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Stepwise approach to inpatient diabetes management

Stepwise approach to inpatient diabetes management. Erin Keely. At the Ottawa Hospital: (From Test Strip Usage). On any given day, 250-300 patients admitted to Ottawa Hospital have diabetes (25-30%)!. Impact of Diabetes on Length of Stay – The Ottawa Hospital.

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Stepwise approach to inpatient diabetes management

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  1. Stepwise approach to inpatient diabetes management Erin Keely

  2. At the Ottawa Hospital:(From Test Strip Usage) On any given day, 250-300 patients admitted to Ottawa Hospital have diabetes (25-30%)!

  3. Impact of Diabetes on Length of Stay – The Ottawa Hospital Compiled by S. Brez, APN Endocrinology and Metabolism

  4. Increasing information on diabetes and cancer

  5. Hyperglycemia in the Hospitalized Patient: Classification Diabetes Previously Diagnosed – type 1 or type 2 Previously Undiagnosed Confirmed after discharge Secondary diabetes (glucocorticoids) Hospital-related hyperglycemia Reverts to normal after discharge

  6. Glycemic Targets in Hospitalized Patients Medical/surgical floors 6.1 -10.0 mmol/L Increase risk of infection if glucose > 12 mmol/l Glucosuria if >16-18 mmol/l

  7. Potential Benefits of Improving Glucose Control in the Hospital Reduce mortality Reduce morbidity Reduce costs of care Length of stay (LOS) Cost of inpatient complications Fewer rehospitalizations

  8. Goals of Inpatient Diabetes Management Avoid Hypoglycemia Avoid Hyperglycemia Assessment of Patient’s diabetes care Assessment of Risk Factors

  9. Common Errors in Inpatient Glucose Management • Admission orders • Withdrawal or outpatient treatment regimen • Failure to modify outpatient regimen • Overly high glycemic targets • Lack of therapeutic Adjustments • Overuse of Sliding Scale!!!! • Overuse of Sliding Scale!!!! • Overuse of Sliding Scale!!!!

  10. Classification of oral agents • Insulin secretagogues • Sulfonylureas • Diabeta, diamicron (regular and MR) • Amaryl • Meglitinides • Gluconorm • Starlix • Insulin sensitizers • Metformin • Glitazones • Actos • Avandia • Incretins • DPP-4 inhibitors • GLP-1 analogues • CHO absorption • acarbose

  11. Principles of InPatient Diabetes Management • Type 1 different than type 2 • Be safe • Be proactive • Try to continue pre-admission treatment • Unless NPO or decreased intake • HgbA1c> 8.0 – 10 % • Glucose > 10-12 mmol/L • Frequent hypoglycemia

  12. Types of Insulin • Two main manufacturers • Novolin, Humulin • duration of action • rapid aspart, lyspo, apidra • short regular (toronto) • intermediate NPH, lente • Very long glargine, detemir

  13. Action Profiles of Bolus & Basal Insulins lispro/aspart 4–6 hours • BOLUS INSULINS • BASAL INSULINS regular 6-10 hours NPH 12–20 hours detemir ~ 6-23 hours (dose dependant) Plasma Insulin levels glargine ~ 20-26 hours Hours Note: action curves are approximations for illustrative purposes. Actual patient response will vary. Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

  14. Expected insulin changes during the day for individuals with a healthy pancreas. Basal-Bolus Approach therapy addresses: Basal needs: Glargine, Detemir, NPH Bolus needs: Lispro, Aspart Meal Meal Meal *Insulin effect images are theoretical representations and are not derived from clinical trial data.

  15. Principles of insulin managment • “Usual” = Proactive • Basal • NPH • Levemir • Lantus • Meal-time • Regular • Novorapid • Humalog • Pre-mixed • “Corrective” = Reactive • sliding scale • Amount depends on insulin sensitivity • One size does not fit all!! • Use same type of insulin as meal-time

  16. So What to Do??

  17. Diabetes Pocket Card

  18. Is patient on diet/oral agents/insulin Is patient going to eat, be NPO, tube/parenteral feeds Look at glucose trends and adjust

  19. Patient with Diet controlled diabetes Order: Blood glucose monitoring QID Consider doing a HgbA1c Consider oral hypoglycemic agent or insulin if blood sugars in hospital persistently >11.0 mmol/L

  20. Patient with diabetes on oral hypoglycemic agents Continue oral agents Caution if on metformin or actos (pioglitazone) and renal, cardiac or hepatic dysfunction If blood sugars persistently >10.0 mmol in hospital: Step 1: maximize oral agents, add another oral agent (from a different class)  Step 2: if not at target, add insulin

  21. Do not use • Metformin: • If congestive heart failure • If renal failure • If requiring a test with IV contrast dye • Thiazolidinediones • If Congestive Heart Failure

  22. How to start Insulin • Discontinue oral agents except metformin • Corrective sliding scale alone(if temporary) – if needs >8-10 units for longer than 48 hrs, consider starting “usual” insulin • Start “usual insulin” • basal – 0.2-0.3 u/kg/day (either NPH split ac breakfast and supper) or levemir/lantus qhs • Mealtime – 0.1-0.2 u/kg/day (breakfast and supper if using NPH, all 3 meals if levemir/lantus) • Continue corrective scale

  23. Why don’t sliding scales work? • Action is Retrospective not Prospective • Higher risk of Hyper and Hypoglycemia • Threshold for insulin administration may be too high • Sliding scales can be useful and effective if used appropriately (I.e. as supplemental insulin only) • Same amounts given if eating meal or not

  24. How to Use Sliding Scale Insulin • Sliding scale insulin can be effective IF used appropriately • Never use sliding scale alone (unless for 1 to 2 days to get idea of insulin requirements) • Should be used in addition tooral agents or long acting insulin • NEVER NEVER NEVER use sliding scale alone in patient with TYPE 1 DIABETES

  25. Choosing a sliding scale

  26. Correction Insulin X X Total Daily Insulin Dose = Lantus 40 units + Novorapid 5 with meals = 40 units + 5 units x B, L, D = 55 units

  27. How do I change the scale? If patient hyperglycemic and needs more insulin, choose scale to the RIGHT If patient hypoglycemic and needs less insulin, choose scale to the LEFT

  28. Patient on Insulin Determine if patient is Type 1 or Type 2!! If unsure treat as type 1 (i.e. needs insulin all of the time) NEVER put a patient with type 1 Diabetes on sliding scale alone even if not eating Insulin requirements may be more or less than as required as outpatient Likely needs long-acting insulin (unless Type 2 and sugars are excellent without it)

  29. Patient on Insulin Order Blood glucose monitoring QID Continue outpatient regimen unless contraindicated (patient not eating, Type 1 with DKA, etc..)

  30. Patient on insulin and eating • If HgbA1c < 8, continue preadmission • If HgbA1c > 8, or CBG > 10 • Start usual insulin • Use corrective scale • Adjust based on glucose pattern

  31. Dosage Titration Practical Example 1. First adjust insulin that caused the low blood glucose • 2. Then adjust insulin that caused first high BG of the day

  32. Pre-opGoal Blood sugar 6-10 mmol Start IV D5W at 75 to 100 cc/hour Previously on oral agents/diet Hold oral agents if not eating No basal insulin No meal-time insulin Corrective scale only Previously on insulin 1/2 – 2/3 usual basal insulin No meal-time insulin Corrective scale

  33. NPO Patient with Diabetes on Oral Agents • Hold oral agents: • Humalog or NovoRapid sliding scale may be added q 4-6 h in case of hyperglycemia: • Note: 1 unit of humalog usually decreases blood sugar by 2 to 3 mmol/L OR • IV Insulin

  34. NPO Patient with Diabetes on Insulin (2+ shots/day) • Option 1: IV Insulin OR • Option 2: Subcutaneous Insulin:

  35. NPO Patient with Diabetes on Insulin (2+ shots/day): SC insulin option • Order 70-80% of long acting insulin (will need for basal insulin requirements) • Add sliding scale to control marked hyperglycemia • Remember to order IV D5W to prevent catabolism

  36. Patient with Diabetes on Feeds IF feeds are continuous, no previous insulin: Put patient on basal insulin 0.3-0.4 units/kg/day Lanuts qhs or NPH q. 12 h Use corrective scale If feeds stopped suddenly start D5W at 100cc/hr! IF feeds are continuous, previous insulin: 2/3 usual basal insulin No meal-time insulin Use corrective scale If feeds stopped suddenly start D5W at 100cc/hr!

  37. IF getting bolus feeds: • Basal- 0.2 u/kg/day or 2/3 usual basal • Give meal-time insulin before bolus feed (3-4 units rapid insulin before 250 cc feed) • If feeds stopped suddenly start D5W at 100cc/hr!

  38. Patient on TPN 2 options: Insulin included in TPN Subcutaneous insulin if needed Start long-acting insulin at time when has TPN running (i.e. if receives overnight, start NPH when feeds start and titrate up)

  39. How to control glucose levels on TPN • Very poorly studied • In the TPN bag or subcutaneous? • If subcutaneous • 0.3-0.4 units/kg/day • NPH q. 12 hr • levemir/lantus q. 12 or 24 hr • regular q. 6 h • rapid q. 4 h • If in TPN bag • 0.1 units regular/gm of CHO plus s.c. sliding scale • 3-6 gm/kg/day dextrose = 210-420 gm 50% dextrose = 21-42 units insulin in 24 hr supply • Next day add 80% of insulin given as sliding scale to insulin bag

  40. Assess Blood Glucoses at Daily, Adjusting Insulin Doses as Appropriate Blood glucose targets can only be achieved via continuous management of the insulin program There is no “autopilot” insulin regimen for a hospitalized patient!

  41. Pre-Printed Insulin Orders

  42. X 2 X

  43. 40 X 3 3 3 X

  44. X X X

  45. Consult Diabetes Specialty Team – RN +/- MD Insulin pump Severe or frequent hypoglycemia Poorly controlled prior to admission (eg. HbA1c>10%) Unrecognized diabetes complications IS BEING D/C ON INSULIN AND WAS NOT ON INSULIN PRIOR TO ADMISSION – and PLEASE, not on day of d/c!!

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