Management of Inpatient Diabetes and Hyperglycemia Kendall Rogers MD CPE FACP SFHM

1. Thursday School 2013 Management of Inpatient Diabetes and Hyperglycemia Kendall Rogers MD CPE FACP SFHM Associate Professor Chief – Division of Hospital Medicine

2. Objectives For This Lecture • Recognize the importance of good glycemic control for hospital inpatients • Appreciate the obstacles to achieving good glycemic control in hospital patients • Understand and apply the best practice of inpatient hyperglycemia/diabetes management using subcutaneous insulin, including the use of anticipatory, physiologic insulin dosing in a variety of clinical situations • Review special cases including steroids and discharge

3. Case 1 56 year old woman with DM2 admitted with a diabetes-related foot infection which may require surgical debridement in the near future, eating regular meals. • Weight: 100 kg • Home medical regimen: Glipizide 10 mg poqd, Metformin 1000 mg po bid, and 20 units of NPH q HS • Control: A recent HbA1c is 10%, POC glucose in ED 240 mg/dL What are your initial orders?

4. You put the patient on the ‘Insulin Order Set’ with the reg diet checked, ‘moderate dose’ option with nutritional and basal insulin ordered • Write down: • When will the CBGs be checked? • Exactly what insulin is scheduled and at what times? • If the patient is hypoglycemic, what will happen?

5. Managing Diabetes in the Hospital Presents Different Challenges than Managing Diabetes in the Outpatient Arena! The hospital is associated with: • Nutritional and clinical instability • The need for changes from the home diabetes medical regimen • Acute illness, “stress-related” hyperglycemia • Use of medications that impact glycemic control

6. Why Should We Care? • Hyperglycemia occurs frequently in hospital patients, and is associated with poor outcomes • Hypoglycemia occurs frequently in hospital patients, and is unpleasant and dangerous • Adequate metabolic control is an attainable goal for hospital patients

7. Inpatient Glycemic Goals GOOD BAD Somewhere in the Middle Hypoglycemia Hyperglycemia <40 70 110 140 170 >200 BAD

8. Recommended Inpatient Glycemic Targets • Maintain fasting and preprandial BG <180 mg/dL (ideal <140 preprandial, acceptable <180) • Modify therapy for BG < 100 mg/dl to avoid risk for hypoglycemia • More stringent targets may be appropriate in stable patients with previous tight glycemic control. • Less stringent targets may be appropriate in terminally ill patients or in patients with severe co-morbidities.

9. UNM Glycemic Goals • If 2 readings >180 in 24 hours, diabetes is uncontrolled and a change should be made to scheduled insulin • Our definitions: • >300 Severe Hyperglycemia • 180-299 Hyperglycemia • 100-180 Controlled • <70 Hypoglycmia • <40 Severe Hypoglycemia

10. Recommendations for Managing Patients With Diabetes in the Hospital Setting Antihyperglycemic Therapy Insulin Recommended OADsNot Generally Recommended IV Insulin Critically ill patients in the ICU SC Insulin Non-critically ill patients • ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care. 2006 & 2009 • Diabetes Care. 2009;31(suppl 1):S1-S110.

11. Considerations with non-insulin therapies in the hospital • Sulfonylureas are a major cause of prolonged hypoglycemia • Metformin is contraindicated in patients with decrease renal function, use of iodinated contrast dye, and any state associated with poor tissue perfusion (CHF, sepsis) • Thiazolidinediones associated with edema and CHF • α glucosidase inhibitors are weak glucose lowering agents • Amylin and GLP1 agonists can cause nausea and exert a greater effect on postprandial glucose • Time action profiles of oral agents can result in delayed achievement of target glucose ranges in hospitalized patients

12. What is the “Best Practice” for Managing Diabetes and Hyperglycemia in the Hospital? • Anticipatory, physiologic insulin dosing, prescribed as a basal/bolus insulin regimen • Giving the right type of insulin, in the right amount, at the right time, to meet the insulin needs of the patient • Not ‘Sliding Scale Insulin’

13. The Components of a Physiologic Insulin Regimen • Basal insulin • Nutritional insulin • Correctional insulin

14. The Components of a Physiologic Insulin Regimen • Basal insulin • long-acting insulin required in all Type 1 (and most Type 2) patients to maintain euglycemia by preventing gluconeogenesis • Nutritional insulin • scheduled short-acting insulin given just before a meal, in anticipation of the glycemic spike that occurs due to carbohydrate ingestion (this dose is given even when the blood sugar is in the normal range). • Correctional insulin • short-acting insulin that is given in addition to scheduled nutritional insulin (or given at other times of the day) as a response to preexisting high blood glucose levels

15. Physiologic Insulin Secretion: Basal/Bolus Concept Nutritional (Prandial) Insulin 50 Insulin (µU/mL) Suppresses Glucose Production Between Meals & Overnight 25 0 Basal Insulin Breakfast Lunch Supper 150 Nutritional Glucose The 50/50 Rule 100 Glucose (mg/dL) 50 Basal Glucose 0 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 A.M. P.M. Time of Day

16. Providing Exogenous Basal Insulin • Long-acting, non-peaking insulin is preferred as it provides continuous insulin action, even when the patient is fasting • Required in ALL patients with type 1 diabetes • Many patients with type 2 diabetes will require basal insulin in the hospital • Can be estimated to be about 1/2 of the total daily dose of insulin (TDD)

17. NPH Detemir (Levemir) Which Insulins are Best for Basal Coverage? Glargine (Lantus) Regular Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) InsulinEffect 0 6 12 18 24 Time (hours)

18. Providing Exogenous Nutritional Insulin • Usually given as rapid-acting analogue (preferred in most cases) or regular insulin, for those patients who are eating meals • Must be matched to the patient’s nutrition • Should not be given to patients who are not receiving nutrition (e.g. NPO) • Can be estimated to be about ½ of the total daily dose of insulin (TDD)

19. NPH Detemir (Levemir) Which Insulins are Best for Basal Coverage? Glargine (Lantus) Regular Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) InsulinEffect 0 6 12 18 24 Time (hours)

20. Providing Exogenous Correctional Insulin • Correctional insulin is extra insulin that is given to correct pre-existing hyperglycemia • Usually rapid-acting or regular insulin (usually the same as the nutritional insulin) • Often written in a “stepped” format that is used in addition to basal and nutritional insulin • Customized to the patient using an estimate of the patient’s insulin sensitivity • If correctional insulin is required consistently, or in high doses, it suggests a need to modify the basal and/or nutritional insulin doses

21. A Stepwise Approach to Physiologic Insulin Dosing in the Hospital • Decide if patient is appropriate for the subcutaneous insulin and discontinue oral anti-diabetic agents • Calculate the estimated total daily dose (TDD) of insulin • Determine the distribution of the TDD between basal and nutritional insulin based on nutrition regimen. • Re-evaluate & adjust the TDD daily based on the glycemic control of the previous 24h

22. Step 1: Which Patients Should be Treated with a Physiologic Insulin Regimen? During hospitalization • Any patient with blood glucose levels consistently above the target range Immediately at the time of admission • All patients with type 1 diabetes • Patients with type 2 diabetes if… • They are known to be insulin-requiring • They are known to be poorly controlled despite treatment with significant doses of oral agents • They are known to require high doses of oral agents that will be held in the hospital

23. Indications for IV Insulin Therapy • Prolonged fasting (>12 h) in type 1 DM • Critical illness • Before major surgical procedures • After organ transplantation • DKA • Labor and delivery • Acute MI • Other illnesses requiring prompt glucose control ACE Position statement on inpatient diabetes 2004

24. Step 2: Estimate the Amount of Insulin the Patient Would Need Over One Day, If Getting Adequate Nutrition = Total Daily Dose (TDD) • For patients already treated with insulin, consider the patient’s preadmission subcutaneous regimen and glycemic control on that regimen • Weight-based estimate: • TDD = 0.4 units x Wt in Kg • Adjust down to 0.3 units x Wt in Kg for those with hypoglycemia risk factors, including kidney failure, type 1 diabetes (especially if lean), frail/low body weight/ malnourished elderly, or insulin naïve patients • Adjust up to 0.5-0.6 units (or more) x Wt in Kg for those with hyperglycemia risk factors, including obesity and high-dose glucocorticoid treatment • Insulin drip-based estimate

25. Step 3: Decide Which Components of Insulin the Patient Will Require, and Which Percentage of the TDD Each Should Represent • Basal insulin can generally be estimated to be 1/2 of the TDD • Nutritional insulin makes up the remaining 1/2 of the TDD

26. STEP 3: Decide Which Components of Insulin the Patient Will Require, and Which Percentage of the TDD Each Should Represent • In most cases, basal insulin should be provided • In most cases, well-designed corrective insulin regimens should be provided • When a patient is not receiving nutrition, nutritional insulin should not be given • Nutritional insulin needs must be matched to the actual nutritional intake

27. STEP 3: Assess the Patient’s Nutritional Situation • Eating meals or receiving bolus tube feeds • Eating meals but with unpredictable intake • Getting continuous tube feeds • Getting tube feeds for only part of the day • Getting parenteral nutrition • NPO

28. Examples for Initial Orders • 55 yo male presents with CBG 250, HgA1c of 9.5 on 30 lantus and metformin • 65 yo female with renal insufficiency presents on only glipizide, HgA1c 7.9 with CBG of 145 • 45 yo female presents with CBG of 320, HgA1c of 13.5 prescribed 85 units of lantus and 15 lispro each meal • 47 yo male no known history of DM with CBG of 240 in ER

29. Back to our patient 56 year old woman with DM2 admitted with a diabetes-related foot infection which may require surgical debridement in the near future, eating regular meals. • Weight: 100 kg • Home medical regimen: Glipizide 10 mg poqd, Metformin 1000 mg po bid, and 20 units of NPH q HS • Control: A recent HbA1c is 10%, POC glucose in ED 240 mg/dL

30. Initial Orders • Stop orals • Basal Insulin: 20-30 units • Nutritional Insulin: 21-30 units (7-10 units each meal) • Moderate dose correction scale • Monitor for 24 hours and begin adjusting

31. Other answers • When will the CBGs be checked? • Before each meal and at 9PM • Exactly what insulin is scheduled and at what times? • Before each meal and at 9PM • If the patient is hypoglycemic, what will happen?

32. STEP 4: Assess Blood Glucoses at Least Daily, Adjusting Insulin Doses as Appropriate • 2 readings above 180 are consider uncontrolled • Get your data • Review current orders for insulin • Check MAR for insulin administration for previous day • Investigate meals and snacks • Calculate correction scale usage • There is no “autopilot” insulin regimen for a hospitalized patient! Make a change.

33. STEP 4: Assess Blood Glucoses at Least Daily, Adjusting Insulin Doses as Appropriate • Hyperglycemia • Use previous correction day scale and redistribute • 10/20/30/40 rule • Adjust based on which values are elevated • Hypoglycemia • If hypoglycemic event, evaluate cause and adjust • If under 100 back off insulin by 10%

39. Issues- It is not just about glycemic target • Choice of initial regimen in the hospital. • Poor glycemic control ignored/accepted. • Reliance on sliding scale insulin. • Inappropriate follow up of hypoglycemia. • “Stacking” of insulin dosing. • Communication between services. • Inconsistent approach to insulin ordering • Nurse to physician communication. • Poor coordination of tray delivery, monitoring, and insulin

40. “Basal Plus”

42. “Basal Plus” • New regimen proposed by Umpierrez • If using less than .4 u/kg/day can consider .2 u/kg basal without nutritional • Must select the right patients: • Known type 2 DM • Diet controlled, on orals only or using <.4 u/kg at home • No hepatic or renal impairment • CBG <400 in hospital • 2 consecutive readings >240 or daily mean BG >240 were switched to basal bolus

43. Dangers with Basal Plus • Validating inappropriate use of only basal and escalation into covering nutritional • Risk of hypoglycemia

44. Special Situations • Insulin Pump • Steroids • Discharge

45. Insulin Pump • Some patients may remain on pump if self-managed • Always consult endocrine • If stopping pump, must be on subcutaneous or intravenous insulin within 30 minutes • Insulin pumps must be discontinued for an MRI. If the pump is interrupted for more than one hour, another insulin source needs to be ordered.

47. Steroids • The majority of patients receiving > 2 days of glucocorticoid therapy at a dose equivalent of at least 40 mg per day of Prednisone developed hyperglycemia • No glucose monitoring was performed in 24% of patients receiving high dose glucocorticoid therapy

48. Treatment on Steroids • For patients without prior DM or hyperglycemia or those with diabetes controlled with oral agents: • Initiate glucose monitoring with low dose correction insulin scale administered prior to meals • For patients previously treated with insulin • Increase total daily dose by 20 to 40% with start ofhigh dose steroid therapy • Increase correctional insulin by one step(low to moderate dose) • Adjust insulin as needed to maintain glycemic control

49. Covering once daily prednisone • If patient is taking basal/bolus already • Continue same regimen • Order prednisone as single AM dose daily • Day 1 of prednisone: establish that prednisone hyperglycemia occurs (cover with correction) • Day 2: add AM dose of NPH and titrate up to cover daytime hyperglycemia • Use NPH does equal to ½ sum of correction for day 1