Management of Inpatient Type 2 Diabetes

1. Management of Inpatient Type 2 Diabetes Nathan R. Harmon, D.O.

3. Why are we concerned? Prevalence of DM-2 in the U.S. increased by >55% from 1990 to 2000 Estimated 1 in 3 people born in the year 2000 will develop DM-2 in their lifetime Diabetes as a financial epidemic Length of stay Long term complications Financial � 2001 � hosptializations assoc w/ diabetes accounted fro 17 million hospital days and $40 billion Scotland study � compared non-diabetic to diabetic patients, and diabetic patients had an average of 4 day longer hospital stays One study showed the annual per capita cost for a diabetic pt as $6300 vs $3000 for a nondiabetic Increased risk of Cardiovascular complications � MI, PAD, etc, stroke, renal failure, etc Financial � 2001 � hosptializations assoc w/ diabetes accounted fro 17 million hospital days and $40 billion Scotland study � compared non-diabetic to diabetic patients, and diabetic patients had an average of 4 day longer hospital stays One study showed the annual per capita cost for a diabetic pt as $6300 vs $3000 for a nondiabetic Increased risk of Cardiovascular complications � MI, PAD, etc, stroke, renal failure, etc

4. Sliding Scale Insulin Studies have shown that: Sole SSI coverage in the inpatient setting leads to: Increased hyerglycemic and hypoglycemic episodes Increased length of stay Improved BG control decreases mortality in Critically ill patients (ICU) Acute MI patients There have been no randomized controlled studies to specifically address tight glycemic control in general medical patients, however, research has shown that hyperglycemia: --decreases Neutrophil function Impairs phagocytosis Elevated CRP levels And improved glycemic control improves these Van de Burg ICU � maintaining BG 80-110 reduced mortality by 34%, sepsis by 46% post MI � pt�s with acute MI received IV insulin for 24 hours, and SQ insulin for 3 months, had 29% reduction in mortality at one year. Meta analysis of 15 studies showed that BG >110 ? proportional increase in mortality and CHFThere have been no randomized controlled studies to specifically address tight glycemic control in general medical patients, however, research has shown that hyperglycemia: --decreases Neutrophil function Impairs phagocytosis Elevated CRP levels And improved glycemic control improves these Van de Burg ICU � maintaining BG 80-110 reduced mortality by 34%, sepsis by 46% post MI � pt�s with acute MI received IV insulin for 24 hours, and SQ insulin for 3 months, had 29% reduction in mortality at one year. Meta analysis of 15 studies showed that BG >110 ? proportional increase in mortality and CHF

5. Sliding Scale Insulin �A common misconception is that a sliding scale insulin regimen alone is sufficient for diabetes management� Lien, et al. Inpatients management of Type 2 Diabetes Mellitus �This autopilot approach as the sole mode of treatment for inpatient hyperglycemia has been strongly condemned.� Abourizk, N. Inpatient Diabetology SSI alone REACTS to episodes of hyperglycemia instead of PREVENTING them SSI alone can lead to HYPOglycemia ? hyperglycemiaSSI alone REACTS to episodes of hyperglycemia instead of PREVENTING them SSI alone can lead to HYPOglycemia ? hyperglycemia

6. Goals of Treatment Safety The fear of HYPOglycemia is a barrier to adequate care BUT � HYPOglycemia is a major safety issue As orders become more complex, the risk of error increases Need for protocols and system based approaches SAFETY = #1 goal JCAHO considers Insulin to be one of the five highest risk medications (6)SAFETY = #1 goal JCAHO considers Insulin to be one of the five highest risk medications (6)

7. Goals of Treatment Glycemic Control � upper limits Intensive Care � 110 mg/dL Non-Critical Care Preprandial 110 mg/dL Post-Prandial / MAX � 180 mg/dl American College of Endocrinology. Position Statement on Inpatient Diabetes and Metabolic Control. Endocr Pract 2004; 10:77-82

8. Barriers to Reaching Goals Staffing Timing of meals Education Staff Patients Discharge Planning It takes time and people to get BG levels multiple x per day, give insulin at appropriate timing to meals Studies have shown that a team approach (DM educator, Endocrinologist, DM nurse) were able to achieve goal BG levels signicantly more consistently than a general internist. Studies have shown that inpatient self management can improve inpt BG and lead to better outpt controls. D/C � inpatient education before D/C is imperative to maintaining control after d/c. It takes time and people to get BG levels multiple x per day, give insulin at appropriate timing to meals Studies have shown that a team approach (DM educator, Endocrinologist, DM nurse) were able to achieve goal BG levels signicantly more consistently than a general internist. Studies have shown that inpatient self management can improve inpt BG and lead to better outpt controls. D/C � inpatient education before D/C is imperative to maintaining control after d/c.

9. Assessing the Diabetic Patient History Current medications � recent changes Insulin � time of day, relation to meals Orals � relation to meals COMPLIANCE???? Other medication which may affect control (B-blockers, Steroids) History of episodes of hypoglycemia Diet Caloric intake � Are they counting calories? Do they eat a regular diet? Many patients take insulin at different times � ie lantus at HS or AM � should try to mimick their outpatient dosing schedule to ensure compliance when discharged ARE they compliant? If not, and we place them on a large dose of insulin / dose of oral meds ? hypoglycemia DIET � We commonly place people on an ADA diet during hospitalization for better control, however, if they eat a regular diet, then their medications may need to be adjusted once d/c�d � at least mention in D/C summary, possible referral to outpatient dietary counsellingMany patients take insulin at different times � ie lantus at HS or AM � should try to mimick their outpatient dosing schedule to ensure compliance when discharged ARE they compliant? If not, and we place them on a large dose of insulin / dose of oral meds ? hypoglycemia DIET � We commonly place people on an ADA diet during hospitalization for better control, however, if they eat a regular diet, then their medications may need to be adjusted once d/c�d � at least mention in D/C summary, possible referral to outpatient dietary counselling

10. Assessing the Diabetic Patient Physical Exam Vital Signs � Weight � for insulin calculations Retinopathy Neuropathy Labs HgA1c Renal function Clues to poor control Poor renal function may affect medication duration and action ? adjustmentClues to poor control Poor renal function may affect medication duration and action ? adjustment

11. Inpatient Monitoring Bedside glucose monitoring At least QID (before meals and at HS) May obtain 3AM level If pt NPO � check every 6 hours Continuous tube feedings � check q 6 hours Bolus tube feedings � check pre-feeding and 2 hours post- PM feeding (post prandial) 3AM level � useful in patient with elevated fasting glucose If 3AM level elevated = inadequate nightime dosing If 3AM level low= early peak in PM insulin or need for bedtime snack. 3AM level � useful in patient with elevated fasting glucose If 3AM level elevated = inadequate nightime dosing If 3AM level low= early peak in PM insulin or need for bedtime snack.

12. Inpatient Monitoring Understand how your orders are followed QID Accuchecks Done at 600, 1100, 1600 and 2100 unless otherwise specified Insulin Dosing With meals � 0800, 1200, 1700 HS = 2100 These times are ideal times, as the lab performs these, and there are only so many lab techs, ie the 6am may actually be later Insulin dosing � usually given with meals � ideal times, but should not be given after meals, again may not have perfect timing. These times are ideal times, as the lab performs these, and there are only so many lab techs, ie the 6am may actually be later Insulin dosing � usually given with meals � ideal times, but should not be given after meals, again may not have perfect timing.

13. Inpatient Glycemic Management Oral Medications Generally not adequate for sole treatment May need to hold oral medications (see individual medications) Do not use if NPO or eating poorly

14. Biguanides (Metformin) MOA: Decreases hepatic glucose output / increases peripheral glucose uptake Pros: May facilitate weight loss, does not cause hypoglycemia Cons: Lactic Acidosis Contrast media Lactic Acidosis � 2 types A � caused from hypoperfusion in the sick patient ? anaerobic metabolism ? lactic acid B � not caused from hypoperfusion, mechanism poorly understood, attributed to accumulation of Metformin Incidence of lactic acidosis higher in patients w/: Hypoxia, Renal Insufficiency, CHF and Sepsis; CONTRAST MEDIA � When renal function is impaired (contrast induced nephropathy)? accumulation of metformin? increased risk of type B lactic acidosis (Actual incidence estimated at 2 Cases per million per year in DM-2 patients on metformin receiving Contrast media) ? Stop metformin before and for 48 hours after Contrast media given, may pretreat with Mucomyst to reduce incidence of Contrast induced nephropathy Lactic Acidosis � 2 types A � caused from hypoperfusion in the sick patient ? anaerobic metabolism ? lactic acid B � not caused from hypoperfusion, mechanism poorly understood, attributed to accumulation of Metformin Incidence of lactic acidosis higher in patients w/: Hypoxia, Renal Insufficiency, CHF and Sepsis; CONTRAST MEDIA � When renal function is impaired (contrast induced nephropathy)? accumulation of metformin? increased risk of type B lactic acidosis (Actual incidence estimated at 2 Cases per million per year in DM-2 patients on metformin receiving Contrast media) ? Stop metformin before and for 48 hours after Contrast media given, may pretreat with Mucomyst to reduce incidence of Contrast induced nephropathy

15. Sulfonylureas MOA: Close ATP / K+ channel in the B-cell ?Insulin release Cons: Can cause hypoglycemia Metabolism affected by Renal / Hepatic impairment Glyburide should be avoided Renal Insufficiency Blocks Ischemic Preconditioning Glyburide � may block ischemic preconditioning (ie when myocardium subjected to repeated ischemia, it can become more resistant to Infarction when an artery occludes = ischemic preconditioning) --Not tolerated well with Renal insufficiencyGlyburide � may block ischemic preconditioning (ie when myocardium subjected to repeated ischemia, it can become more resistant to Infarction when an artery occludes = ischemic preconditioning) --Not tolerated well with Renal insufficiency

16. Thiazolidinediones (TZD�s) MAO: Enhance peripheral insulin sensitivity Cons: Concerns for increased fluid retention Should not be used in setting of Hepatic Impairment Fluid Retention � affect on CHF may be over estimated, mostly cause peripheral edema, should not be used in acute CHF, but may be used with caution in the pt with stable CHF. Fluid Retention � affect on CHF may be over estimated, mostly cause peripheral edema, should not be used in acute CHF, but may be used with caution in the pt with stable CHF.

17. Other Oral Agents Meglitinides and Alpha-Glucosidase Inhibitors Not well studied in the inpatient setting Potential for hypoglycemia is low Mainly act by affecting post-prandial glycemic levels, thus role in patient with reduced PO or NPO is limited.

18. Inpatient Insulin Management Review History Dietary habits Usual weight HgA1C History of episodes of Hypoglycemia

19. Inpatient Insulin Management Before prescribing Insulin, you need to know how it works, timing: Types of Insulin Ultrashort needs to be given 0 to 15 minutes before a meal Short needs to be given 30-45 minutes before a meal Intermediate Long-actingBefore prescribing Insulin, you need to know how it works, timing: Types of Insulin Ultrashort needs to be given 0 to 15 minutes before a meal Short needs to be given 30-45 minutes before a meal Intermediate Long-acting

21. Here you can see how this TID schedule mimicks what would be the natural insulin release to caloric intake. Blue line is physiologic Insulin release � notice how there is ALWAYS a basal insulin amount in our system!!!!!Here you can see how this TID schedule mimicks what would be the natural insulin release to caloric intake. Blue line is physiologic Insulin release � notice how there is ALWAYS a basal insulin amount in our system!!!!!

22. Comparison of NPH (intermediate) and Glargine (Lantus) = long actingComparison of NPH (intermediate) and Glargine (Lantus) = long acting

23. Comparison of Lispro (ultra short) and Regular (short) Comparison of Lispro (ultra short) and Regular (short)

24. Insulin Regimens � where to START History -- home dosing? Weight based dosing (SQ administration) Type 2 DM � 0.3-0.6 Units/kg/day for most patients 0.6 to 1.0 Units/kg/day if insulin resistant IF NPO, cut dose in half, and do not use Ultra-short acting Insulin This is a beginning point, and you need to remember to ALWAYS treat insulin and diabetes management as an ACTIVE issue, unless it really is stable (ie blood glucose is at goal � then, you need to start thinking of D/C planning) HOME DOSING � if it works, use it (ie if they have good control, and they are COMPLIANT, start w/ their home dose�this will make d/c planning easier � make sure to note in you H/P exact dosing for transfer of care for d/c planning) Type 2 DM � 0.3-0.6 Units/kg/day � (INSULIN Sensitivity Factor) remember this is a starting place, and you need to take into account if the person is insulin Na�ve (start at low end) or insulin resistant (ie ralready requires high doses of insulin and DM not well controlled This is a beginning point, and you need to remember to ALWAYS treat insulin and diabetes management as an ACTIVE issue, unless it really is stable (ie blood glucose is at goal � then, you need to start thinking of D/C planning) HOME DOSING � if it works, use it (ie if they have good control, and they are COMPLIANT, start w/ their home dose�this will make d/c planning easier � make sure to note in you H/P exact dosing for transfer of care for d/c planning) Type 2 DM � 0.3-0.6 Units/kg/day � (INSULIN Sensitivity Factor) remember this is a starting place, and you need to take into account if the person is insulin Na�ve (start at low end) or insulin resistant (ie ralready requires high doses of insulin and DM not well controlled

25. You have the dose, now where to go? How many times per day? Once daily (ie Lantus)� generally not adequate Twice daily 2/3 Total in AM (preprandial), of which 2/3 NPH and 1/3 regular (a good place for 70/30 mix) 1/3 in PM (before evening meal), of which 50% NPH and 50% regular A 70 kg man dosed at 0.5 Units/kg/day would get AM 16 Units NPH, 8 Units Regular PM 6 Units NPH , 6 Units Regular REMEMBER, you are concerned not only for inpatient compliance (taking into account nursing and staff (LAB) issues), There are many ways to do this 70 x 0.5 = 35, round to 36 for ease of dosing REMEMBER, you are concerned not only for inpatient compliance (taking into account nursing and staff (LAB) issues), There are many ways to do this 70 x 0.5 = 35, round to 36 for ease of dosing

26. Twice Daily Dosing So, you need to know what type of insulin covers what meal/time of day, so that when BG are low/high at different points of the day, you can adjust the insulin (more later) So, you need to know what type of insulin covers what meal/time of day, so that when BG are low/high at different points of the day, you can adjust the insulin (more later)

27. Three Times per day Generally not used if NPO Useful if experiencing fasting hyperglycemia 2/3 in AM, of which 2/3 NPH, 1/3 Regular 1/6 before evening meal, all Regular 1/6 as NPH at bedtime 70 kg patient at 0.5 Units/kg/day 24 Units in AM; 16 NPH, 8 Regular 6 Units Regular before evening meal 6 Units NPH at bedtime

28. Three Times per day

29. Four Times per day Two options NPH and Regular � of total daily dose as Regular before Breakfast, Lunch and Dinner � of total daily dose as NPH before bedtime Ultra Short and Long (peakless) Acting 1/6 of total daily dose as Ultra short before Breakfast, Lunch and Dinner (3 x 1/6 = 3/6 = 50% of total daily dose) 1/2 (50%) of total daily dose given as long acting (ie Lantus) before bedtime. REMEMBER, Regular insulin needs to be given 30-45 minutes before a meal IF NPO for a long period of time, NPH should not be used , OK to use if preop NPO (remember, if NPO, cut total daily dose by 50%) REMEMBER, Regular insulin needs to be given 30-45 minutes before a meal IF NPO for a long period of time, NPH should not be used , OK to use if preop NPO (remember, if NPO, cut total daily dose by 50%)

30. Four Times per day PATIENTS who are NPO should not receive Ultra short acting insulin , can either be converted to Regular Insulin every 6 hours or Glargine can be used alone. PATIENTS who are NPO should not receive Ultra short acting insulin , can either be converted to Regular Insulin every 6 hours or Glargine can be used alone.

31. Which One to Use? Things to remember Insulin Na�ve or Resistant? Hx of Hypoglycemic Episodes Home dose? Patient NPO? � Don�t use TID or Ultra short Easy of administration and management i.e. Can you adjust the dose, and are your orders able to be followed (Can the patient get the Regular insulin 45 minutes before their meal) I think the four daily offers mimicks the physiologic response the best, and may be the easiest to adminsiter � see next slide i.e. Can you adjust the dose, and are your orders able to be followed (Can the patient get the Regular insulin 45 minutes before their meal) I think the four daily offers mimicks the physiologic response the best, and may be the easiest to adminsiter � see next slide

32. Blue line is physiologic Insulin release � notice how there is ALWAYS a basal insulin amount in our system!!!!! Blue line is physiologic Insulin release � notice how there is ALWAYS a basal insulin amount in our system!!!!!

33. Phsyiologic Insulin. Phsyiologic Insulin.

34. Adding a sliding scale (what?) How do we correct for preprandial hyperglycemia? We use a SLIDING SCALE!!! Rules Only given with meals Do not use at bedtime or at 3am Use the same type of short acting as your SCHEDULED short acting Add this to the amount of your SCHEDULED short acting Do not use at bedtime or at 3am ? to prevent Hypoglycemia Use the same type of short acting as your SCHEDULED short acting ? ie if using Regular, SSI will be regular, if using Novolog, use novolog Do not use at bedtime or at 3am ? to prevent Hypoglycemia Use the same type of short acting as your SCHEDULED short acting ? ie if using Regular, SSI will be regular, if using Novolog, use novolog

35. Adding a sliding scale Different Methods Based on a % of the Total Daily Schedule Insulin Based on Insulin Resistance

36. Adding a Sliding Scale 5% of the Total Daily Scheduled Insulin (eg pt requiring 100 Units per day) 70- 150 Schedule only 151-200 5 Units (ie 5% of 100) 201-250 10 Units 251-300 15 Units Etc.

37. Adding a sliding scale<= 40 Units per day 40-80 Units per day > 80 Units per day Based on Insulin Resistance. Based on Insulin Resistance.

38. Case Example 70 y/o WM Hx of CAD, COPD, DM-2, HTN and obesity Admitted for Recurrent Pneumonia Current Meds: Metoprolol, Metformin 1000mg BID, Glyburide 5 mg daily, ASA, Lisinopril VS � T 100.1, B/P 150/90, P 90, RR 24, Wt 250 lbs, Ht 5�8� Physical: Early peripheral neuropathy, no retinopathy LABS: WBC 15K, BG 250, HgA1c (3 months ago) 8.2 Cr 1.4 (baseline), BUN 28, Alb 2.7

39. Case continued History � what else do you want to know? Diet at home �I eat whatever I want!� Recent change in medications? Glyburide was just added one month ago Hx of hypoglycemic episodes? NO Medication Compliance? �I take whatever the give me� Recent BG at home? When does he check? Creatinine Clearance? Glyburide was just added one month ago � maybe his control is better Hx of hypoglycemic episodes? NO -- espiecially with Glyburide Medication Compliance? �I take whatever the give me� � It is useful to ask patients when / how often they take certain medications, most rely on a list � look at the list � is it up to date? Recent BG at home? When does he check? Has there been an improvement on Glyburide, does he check fasting appropriately, post-prandial (2 hours after eating) Creatinine Clearance = MDRD = 44 � stop the glyburide Glyburide was just added one month ago � maybe his control is better Hx of hypoglycemic episodes? NO -- espiecially with Glyburide Medication Compliance? �I take whatever the give me� � It is useful to ask patients when / how often they take certain medications, most rely on a list � look at the list � is it up to date? Recent BG at home? When does he check? Has there been an improvement on Glyburide, does he check fasting appropriately, post-prandial (2 hours after eating) Creatinine Clearance = MDRD = 44 � stop the glyburide

40. ORDERS Meds to stop BG monitoring Insulin orders Wt in Kg Insulin Dosing Insulin resistant vs. Insulin Naive? QID dosing Sliding scale

41. Four Times per day Two options NPH and Regular � of total daily dose as Regular before Breakfast, Lunch and Dinner � of total daily dose as NPH before bedtime Ultra Short and Long (peakless) Acting 1/6 of total daily dose as Ultra short before Breakfast, Lunch and Dinner (3 x 1/6 = 3/6 = 50% of total daily dose) 1/2 (50%) of total daily dose given as long acting (ie Lantus) before bedtime. REMEMBER, Regular insulin needs to be given 30-45 minutes before a meal IF NPO for a long period of time, NPH should not be used , OK to use if preop NPO (remember, if NPO, cut total daily dose by 50%) REMEMBER, Regular insulin needs to be given 30-45 minutes before a meal IF NPO for a long period of time, NPH should not be used , OK to use if preop NPO (remember, if NPO, cut total daily dose by 50%)

42. ORDERS 250 lb = 114 kg Total Daily Dose of Insulin 114kg x 0.3 Units/kg/Day = 34 Units/Day QID (Lantus and Lispro) 5.6 ?5 Units Lispro before each meal 17 Units Lantus at HS Sliding Scale � 5% of total daily dose as a scale REMEMBER � to write same hypoglycemia orders � ie � amp of D50 IV or juice snack if BG < 70. REMEMBER � to write same hypoglycemia orders � ie � amp of D50 IV or juice snack if BG < 70.

43. Adding a Sliding Scale 5% of the Total Daily Scheduled Insulin (eg pt requiring 34 Units per day) 70- 150 Schedule only 150-200 1.7->2 Units (ie 5% of 34) 201-250 4 Units 251-300 6 Units Etc.

44. Goals of Treatment Glycemic Control � upper limits Intensive Care � 110 mg/dL Non-Critical Care Preprandial 110 mg/dL Post-Prandial / MAX � 180 mg/dl American College of Endocrinology. Position Statement on Inpatient Diabetes and Metabolic Control. Endocr Pract 2004; 10:77-82

45. Diabetes as an Active Issue Which dose would you change if: His AM fasting glucose was 250? His 11 AM sugar is 250? Rapid Acting: 1800/TDD = drop in BG (mg/dL) per Unit of short acting insulin given To drop the 11 AM sugar to 180, you would give: 1800/34 = 70/x ?x = (70x34)/1800 = 1.3 Units Regular: 1500/TDD = drop in BG (mg/dL) per Unit of regular insulin given His AM fasting glucose was high? Would you check a 3AM sugar first? His 11 AM sugar is 220? How much drop in the BG per Unit of insulin? His AM fasting glucose was high? Would you check a 3AM sugar first? His 11 AM sugar is 220? How much drop in the BG per Unit of insulin?

46. Four Times per day Look at which insulin covers which time frame Long acting covers all day and fasting (thus if all sugars are up, consider increasing basal dose, consider changing Dose � 0.3 ? 0.6 U/kg/Day Short acting - AM covers breakfast post prandial Noon covers lunch post-prandial Dinner covers Bedtime Look at which insulin covers which time frame Long acting covers all day and fasting (thus if all sugars are up, consider increasing basal dose, consider changing Dose � 0.3 ? 0.6 U/kg/Day Short acting - AM covers breakfast post prandial Noon covers lunch post-prandial Dinner covers Bedtime

47. A Word On Dietary Orders �ADA Diet� is a misnomer Caloric Restriction vs. Consistent Carbohydrate Method Caloric Needs Avg hospitalized pt: 25-35 kcal/kg/day 1.0-1.5 g/kg of protein (unless Hepatic/Renal insufficiency) �ADA Diet� is a misnomer � the ADA has not recommended a specific diet for over one decade Caloric Restriction vs. Consistent Carbohydrate Method � We calorically restrict patients, but are we really controlling Carbohydrates, which affect BG the most The Consistent Carbohydrate method = consistent amounts of carbs day to day at breakfast, lunch, dinner, snacks, BUT breakfast not = to lunch, not = to dinner ? this hasn�t gained widespread use yet Pt should receive approx 50% of calories from Carbs, 20% from protein, 30% from fat. �ADA Diet� is a misnomer � the ADA has not recommended a specific diet for over one decade Caloric Restriction vs. Consistent Carbohydrate Method � We calorically restrict patients, but are we really controlling Carbohydrates, which affect BG the most The Consistent Carbohydrate method = consistent amounts of carbs day to day at breakfast, lunch, dinner, snacks, BUT breakfast not = to lunch, not = to dinner ? this hasn�t gained widespread use yet Pt should receive approx 50% of calories from Carbs, 20% from protein, 30% from fat.

48. A Word On Dietary Orders Clear or Full Liquid Diets At least 200g of Carbohydrates divided in equal doses Low or no sugar diets are not acceptable Prompt Dietary consultation is recommended Remember D/C planning Low or no sugar diets are not acceptable � Unnecessarily restricts Sucrose, and simply restricting sucrose does not lead to better glycemic control Remember D/C planning == if a pt eats a regular diet at home, we should be conscious of this if we have restricted his diet during hospitalization. Low or no sugar diets are not acceptable � Unnecessarily restricts Sucrose, and simply restricting sucrose does not lead to better glycemic control Remember D/C planning == if a pt eats a regular diet at home, we should be conscious of this if we have restricted his diet during hospitalization.

49. Inpatient Education Let your patient know what you have changed Educate on Symptoms of hypoglycemia Dietary Consultation Insulin education if new or different dose Close f/u as out-patient

50. D/C Planning Try to have the patient on what will be his home medications / diet for at least 24 hours prior to D/C Close out-pt f/u Referral to Diabetes and Nutrition Any admission with diabetes as an active issue qualifies Medicare for referral.

51. Goals Review ADA goals for blood glucose levels Importance of maintaining euglycemia Discuss why ISS is not acceptable for sole coverage Give options for insulin regimens Discuss inpatient education Discharge planning

52. References Abourizk, N., Inpatient Diabetology:The New Frontier, Journal General Internal Medicine, 19:466-471 American Diabetes Association, Translation of the Diabetes Nutrition Recommendations for Health Care Institutions, Diabetes Care 25: S1, S61-63 American Diabetes Association, American College of Endocrinology and American Diabetes Association Consensus Statement on Inpatient Diabetes and Glycemic Control, Diabetes Care, 29:1955-1962, 2006. Bloomgarden, Z., Inpatient Diabetes Control: Approaches to Treatment, Diabetes Care, 27:9, 2272-2277 Lien, L. In-hospital Management of Type 2 Diabetes Mellitus, Med Clin N Am, 88 (2004): 1085-1105 Moghissi, E, et. al, Hospital Management of Diabetes, Endocrinol Metab Clin N Am, 34 (2005): 99-116 Swift, C, et. al, Nutrition Care For Hospitalized Individuals with Diabetes, Diabetes Spectrum 18:1, 34-38