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Inpatient Management of Diabetes

Armed Forces Academy of Medical Sciences. Inpatient Management of Diabetes. Which diabetic medication regimen does ADA, AACE and endocrine society recommend for non-ICU inpatients?. Insulin sliding scale Basal/bolus insulin Basal insulin alone Oral hypoglycemics.

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Inpatient Management of Diabetes

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  1. Armed Forces Academy of Medical Sciences Inpatient Management of Diabetes

  2. Which diabetic medication regimen does ADA, AACE and endocrine society recommend for non-ICU inpatients? • Insulin sliding scale • Basal/bolus insulin • Basal insulin alone • Oral hypoglycemics

  3. Which diabetic medication regimen do most hospital in America use for their non-ICU inpatients? • Insulin sliding scale • Basal/bolus insulin • Basal insulin alone • Oral hypoglycemics ~60% of inpatients receive an ISS alone (Schnipper, 2006)

  4. The problem • Schnipper et al reviewed inpatients on general medicine services with DM or hyperglycemia

  5. The problem • Knecht et al in 2006 reviewed inpatients of diabetics • 11% had a FS of < 70 • 71% had a FS >200 • Only 34% had adjustments in their insulin regimens

  6. What effect does new hyperglycemia have on inpatients? • Shorter lengths of stay • Increased risk of mortality • Higher ICU admission rates • Fewer dispositions to transitional care or nursing home

  7. Effect of Blood Glucose on Outcomes In Non-ICU Inpatients • Umpierrez et al in 2002 reviewed 2030 adults (p<0.01)

  8. Umpierrez, 2002

  9. Effect of Blood Glucose on Outcomes In Non-ICU Inpatients • Kosiborod et al in 2009 reviewed 7820 patients with an MI and hyperglycemia

  10. Effect of Blood Glucose on Outcomes In Non-ICU Inpatients • Pomposelli et al in 1998 • A prospective observation • 100 diabetics undergoing elective surgery • Patients with a glucose > 220 on POD1 had a 2.7 times risk for infection (31.3% vs 11.5%) • Excluding minor UTI’s, the risk of more serious infections was 5.7 times as high

  11. Effect of Blood Glucose on Outcomes In Non-ICU Inpatients • McAlister et al in 2007 prospectively observed 2,471 patients admitted for CAP • 279 had glucose levels >198mg/dl

  12. Which diabetic medication regimen do most WRNMMC teams use for their non-ICU inpatients? • Insulin sliding scale • Basal/bolus insulin • Basal insulin alone • Oral hypoglycemics

  13. State of the Union • Inpatient insulin order set • DM training • Meal times • Insulin times • Order writing

  14. WRNMMC insulin order set

  15. Which is in accordance ADA and AACE about inpatient glycemic control? • Uncontrolled hyperglycemia is NOT associated with poor outcomes • Train nurses and doctors about glucose management as it is cost effective • Using IV insulin drips in all medical wards is recommended • Glucose management is NOT a quality of care and safety issue

  16. What person is DC named after? • Christopher Columbus

  17. What is the target blood glucose for inpatients according to ADA, AACE and Endocrine Society? • 40-60 • 80-120 • 140-180 • 200-300

  18. RABBIT 2 Table 2 Baseline Characteristics

  19. RABBIT 2 Glargine/Glulisine Group • For FS of 140-200, got a total daily insulin (TDI) of 0.4units/kg • For FS of 200-400, got a total daily insulin (TDI) of 0.5units/kg • When NPO, continued glargine was but held prandialglulisine • Increase glargine by 20% if fasting and premeal FS were >140 • Decreased glargine by 20% for FS < 70 • Adding sliding scale insulin for FS >140

  20. RABBIT 2 Table 1 ISS

  21. RABBIT 2 Trial Results • 66% of the basal/bolus group achieved a finger stick (FS) of <140 • 38% of the ISS group achieved a FS of <140 • Mean TDI for basal/bolus: 42 units • Mean TDI for ISS: 12 units • 2 patients on ISS had a FS <60 but not <40 • 2 patients basal/bolus had a FS <60 but not <40

  22. RABBIT II Fig 1: basal/bolus with lower mean FS

  23. RABBIT II Fig 2: Refractory Hyperglycemia on ISS Improved with Basal/Bolus

  24. What is the average annual rainfall in DC? • 39 inches of rainfall a year • more than Seattle

  25. RABBIT 2 Surgery • When NPO, held prandial insulin and continued glargine • If mean FS >240 or FS>240 3 times consecutively, changed from ISS to basal/bolus • Patients returned to endocrine clinic for a 1 month follow up

  26. RABBIT 2 Surgery Results Table 1 Average TDI 12 units 45 units p<0.001 Mean Fasting FS 165 155 p=0.37 Mean Daily FS 176 157 p<0.001 Mean FS after 1 day of treatment 172 157 p<0.01 Wound infection rate 30.8% 7.5% p=0.027

  27. RABBIT 2 Surgery Results Fig 1 Lower mean FS in basal/bolus than ISS Pre-meal FS lower in basal/bolus than ISS

  28. RABBIT 2 Surgery Table 2: Surgical Complication Results

  29. RABBIT 2 Surgery Table 3: Hypoglycemia

  30. RABBIT 2 Surgery Results • 193 started insulin the day of or day after surgery • Mean FS: 166.7 • Hypoglycemia: 14% • 18 started insulin prior to surgery • Mean FS: 163.9 (NS, p=0.93) • Hypoglycemia: 11.1% (NS, p>0.99)

  31. DiNardo, 2011: basal 50% and correction insulin for same day surgery

  32. In the Western Hemisphere where is the only Leonardo da Vinci painting? Washington DC, National Gallery of Art is home to the Ginevra de Benci

  33. Effectiveness of a Computerized Insulin Order Template in General Medicine Inpatients with DMII • Wexler et al, 2010 • 7 general medicine teams • Randomized to a basal/bolus computerized calculator vs usual care • Instructions recommended a TDI of 0.5units/kg

  34. Computerized Insulin Order Template

  35. What helps reduce errors in insulin management? • Electronic protocols • Insulin order sets • Administrative support for insulin management improvement • Method of collecting point of care blood glucose results • All of the above

  36. Teaching: Home to Hospital • Diet controlled T2DM with FS<140: monitor FS for 24-48 hrs to assess insulin needs • T2DM on non-insulin diabetic medis: change to insulin upon admission  • T2DM on outpatient insulin: continue insulin inpatient and adjust dose PRN

  37. Teaching: Estimating Starting TDI • GFR <15 and/or age>70: TDI is ~0.2 units/kg • GFR 15-30: TDI ~ 0.3 units/kg • Insulin sensitive patient, TDI ~ 0.4units/kg • Insulin resistant patient, TDI 0.5 units /kg to 1 unit/kg or higher.

  38. Teaching: Determining Basal and Bolus Doses • Basal dose of insulin • Long acting insulin • TDI/2 • When NPO: give 50% and start D5W at ~50ml/hr • Bolus insulin • GIVE WITH MEAL AT BEDSIDE • Short acting insulin • basal dose/3 • hold when NPO

  39. Teaching: Correction Factor • Correction Factor : 1800/TDI • Give in same injections as bolus dose • Give correction factor insulin starting at a FS of 150 during the day • Give half the correction factor at bedtime starting at a FS of 200 • Continue when NPO

  40. Teaching: Adjusting Insulin • For FS <100, reduce the TDI by 10% • For FS <70, reduce the TDI by 20% (Endo soc, unpublished) • For fasting FS persistently >180, increase the TDI by 10% • For fasting FS persistently >200, increase the TDI by 20%

  41. 60 y.o. T2DM who takes metformin 1g BID, glipizide 10mg BID and piogltiazone 15mg daily at home gets admitted for a CHF exacerbation. His FS upon admission is 190 and weight is 70kg. He is tolerating food and you decide to feed him. How do you manage his T2DM? • Hold PO DM meds • TDI = 28 • Glargine 14 units QHS • Novolog 4 units TID with meals • Correction factor 64 ~ 60

  42. You later decide he needs a cardiac catheterization and make him NPO. How do you adjust his DM meds? • Decrease glargine to 7units • Start D5W @ 50ml/hr • Hold mealtime insulin • Continue correction factor at 60

  43. He does well with his cath. You re-start his diet, glargine 14units and novolog 4units. His blood sugars are now ranging 200-300. How do you adjust his insulin? • Increase TDI by 20% (28 x 1.2 = 34) • Glargine 17 units QHS • Novolog 6units TID with meals • Correction factor 53 ~ 50

  44. Which medications change blood glucose? • Steroids • Octreotide • Beta blockers • Quinolones • All of the above

  45. What reduces the risk of hypoglycemia and hyperglycemia? • Changing diet to NPO • Adding TPN • Adding steroids • Lack of insulin adjustments • Prolonged ISS use • Proper correlation of FS testing with meals and insulin administration • Sulfonylurea use in the elderly or CKI • Errors in order writing ADA/AACE 2009

  46. Insulin Regimen Order Set

  47. Insulin Regimen Order Set

  48. Insulin Regimen Order Set

  49. What is the best way to teach primary teams to manage DM inpatient ?

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