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Inpatient Glycemic Management

Inpatient Glycemic Management. Shruti Scott, DO, MPH UCI Hospitalist Program July 24, 2013. Pharmacokinetics of Insulin Products. Rapid ( lispro , aspart , glulisine ) (Humalog/ Novolog /Apidra). Insulin Level. Short (regular). Intermediate (NPH). Long ( glargine ). Long ( detemir ).

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Inpatient Glycemic Management

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  1. Inpatient Glycemic Management Shruti Scott, DO, MPH UCI Hospitalist Program July 24, 2013

  2. Pharmacokinetics of Insulin Products • Rapid (lispro, aspart, glulisine) (Humalog/Novolog/Apidra) Insulin Level Short (regular) Intermediate (NPH) Long (glargine) Long (detemir) 0 2 4 6 8 10 12 14 16 18 20 22 24 Hours Adapted from Hirsch I. N Engl J Med. 2005;352:174–183.

  3. Case 1 Tom has Type 2 DM, weighs 85 kg and is admitted for diabetic foot ulcer. He takes Metformin 1000mg bid, glipizide 10mg daily at home. He has a normal GFR. His hemoglobin A1c is 10 and his blood sugars since admission have ranged 250-300. How do you manage his DM?

  4. Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: Effect of structured subcutaneous insulin orders and an insulin management algorithm Journal of Hospital MedicineVolume 4, Issue 1, pages 3-15, 12 JAN 2009 DOI: 10.1002/jhm.391http://onlinelibrary.wiley.com/doi/10.1002/jhm.391/full#fig2

  5. Case I Answer: • Tom weighs 85kg, normal GFR • Using standard, 0.4unit/kg = 34 units TDD • Lantus 17 units QAM and Lispro 5 units tid before meals • Lispro Correctional Learning Points: • Hold oral diabetes meds when inpatient (to minimize hypoglycemia and for better glycemic control) • DO NOT place diabetic patients only on Correctional Insulin • Use weight based method to get accurate insulin requirement • Adjust insulin dose for GFR: GFR > 50, no correction GFR 30-50, 20% reduction GFR < 30, 30-50% reduction

  6. Case 1 Learning Points • Each order will have 2 or 3 types of insulin: Basal - provides continuous insulin coverage to diminish BS swings Nutritional - treats the anticipated BG increase with meals Correctional - corrects current BS level • Nutritional and Correctional coverage should be the same type of insulin (both Lispro or both Regular)

  7. Case 2 Tom has Type 2 DM and was admitted for diabetic foot ulcer. Today is HD3 and his blood sugars have been stable with Lantus 22 units qhs, Humalog 5 units tid and Humalog Correctional. Tomorrow he is having a L foot amputation. How should his insulin regimen be adjusted?

  8. Case 2 Answer Choices • Hold Humalog morning dose • Cont Humalog morning dose • Hold Lantus evening dose • Decrease evening dose of Lantus • Cont evening Lantus dose • Start IVFs (NS, D5 or D10 – does it matter?) • Do nothing • Page endocrine fellow and ask him/her

  9. Case 2 Answer • Hold Humalog nutritional dose while pt is NPO • Cont evening Lantus dose (basal insulin) • Start IVFs (either D5 or D10) • Continue Humalog correctional coverage

  10. Case 2 Learning Points • Start D5 or D10 if carb source is interrupted (NPO). The infusion rate will have to take into account the patient’s general condition (CHF, cirrhosis) • Do not hold basal insulin if long acting (levemir or glargine) • 1 L of D5 1/2NS provides less calories than a small candy bar (170 calories per L) • In the Quest NPO Order Set, the number of calories (per liter IVF) is provided for you • Remember, Type I DM requires insulin AND carb source (D5 or D10) at all times (even when NPO, to prevent DKA). So if Type I diabetic is NPO, DO NOT hold basal insulin and DO start D5 or D10

  11. Case 3 Tom has Type 2 DM and was admitted for diabetic foot ulcer. Today is HD3 and his blood sugars have been stable with NPH 22 units bid and Regular Correctional. Tomorrow he is having a L foot amputation. How should his insulin regimen be adjusted?

  12. Pharmacokinetics of Insulin Products • Rapid (lispro, aspart, glulisine) (Humalog/Novolog/Apidra) Insulin Level Short (regular) Intermediate (NPH) Long (glargine) Long (detemir) 0 2 4 6 8 10 12 14 16 18 20 22 24 Hours Adapted from Hirsch I. N Engl J Med. 2005;352:174–183.

  13. Case 3 Answer • Continue evening NPH dose • Half morning NPH dose • Start patient on D5 or D10 • Continue Correctional insulin Alternatively • On admission, change from NPH to Lantus for better glycemic control

  14. Case 4 Tom has Type 2 DM, admitted for diabetic foot ulcer and today is HD3. He is treated with Humalog 5 units tid & Lantus 22 units qhs. Tom has premealbs of 65 before lunch, does not have any symptoms of hypoglycemia, what should you do?

  15. PRIORITY: DRINK UP! • If possible, PO FIRST • Treat the SYMPTOMS, not just the number • 4 oz Juice/8 oz FF milk = 15 gram carb • 15 grams carb can increase BG 30-50mg/dl The 15-15 Rule • Treat with 15 grams of carb • Recheck in 15 minutes • Retreat with 15 grams of carb and recheck every 15 minutes until BG is > 75mg/dl

  16. Things to think about • BG within range 70-100mg/dl - DO NOT HOLD INSULIN (basal insulin) - may need dose adjustment • Check to see how much patient is eating • Has patient been experiencing nausea or vomiting For our patient Tom, if he has few premeal blood glucose readings that are low, need to decrease Lispro nutritional insulin from 5 units tid to 3 units tid

  17. Case 5 Jerry is a 65 yo male who is receiving continuous TPN. He has a h/o DM, weighs 80kg and is on continuous TPN. His blood glucose readings have ranged 250-300, how do you manage his DM and hyperglycemia?

  18. Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: Effect of structured subcutaneous insulin orders and an insulin management algorithm Journal of Hospital MedicineVolume 4, Issue 1, pages 3-15, 12 JAN 2009 DOI: 10.1002/jhm.391http://onlinelibrary.wiley.com/doi/10.1002/jhm.391/full#fig2

  19. Case 5 Answer • Start Lantus 12 units qhs • Start Regular 5 units Q6H • Regular Correctional Learning Points • For patients who are receiving continuous feeds (either TPN or tube feeds), check blood glucose levels Q6H • Regular correctional insulin preferred over Rapid acting (Aspart/Lispro) since patient is not taking food in orally and regular lasts longer then rapid acting

  20. Inpatient Diabetes Management Pearls • Hold all oral DM meds and noninsulin injectable meds on admission • If patient is on insulin, give them 2/3 of their home dose (basal and nutritional) as they don’t eat the same foods in the hospital vs at home • Always account for renal function • When NPO, always give carb source (D5@100 or 125 or D10@50 depending on overall fluid state) • Pt should be on same insulin for nutritional and correctional

  21. Diabetic Goals • Avoid Hypoglycemia • Avoid Severe Hyperglycemia 3. Adequate Nutrition 4. Pre-discharge education

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