, S. et al. Management of Diabetes and hyperglycemia in Hospitals. Diabetes Care, vol 27, number 2. Feb 2004. 553-579. • Clinical Practice Recommendations. Diabetes Care 2005; 28 Suppl 1:S1.

  29. References • McCulloch, D. Inzucchi, S. Management of diabetes in acute care setting. www.uptodate.com may 2007. • Van den Berghe, G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345:1359.

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