Optimal Glycemic Control for the Hospitalized Patient Target Diabetes MaineHealth June 7, 2007

1. Optimal Glycemic Control for the Hospitalized PatientTargetDiabetesMaineHealth June 7, 2007 David Baldwin MD Section of Endocrinology Rush University Medical Center Chicago, IL david_baldwin@rush.edu

3. Hyperglycemia in Patients With Undiagnosed Diabetes • Hyperglycemia occurred in 38% of patients admitted to the hospital • 26% had known history of diabetes • 12% had no history of diabetes • Newly discovered hyperglycemia was associated with: • Higher in-hospital mortality rate (16%) compared with patients with a history of diabetes (3%) and patients with normoglycemia (1.7%; both P<.01) • Longer hospital stays; higher admission rates to intensive care units (ICUs) • Less chance to be discharged to home (required more transitional or nursing home care) Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:978–982.

4. Potential Benefits of Improving Glucose Control in the Hospital • Improving inpatient glycemic control provides an opportunity to: • Reduce mortality • Reduce morbidity • Reduce costs of care • Length of stay (LOS) • Cost of inpatient complications • Fewer re-hospitalizations • Reduced extended care

5. Intensive Glucose Management in Critically Ill Patients

6. Intensive Insulin Therapy in Critically Ill Surgical Patients • Setting: surgical intensive care unit in University Hospital, Leuven, Belgium • Hypothesis: normalization of blood glucose levels with insulin therapy can improve prognosis of patients with hyperglycemia or insulin resistance • Design: prospective, randomized, controlled study • Conventional: insulin when blood glucose > 215 mg/dL • Intensive: insulin when glucose > 110 mg/dL and maintained at 80–110 mg/dL van den Berghe G, et al. N Engl J Med. 2001;345:1359–1367.

8. ICU MortalityEffect of Average BGVan den Berghe et al (Crit Care Med 2003; 31:359-366) BG >150 110 <BG< 150 BG <110

11. Krinsley Prospective Study IV Insulin in the Mixed ICU • Blood glucose < 120 mg/dL • Overview • Frequent FSG checks • Insulin IV infusion if > 200 twice in a row • Intensive regular insulin coverage otherwise • Minimal initial monitoring: FSG Q3h; Q1h during IV insulin infusions

13. Krinsley: Incidence of Hypoglycemia • Percentage of blood glucose values < 40 mg/dL • Baseline—0.35% • Treatment—0.34% • NO ADVERSE CLINICAL CONSEQUENCES

15. VB 1--SICU VB 2--MICU Glucose C 153 mg% 153 mg% Glucose I 103 mg % 111 mg% APACHE II 9 23 % Mortality C 8% 40% % Mortality I 4.6% 37.3% % Mort >5 Days C 20.2% 54.9% % Mort >5 Days I 10.6% 45.9% The Two Van den Berghe Studies C- Control Group I- Intensive Group

17. Rush IV Insulin Infusion Protocol

18. Surgical ICU3550 blood glucose tests 30 days Mean BG 119 mg/dl

19. Medical ICUMean BG 135 mg/dl

20. Control of Blood Glucose in the SICUPercentage of Blood Glucoses 80-120 mg/dl p=.009 Percent of All Blood Glucoses

21. Control of Blood Glucose in the SICUFrequency of Hypoglycemia Percent of All Blood Glucoses

22. Control of Blood Glucose in the SICUFrequency of HypoglycemiaThe Effect of End Stage Renal Failure p=.05 Percent of All Blood Glucoses Transplant Surgery Subset: 31 Patients

25. RUSH UNIVERSITY MEDICAL CENTER CHICAGO, ILLINOIS • RUSH MEDICAL COLLEGE • PRESBYTERIAN ST LUKES HOSPITAL • 180 patient medical service • 54 PGY-1’s • 38 PGY-2’s and 38 PGY-3’s • 120 patient surgical service • 80 postgraduate trainees

26. MEDICAL HOUSEOFFICER DIABETIC EDUCATION PROJECT • 115 hyperglycemic patients identified • Mean duration of diabetes was 10.4 years. • 7 new onset diabetes • 67% were testing BG at home • Mean HbA1C was 8.7% • 26% <6.5%, 50%> 8 % • All patients had therapy changed if HbA1C > 7% • 21/36 patients not testing BG at home were given meters and instruction Diabetes Care 28: 1008-1011 2005

27. INPATIENT THERAPY

28. Glucose Control Parameters

29. HBAIC GUIDED CHANGE IN THERAPY

30. The Rush Medical Resident Education Program for Inpatient Diabetes ManagementEndocrinologist taught • 2002 30 min each AM, 60 min- 5/7 PM’s with 2 on-call PGY-1’s/day.. 10 sessions per month per PGY-1= 8 hours 8 PGY-1’s each attend for 4 weeks = 7 months for all • 2003-2007 60 min each M-F PM with 3 PGY-1’s/day, 4 sessions per month per PGY-1 All PGY-1’s each attend for 8 weeks, = 8 months for all Baldwin et al. Diabetes Care 28:1008-1011, 2005

31. July 2005 Hospital-Wide Diabetes Care Improvement Initiative • Eliminate all isolated use of regular insulin sliding scales • Eliminate all SQ insulin products ex: • Glargine • NPH • Aspart • Insulin guideline pocket cards • Insulin guideline hospital intranet web • Specialized CPOE insulin ordersets • Hypoglycemia prevention-treatment orderset

32. 2 3 4 5 6 7 8 9 12 13 14 15 16 17 18 19 20 21 22 23 24 0 1 10 11 Action Profiles of Therapeutic Insulins Plasma insulin levels aspart, glulisine, lispro 3-4 hours Regular 6–8 hours NPH 10–16 hours glargine, detemir 18-24 hours Hours

33. Overall Therapy of Hyperglycemia on Rush General Medical Units • AM glargine ~ PM Glargine • Glargine +/- aspart……29% • NPH(BID) +/- aspart……34% • Sliding scale aspart…..10% • Metformin………………10% • Sulfonylurea +/- Met/TZD….17%

34. Common Challenges in the Care of the Inpatient with Hyperglycemia • Initiation of SQ insulin therapy at hospital admission.

35. Common Challenges in the Care of the Inpatient with Hyperglycemia • Initiation of SQ insulin therapy at hospital admission. • Transition from the ICU to a general medical/surgical unit.

36. Common Challenges in the Care of the Inpatient with Hyperglycemia • Initiation of SQ insulin therapy at hospital admission. • Transition from the ICU to a general medical/surgical unit. • Problem areas: glucocorticoids or enteral tube feeds

37. Common Challenges in the Care of the Inpatient with Hyperglycemia • Initiation of SQ insulin therapy at hospital admission. • Transition from the ICU to a general medical/surgical unit. • Problem areas: glucocorticoids or enteral tube feeds • The discharge handoff: HBA1C and the avoidance of clinical inertia. A golden opportunity for quality improvement

38. Initiation of SQ insulin therapy at hospital admissionThe case of the new diabetic 51 year old man presents to the ER with a 2 week history of polyuria and fatigue. He weighs 305 lbs (138 kg) and blood glucose is 939 mg/dl. DKA is ruled out, he is dehydrated but alert and awake. He has no PMH but + FH of type 2 diabetes. A diagnosis of type 2 DM is apparent. HBA1C = 12.6%

39. Initiation of SQ insulin therapy at hospital admissionThe case of the new diabetic • Phase 1 (12 hours) • IV hydration • Initiation of insulin • IV insulin infusion- probably not necessary • Preferred: SQ rapid-acting insulin analog • 0.2 units per kg SQ every 2 hours * • Monitor BG every 2 hours and continue Q2 hour analog until BG < 200 mg/dl *Umpierrez protocol, Diabetes Care 27:1873-1878, 2004

40. Initiation of SQ insulin therapy at hospital admissionThe case of the new diabetic • Phase 2 (12 hours) • Because of beta cell glucotoxicity, SQ insulin will be required for 4-10 weeks. • Begin NPH 0.2 U/kg QAM, 0.1 U/kg QPM • Begin rapid analog 0.1 U/kg BID • Complete IV hydration +/- potassium Rx

41. Initiation of SQ insulin therapy at hospital admissionThe case of the new diabetic • Phase 2 (12 hours) contin. • Teaching survival skills: diet, insulin, glucose monitoring, provide meter, hypoglycemia. • Can discharge home in 24-36 hours • Provide rapid access to comprehensive outpatient diabetic education • Provide telephone access for daily or every other day insulin dose adjustment

42. Initiation of SQ insulin therapy at hospital admission • 71 year old woman presents with pneumonia. She has a 14 year history of type 2 DM. She takes metformin and glimepiride. Weight is 80 kg. She has fever and dehydration but is not unstable. Blood glucose is 273 mg/dl. She is treated with IV fluids and antibiotics. HBA1C = 8.6%

43. Initiation of SQ insulin therapy for a New Medical Admission • Therapeutic options: • Continue oral agents? • Continue oral agents with a sliding scale? • Begin sole therapy with a sliding scale?

44. Initiation of SQ insulin therapy for a New Medical Admission • Therapeutic options: • Continue oral agents? • Continue oral agents with a sliding scale? • Begin sole therapy with a sliding scale? • Begin Basal - Bolus Insulin Therapy

45. Initiation of SQ insulin therapy for a New Medical Admission • Initiation of SQ basal - bolus insulin therapy is preferred given the infectious process and the degree of BG elevation. • OPTIONS: • Basal: daily glargine/detemir or BID NPH 0.3 - 0.4 units/kg • Prandial: if eating rapid-act analog 0.1 U/kg per meal • Correction: 5% of total daily dose for every blood glucose 30 mg/dl above 140 mg/dl

46. Initiation of SQ insulin therapy for a New Medical Admission • Initiation of SQ basal - bolus insulin therapy: • Basal: 80kg X 0.3U = 24 units glargine • Prandial: 80kg X 0.1U= 8 units rapid- acting analog TID with meals • Correction: 2 units added for BG 140-170, 4 units added for BG 170-200 etc

47. Initiation of SQ insulin therapy for a New Surgical Admission • 43 year old man is admitted after emergent cholecystectomy. He has a history of type 2 DM for 8 years Rx with rosiglitazone 4 mg BID and exenatide. Weight 88 kg. Post op BG is 220 mg/dl. He is NPO, IV fluid is D5/.45 NS. HBA1C = 7.8%.

48. Initiation of SQ insulin therapy for a New Surgical Admission • Avoid the sole use of sliding scale • Consider changing IV fluids to 0.45 ie glucose free. • Begin glargine/detemir 0.3 U/kg= 26 units • Monitor BG Q 6 hours, adjust basal dose daily based on the AM glucose target = 90-120 mg/dl • When PO diet introduced, add rapid analog 0.05 units/kg TID with meals.

49. Transition from the ICU to a general medical/surgical unit • Many patients in the ICU require IV insulin infusion for control of hyperglycemia especially after cardiovascular or transplant surgery. • Nearly all such patients with a prior history of diabetes will need to be transitioned to a SQ insulin regimen for transfer to a general surgical floor. • ~ 50% of patients with no prior history of DM and normal HBA1C will continue to need daily tapering doses of SQ insulin after transfer. • Thus ~ 75% of these patients will require SQ insulin to maintain blood glucose in the 80-180 mg/dl range.

50. Transition from the ICU to a general medical/surgical unit • Some ICU patients may have already been transitioned from IV to SQ insulin before transfer to the general floor, especially if they were a “long-stayer” in the ICU often receiving tube feeds. • Many patients only receive IV insulin for 12-24 hours and then are stable for transfer and thus require transition to SQ insulin.