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Correction Insulin for Inpatient Hyperglycemia

Correction Insulin for Inpatient Hyperglycemia. Estelle Lin June 2012. Case Vignette.

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Correction Insulin for Inpatient Hyperglycemia

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  1. Correction Insulin for Inpatient Hyperglycemia Estelle Lin June 2012

  2. Case Vignette 45 year old obese female with DM type II is admitted for acute nausea, vomiting, and epigastric pain. CT Abdomen with IV contrast demonstrates acute pancreatitis. Her diabetes is usually controlled on metformin 1000mg BID and glyburide 10mg BID. Admission BMP shows a random glucose of 240. How do you manage her hyperglycemia? A. Continue home regimen • Continue home glyburide and discontinue metformin • Start sliding scale insulin • Start correction insulin

  3. Learning Objectives • Appreciate difference between sliding scale insulin vs correction insulin • Understand optimal glycemic control goals in ICU vs non ICU settings • Review the pharmacokinetics of different insulin preparations • Learn how to use correction insulin and initiate insulin therapy on UCI wards

  4. The problem with sliding scale insulin Typical day battling hyperglycemia • Sliding Scale Insulin • - Treats hyperglycemia with only short/rapid acting insulin without long-acting basal insulin • Reactive therapy given AFTER meal • Treats current hyperglycemia, does not prevent future hyperglycemia • Can cause large swings in glucose levels throughout day

  5. Correction Insulin • Correction Insulin • It is both a concept AND includes a correction scale insulin • Treats current hyperglycemia with the goal of preventing further hyperglycemic events during the hospital course • Administer correction scale insulin BEFORE the meal using a rapid or short acting insulin • For patients already receiving scheduled rapid acting insulin AND scheduled long acting insulin, this is an additional correction scale to treat hyperglycemia • For patients whose primary oral anti-hyperglycemic therapy has been discontinued, this is the initiation of a correction scale to control hyperglycemia and if needed, the initiation of long acting insulin

  6. A better day when using correction insulin Sliding scale: 34 units of rapid/short acting insulin administered Correction scale: 18 units of rapid/short acting insulin Remember, it is the concept of correction insulin we want to practice. If this patient remains hyperglycemic, initiate longer acting insulin therapy

  7. AACE/ADA Consensus Statement on Management of Inpatient Hyperglycemia

  8. Rapid (Prandial, Bolus) Short (Prandial, Bolus) Intermediate (Basal) Long (Basal)

  9. Correction Insulin Tips

  10. Current UCI Glycemic Monitoring Protocol UCI is aggressively pursuing the concept of correction insulin and preventing hyperglycemia. Many more patients will be initiated on insulin therapy When to pursue insulin therapy • All DM I • Most DM II receiving medication treatment • Uncontrolled hyperglycemia > 180 (2 episodes in 24 hours) • If unsure, then monitor qAC/qHS glucose monitoring for 24 hours and then continue if BG > 180

  11. How to Initiate Insulin Therapy (if not already on insulin OR if uncontrolled diabetes)

  12. Correction Scale with Meals

  13. Insulin Dose Adjustment for CKD • No dose adjustment if GFR >50 • Use 75% of baseline insulin dose if GFR 10-50 • Use 50% of baseline insulin dose if GFR <10 Example: At home takes 40 units of glargine qHS If GFR 30: give 30 units of glargine qHS If GFR <10: give 20 units of glargine qHS

  14. Long Beach VA Guidelines on Adjustment of Insulin • If glucose above target, increase insulin doses by 10-20% (2-5 units) every 1-2 days • Once patient clinically stable on insulin regimen, d/c correctional insulin and check glucose 2 hours after meals (target BS <150 two hours after a meal) How to Adjust: Patient on NPH/Regular insulin regimen • If fasting glucoses elevated, increase evening NPH • If pre-lunch or 2 hr post breakfast elevated, increase AM pre-breakfast regular • If pre-dinner or 2 hr post lunch elevated, increase AM NPH • If bedtime or 2 hr post-dinner elevated, increase pre-dinner regular • May need bedtime snack once glucoses are well controlled

  15. Long Beach VA Guidelines on Adjustment of Insulin Patient on Lantus with Regular/Aspart insulin: • If fasting elevated, increase Lantus • If pre-lunch or 2 hr post breakfast elevated, increase pre-breakfast regular/Aspart • If pre-dinner or 2 hr post lunch elevated, increase pre-lunch regular/Aspart • If bedtime or 2 hr post-dinner elevated, increase pre-dinner regular/Aspart • If all glucoses elevated, may need to increase all insulins

  16. Case Vignette 45 year old obese female with DM type II is admitted for acute nausea, vomiting, and epigastric pain. CT Abdomen with IV contrast demonstrates acute pancreatitis. Her diabetes is usually controlled on metformin 1000mg BID and glyburide 10mg BID. Admission BMP shows a random glucose of 240. How do you manage her hyperglycemia? A. Continue home regimen • Continue home glyburide and discontinue metformin • Start sliding scale insulin • Start correction insulin

  17. Case Vignette Answer: D • Answers A and B incorrect because patient likely to be NPO • Answer C, sliding scale insulin is no longer in favor. CORRECT ANSWER(S) Option 1: Initiate insulin therapy (basal, prandial, corrective scale) on admission Option 2: Start q6 accuchecks with correction scale (regular insulin is commonly used). Correct BS per Aggressive Regimen since is obese DM type II BS 160-200 – 4 units BS 201-250 – 6 units, etc. If BS is still >180 after 1-2 days, then initiate longer insulin therapy (basal, prandial, corrective scale). Note Option 2 less preferable because random BS>180 and requires high doses of PO meds already so odds are she will have uncontrolled hyperglycemia

  18. Last Question 55 year old male with DM I comes from with cough and fevers with poor PO intake. Admitted for treatment of pneumonia. He normally takes 20 units glargine qHS and 6 units aspart with each meal. How would you manage his blood sugar? A. Continue home regimen • Give 10 units glargine qHS and 2 units aspart qAC • Give home glargine dose only • Give home aspart doses only

  19. Correct Answer is B Patient likely can eat, albeit he may eat less in setting of illness and restrictive hospital diets. He is DM type I so he needs continuous insulin coverage. The safest option is to decrease his insulin doses by 25-50% and monitor. His goal BS is a FBG <140 and random BS <180. If he continues to experience hyperglycemia, then do the following. • Basal insulin: uptitrate the glargine or redose based on a TDD of 0.3units/kg/day • Prandial insulin: uptitrate the aspart or re-dose based on a TDD of 0.3 units/kg/day • Initiate correction scale: Give additional aspart for BS >160.

  20. Take Home Points • Correction insulin is a concept to prevent hyperglycemia. It may include the initiation of insulin therapy (basal insulin, prandial insulin, AND correction scale) • Correction scale insulin is given before a meal, whereas sliding scale insulin is given after a meal • Avoid hypoglycemia. A safe inpatient BS goal is no lower than 100 • Avoid severe hyperglycemia. A good target is a random BS <180 • Reassess insulin needs after any change in nutritional status (NPO, PO, tube feeds)

  21. Easy self-directed learning materials • American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Diabetes Care June 2009 32(6) 1119 • Intensive insulin therapy in critically ill patients. NEJM 2001; 345(19): 1359 • Management of Hyperglycemia in the Hospital Setting. Inzucci et al. NEJM 2006; 355: 1903-1911 • The Nice-Sugar study investigators: Normoglycemia in Intensive Care Evaluation Survival Using Glucose Algorithm Regulation Intensive vs conventional glucose control in critically ill patients. NEJM 2009; 360:1283 • UpToDate “Management of DM in hospitalized patients” and “General Principals in Insulin Management.” Accessed on June 11, 2012. • UCI Inpatient Glycemic Monitoring and Treatment Guidelines. 2012

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