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Intensive Management of Inpatient Hyperglycemia Nicole L. Artz, MD

Intensive Management of Inpatient Hyperglycemia Nicole L. Artz, MD. “The conventional view serves to protect us from the painful job of thinking.” John Kenneth Galbraith (1908-2006). Outline. Background Data Insulins Protocols Cases. Hyperglycemia – Scenarios.

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Intensive Management of Inpatient Hyperglycemia Nicole L. Artz, MD

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  1. Intensive Management of Inpatient Hyperglycemia Nicole L. Artz, MD • “The conventional view serves to protect us from the painful job of thinking.” • John Kenneth Galbraith (1908-2006)

  2. Outline • Background Data • Insulins • Protocols • Cases

  3. Hyperglycemia – Scenarios • Patient with known diabetes • defined as FBG > 126 mg/dl or random BG >= 200 on 2 or more occasions. • Patient with previously undiagnosed diabetes • HgbA1C abnormal and/or hyperglycemia persists after hospital discharge. • Stress hyperglycemia

  4. Background • Prevalence of DM in hospitalized patients- • 12-26% • Prevalence of inpatient hyperglycemia- • 38% (chart review of 1886 medical and surgical pts at community teaching hospital) • 1/3 with newly discovered hyperglycemia • References: • Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27(2):553-91. • Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978-82.

  5. Background • Why do we care about inpatient hyperglycemia?

  6. Total In-patient Mortality • Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978-82.

  7. Additional studies correlating hyperglycemia with morbidity/mortality…. • Acute MI- Increased risk of CHF, cardiogenic shock, and mortality… • Cardiac Surgery- Greater mortality, increased deep-sternal wound infections, and more overall infections.. • Acute CVA- Increased risk of mortality, poor functional recovery, and increased final infarct size… • Elective Surgery- Increased risk of nosocomial infection w/ early postoperative hyperglycemia Capes SE, Lancet. 2000;355(9206):773-8. Capes SE, Stroke. 2001;32(10):2426-32. Parsons MW, Ann Neurol. 2002;52(1):20-8. Furnary, APCirculation. 1999/100(#18)I-591. Pomposelli, JJ et al. J of Parenteral and Enteral Nurtrition, 1997: 22(2) 77-81.

  8. Cause or Effect?Intervention Studies

  9. Post-CABG Patients • Portland Protocol Study • On-going,17 year pre-post intervention study comparing conventional treatment with subcutaneous insulin (1987-1991) vs. continuous insulin infusion (1992-2001) in patients with diabetes. • CII therapy normalized the rates of hospital mortality (2.5%) and DSWI rates (0.8%) in pts with DM to those of nondiabetic patients. Furnary, et al. J Thoracic Cardiovascular Surgery 125: 1007-1021, 2003

  10. 14.5% Mortality 6.0% 4.1% 2.3% 1.3% 0.9% Average postoperative glucose (mg/dl)

  11. Effect on Healthcare Resources… • Length of Stay • 3-BG (3 day average post-op BG) independently predictive of longer LOS: • 1 day increased LOS for each 50 mg/dL increase in 3-BG. • Cost of Care • Conservatively estimated savings of $680 per patient. Furnary, et al. J Thoracic Cardiovascular Surgery 125: 1007-1021, 2003

  12. SICU patients • Randomized controlled trial of intensive insulin infusion therapy to maintain BG 80-110 mg/dl vs conventional therapy to maintain BG 180-200 mg/dl in mechanically ventilated surgical ICU pts. • 60% were cardiac surgery patients. Van den Berghe G, et al. N Engl J Med. 2001;345(19):1359-67.

  13. Mortality ARR-3.4% ARR-3.7% Intensive therapy also reduced episodes of bacteremia, acute renal failure requiring dialysis, # of blood transfusions, and critical illness polyneuropathy. Reduced ICU length of stay by 3 days for pts requiring >5 days of ICU care.

  14. NO to Sliding Scales!! • WHY? • Sliding scale regimen ordered on admission is usually used throughout the hospital stay without modification • Ineffective- Treats hyperglycemia after it has already occurred, instead of preventing the occurrence of hyperglycemia • This “reactive” approach can lead to rapid changes in blood glucose levels, exacerbating both hyperglycemia and hypoglycemia Queale, W. Arch Intern Med/Vol 157, Mar 10, 1997, 545-552. Smith, WD, Am J Health Syst Pharm. 2005 Apr 1; 62(7): 714-9. Schoeffler JM, Ann Pharmacother. 2005 Oct; 39(10) 1606-9.

  15. Basal/Bolus Concept • In healthy patients, pancreas secretes large amounts of insulin with meals (“bolus or prandial”) • However, it also makes smaller amount of insulin in between meals (when fasting, overnight, etc) to suppress liver glucose production (“basal”) • We try to mimic this as much as possible with current therapy

  16. Physiological Serum Insulin Secretion Profile Breakfast Lunch Dinner 50 Plasma insulin (µU/ml) 25 4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00 Time

  17. The Basal/Bolus Insulin Concept • Basal insulin • Suppresses glucose production between meals and overnight • 40% to 50% of daily needs • Bolus insulin (prandial/mealtime) • Limits hyperglycemia after meals • Immediate rise and sharp peak at 1 hour • 10% to 20% of total daily insulin requirement at each meal

  18. Pharmacokinetics of Current Insulin Preparations Effective Onset Peak Duration Lispro/Aspart <15 min 1 hr 3 hr Regular 1/2-1 hr 2-3 hr 3-6 hr NPH/Lente 2-4 hr 7-8 hr 10-12 hr Glargine 1-2 hr Flat/Predictable 24 hr

  19. Short-Acting Insulin Analogs Aspart Lispro 400 500 450 350 400 300 350 250 300 Plasma insulin (pmol/L) 200 250 Plasma insulin (pmol/L) 200 150 150 100 Regular 100 50 Regular 50 0 0 0 30 60 90 120 150 180 210 240 0 50 100 150 200 250 300 Time (min) Time (min) Meal SC injection Meal SC injection Heinemann, et al. Diabet Med. 1996;13:625–629; Mudaliar, et al. Diabetes Care. 1999;22:1501–1506.

  20. Glargine vs NPH Insulin 6 NPH 5 Glargine 4 NPH Glucose utilization rate (mg/kg/h) 3 2 Glargine 1 0 0 10 20 30 Time (h) after SC injection End of observation period Lepore, et al. Diabetes. 1999;48(suppl 1):A97.

  21. Basal/Bolus Treatment with Rapid-acting & Long-acting Insulin Analogs Breakfast Lunch Dinner LisproLisproLispro Plasma insulin Glargine 4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00 Time

  22. Insulin Requirements • Basal Insulin • Baseline insulin needed whether eating or NPO • ex. Glargine (Lantus®) • Prandial Insulin • Also referred to as bolus or mealtime insulin, usually administered before eating • ex. Lispro (Humalog®) and Aspart (Novolog®) • Correction or Supplemental Insulin • Insulin used to treat hyperglycemia that occurs before meals or between meals • Given in addition to scheduled insulin • At bedtime, often is given at a reduced dose in order to avoid nocturnal hypoglycemia • With NPO patients or patient who is receiving scheduled nutritional and basal insulin but not eating meals

  23. Initial Approach…. • Check HgbA1C • Accuchecks QAC and HS • Discontinue Oral Diabetes Medications • Cannot gain rapid control of hyperglycemia • Sulfonylureas- Increased risk of hypoglycemia w/ decrease in po intake • Metformin- Increased risk of lactic acidosis if ARF • Thiazolidinediones- may be contraindicated by development of chf, edema

  24. Calculating Basal/Bolus Insulin • Type 2 DM on insulin- Add all insulin doses together (this is the Total Daily Dose) • Type 2 DM new to insulin OR Newly Discovered Hyperglycemia- Calculate starting Total Daily Dose of 0.6 units/kg/day. • In general, 50% of the total insulin should be basal and 50% mealtime insulin, the latter divided in 3 doses for each meal

  25. BASAL Insulin • Cut the TDD in half and give as insulin Glargine (Lantus®). • This is Basal insulin. • May give insulin Glargine (Lantus®) at any time and then re-dose every 24 hours.

  26. PRANDIAL Insulin • When the patient is eating, give the remaining 50% of the TDD as rapid acting insulin lispro (Humalog). Give 1/3 AFTER each meal. • This is prandial insulin • Cut the prandial dose in ½ if the patient only eats ½ the meal. • Hold prandial dose if patient does not eat.

  27. Correction Factor Insulin…the new, improved “sliding scale” • To correct pre-meal hyperglycemia • Given in addition to scheduled mealtime insulin as one injection after the meal • Give if pt NPO • Algorithms based upon the total insulin dose per day

  28. Correction Factor Insulin 40 units insulin/day 41-80 units insulin/day

  29. Correction Factor Insulin >80 units insulin/day

  30. Correction Factor Insulin • Only HALF correction dose is given at bedtime

  31. Goals for Ward Patients • Pre-prandial BS 90-130 mg/dL • All BS <180 mg/dl

  32. Adjusting Basal Insulin • Make daily adjustments of basal insulin based on fasting (AM) BG

  33. Adjusting Prandial Insulin • Recalculate prandial insulin dose using new basal insulin amount divided by 3

  34. If the Patient is NPO or unable to eat • Insulin glargine (Lantus) should still be given • Accuchecks every 6 hours • Prandial insulin not needed • Correction insulin should still be given • BG goal 90-130 mg/dl

  35. Patients without History of Diabetes • In patients without a history of diabetes and normal hemoglobin A1C • insulin glargine dose can be TAPERED by 20% of the first dose per day and they can be discharged without treatment

  36. Transition from Drip to SQ Insulin • Patient should be stable on the same IV drip rate for 3 hours • Multiply the drip rate/hour X 20  Give this as daily dose of Glargine (Lantus®) SQ • Discontinue the IV drip 2 hours after the insulin Glargine (Lantus®) dose • May give insulin Glargine (Lantus®) at any time and then re-dose every 24 hours • This is Basal insulin

  37. Transition from Drip to SQ InsulinWhen patient is able to eat • Insulin drip stable at a rate of 3 units/hour • Glargine calculated as 3 X 20 = 60 units • Glargine 60 units SQ given and drip stopped 2 hours later • Patient to start eating • Total lispro dose to be 60 units per day so 60/3  20 units with each meal

  38. If the Patient is on Tube Feeds • Consult Endocrine. • If continuous, ALL insulin requirements should be supplied by Glargine. • If suddenly stopped, immediately begin infusion of D10 at same rate tube feeds were running to avoid hypoglycemia.

  39. If the Patient is on Steroids • Consult Endocrine • Increased post-prandial hyperglycemia- may need to use much greater prandial insulin doses, or change to NPH.

  40. Discharge • Patient with Type 2 Diabetes • HbA1C >7% represents suboptimal diabetic control and anti-diabetic Rx should be improved prior to discharge. • Each oral diabetic agent will only lower HbA1C by 1-2%. A pt w/ HbA1C of 12% on 2 oral agents will require insulin to reach goal <7%. • Note: Illinois public aid now covers Lispro (Humalog) and Glargine (Lantus) for outpaients.

  41. Practice Cases • 45 yr old woman with h/o DM type 2 admitted for elective cholecystectomy. • At home, taking glipizide 10 mg bid and Metformin 1000 mg po bid. • Weight is 100 kg.

  42. Case 1 Cont… • What is her Total Daily Insulin Requirement? • 100 kg X 0.6 units/kg = 60 units • How much basal insulin (Lantus) should you give? • 30 units (50% of TDD) • How much prandial insulin will she need with each meal? • 10 units given AFTER each meal.

  43. Case 1 Cont… • Which correction factor algorithm will she require? • Medium Dose Algorithm 41-80 units insulin/day

  44. Case 1 Cont…. • Post-operative Day 1 her fasting blood glucose is 170. Calculate her new basal and bolus insulin doses. • Lantus 33 units Q 24 hours. • Lispro 11 units after each meal.

  45. Case 1 Cont… • She does well and is ready for discharge on POD #3 • Her HbA1C ordered at admission was 10%. She states that she takes her pills consistently at home. • Discharge regimen?

  46. Case 1 Cont… • What additional things must happen before discharge? • Patient diabetes education- DVD, patient handouts • Ability to use glucometer appropriately • Ability to give insulin injections • Scripts for test strips, lancets, insulin, needles, and syringes!) • Ensure f/u apt with PCP w/in 2 weeks

  47. Case 2 • 58 y/o male with h/o DM type 2 previously treated with oral diabetes medications now admitted to D6 ICU after CABG. • Started on insulin infusion per RN-initiated protocol. • Determined ready for transfer out of the ICU to the floor on POD 2.

  48. Case 2 • The pt is on an insulin gtt at 3 units/hr. The nurse asks you for transfer insulin orders. • What do you need to know to write these? • Has the pt been on a stable drip rate for the last 3 hrs? • Is the patient eating, or NPO?

  49. Case 2 • The nurse reports the insulin gtt has been stable at 3 units/hr for the past 3 hrs and the patient’s most recent BG was 116. • Calculate the initial dose of insulin glargine. • 3 X 20 = 60 units glargine • When will you discontinue the insulin gtt? • 2 hours after glargine is given

  50. Case 2 • Order prandial insulin for this patient. • Lispro 20 units SQ given after each meal • Order a correction factor insulin- which algorithm will you choose? • High Dose Algorithm (>80 units insulin/day)

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