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Achieving Glycemic Control in the Hospital Setting

Achieving Glycemic Control in the Hospital Setting. (Part 3 of 4). Recommendations for Managing Patients With Diabetes in the Hospital Setting. IV Insulin in the ICU Setting. Antihyperglycemic Therapy. Insulin Recommended. OADs Not generally recommended. IV Insulin

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Achieving Glycemic Control in the Hospital Setting

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  1. Achieving Glycemic Control in the Hospital Setting (Part 3 of 4)

  2. Recommendations for Managing Patients With Diabetes in the Hospital Setting

  3. IV Insulin in the ICU Setting Antihyperglycemic Therapy Insulin Recommended OADsNot generally recommended IV Insulin Critically ill patients in the ICU SC Insulin Noncritically ill patients Moghissi ES et al. Diabetes Care. 2009;32(6):1119-1131.

  4. Yale1 Markovitz2 Leuven3 Portland4 Texas Diabetes Council5 DIGAMI6 University of Washington7 Krinsley8 Rush University Protocol9 Northwestern University10 IV Insulin Protocols Multiple published protocols are available that are effective and safe. Some examples include: 1. Goldberg PA et al. Diabetes Care. 2004;27(2):461-467; 2. Markovitz LJ et al. Endocr Pract. 2002;8(1):10-18; 3. Van den Berghe G et al. N Engl J Med. 2001;345(19):1359-1367; 4. Furnary AP et al. Endocr Pract. 2004;10(suppl 2):21-33; 5. Texas Diabetes Council. Available at: http://www.dshs.state.tx.us/diabetes/pdf/algorithms/iv%20insulin%20infusion.pdf; 6. Malmberg K et al. Circulation. 1999;99(20):2626-2632; 7. Ku SY et al. Joint Commission J Quality Patient Safety. 2005;31(3):141-147; 8. Krinsley J. Mayo Clin Proc. 2004;79(8):992-1000; 9. Donaldson S et al. Diabetes Educ. 2006;32:954-962; 10. DeSantis AJ et al. Endocr Pract. 2006;12(5):491-505.

  5. Considerations When Converting From IV to Subcutaneous Insulin • Initial doses of scheduled subcutaneous insulin are based on previously established dose requirements1 • 75%-80% of the total daily IV infusion dose is proportionally divided into basal and prandial components2 • Subcutaneously administered insulin must be given before discontinuation of IV insulin therapy in order to prevent hyperglycemia2 • Intermediate- or long-acting insulin must be injected subcutaneously 2 to 3 hours before discontinuing the IV insulin infusion1 • A short- or rapid-acting insulin should be given subcutaneously 1-2 hours before discontinuation of the IV insulin infusion1 1. Clement S et al. Diabetes Care. 2004;27:553-591; 2. Moghissi ES et al. Endocr Pract. 2009;15(4):353-369.

  6. SC Insulin Is Appropriate for Noncritically Ill Patients Antihyperglycemic Therapy Insulin Recommended OADsNot generally recommended IV Insulin Critically ill patients in the ICU SC Insulin Noncritically ill patients Moghissi ES et al. Diabetes Care. 2009;32(6):1119-1131.

  7. Overview of Subcutaneous Insulin • Preferred method for achieving and maintaining glucose control in non–ICU patients with diabetes or stress hyperglycemia • Effective insulin therapy must contain basal, nutritional, and supplemental (correction) components to achieve target goals • Supplemental-dose insulin is the use of additional short- or rapid-acting insulin in conjunction with scheduled insulin doses to treat blood glucose levels above desired targets • Prolonged therapy with sliding-scale insulin alone is ineffective in the majority of patients and potentially dangerous in those with type 1 diabetes Moghissi ES et al. Endocr Pract. 2009;15(4):353-369.

  8. The Basal-Bolus Principle: Adding Mealtime Control Rapid-acting insulin analog Long-acting insulin analog Insulin level 0:00 06:00 08:00 10:00 12:00 14:00 16:00 18:00 20:00 22:00 0:00 Time of day Theoretical representation of insulin profiles

  9. 240 220 * * 200 * † † 180 † † 160 140 120 100 10 Admit 1 2 3 4 5 6 7 8 9 RABBIT 2: Glycemic Control With Basal-Bolus vs Sliding-Scale Insulin N=130 insulin-naïve hospitalized nonsurgical patients with T2DM n=9 with BG >240 mg/dL 300 Switched from sliding-scale to basal-bolus insulin Sliding-scale 260 220 Blood glucose (mg/dL) 180 140 Basal-bolus‡ 100 Admit 1 2 3 4 1 2 3 4 5 6 7 Days of therapy *P<.01; †P<.05; ‡Long-acting insulin (glargine) once daily + short-acting insulin (glulisine) before meals, total dose 0.4 unit/kg (BG 140-200 mg/dL) or 0.5 unit/kg (BG 201-400 mg/dL). RABBIT 2=Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients with Type 2 Diabetes. Umpierrez GE et al. Diabetes Care. 2007;30:2181-2186.

  10. Estimating SC Insulin Dose • To calculate the estimated total daily dose of insulin: • T2DM: 0.5-0.7 unit/kg • T1DM or type unknown: 0.3-0.5 unit/kg • The total daily dose of insulin is then divided into 50% basal (insulin detemir or glargine) and 50% prandial (insulin aspart, lispro, or glulisine) • The prandial insulin dose is divided into 3 equal doses that are given with meals Model From a Tertiary Care Center DeSantis AJ et al. Endocr Pract. 2006;12(5):491-505.

  11. Therapeutic Options for Glycemic Control in the Medical or Stabilized Surgical Patient From the ADA Diabetes in Hospitals Writing Committee Clement S et al. Diabetes Care. 2004;27(2):553-591.

  12. Subcutaneous Insulin Can Be Augmented With Premeal Supplemental-Dose Insulin From the ADA Diabetes in Hospitals Writing Committee Sample algorithm (worksheet) for supplemental-dose insulin to be administered in addition to scheduled basal and nutritional insulin to correct premeal hyperglycemia Low dose: for patients requiring <40 units/day Medium dose: for patients requiring 40-80 units/day High dose: for patients requiring >80 units/day Clement S et al. Diabetes Care. 2004;27(2):553-591. Online Appendix 1.

  13. Potential Problems With Use of Sliding-Scale Insulin Regimens • Sliding-scale insulin usually consists of regular insulin given alone • This technique has been shown to be ineffective for the following reasons: • Reactive approach can lead to rapid swings in blood glucose, resulting in hyperglycemia and hypoglycemia • Admission regimen is likely to be used throughout hospitalization without appropriate modification • It treats hyperglycemia after the fact instead of proactively anticipating need • Hazards of sliding-scale insulin use exceed the advantages of its convenience ADA. Diabetes Care. 2006;29(suppl):S4-S42.

  14. Current Guidelines on the Use of Sliding-Scale Insulin • American Diabetes Association • Sliding-scale regimen prescribed on admission is likely to be used throughout the hospital stay without modification, even when control remains poor1 • American Association of Clinical Endocrinologists • Sliding-scale regimens are ineffective and potentially harmful when used alone2 • American Medical Directors Association • Sliding-scale is generally not recommended in long-term care facilities, as it is neither effective nor efficient in the inpatient setting3 • American Diabetes Association. Standards of medical care in diabetes—2010. Diabetes Care. 2010;33(suppl 1):S11-S61. • American Association of Clinical Endocrinologists. Medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract. 2007;13(suppl 1):3-68. • American Medical Directors Association. Diabetes Management in the Long-term Care Setting: Clinical Practice Guideline. Columbia, MD: American Medical Directors Association; 2008.

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