DIABETES MELLITUS Inpatient Management

1. DIABETES MELLITUSInpatient Management Alejandro Gonzalez MD, FACP

2. Hyperglycemia in hospitalized patients Associated with: Poor outcomes Prolonged hospitalization Infection Disability after discharge Death.

3. Hospitalized patients with Diabetes Mellitus. • Does improved glycemic control improves outcomes? • Glycemic targets • Treatment options. • Transition to outpatient care

4. Patients already on insulin injections or/pump. • Continue insulin pump. • Continue same insulin regimen

5. Non insulin agents • Not recommended in most hospitalized patients. Discontinue upon admission. • ORAL: Metformin, Sulfonylureas, Meglitinides, Glitazones, DPP-4 inhibitors, Bromocryptine • INJECTABLE: GLP-1 analogs: Exenitide, Liraglutide Amylin analog: Pramlitide

6. Non Critically Ill Patients • No oral or injectable non insulin agents. • We discourage Rapid Acting Insulin coverage without Long Acting Insulin. • Recommend BASAL BOLUS insulin plan: Long Acting Insulin every 24 hrs. Rapid Acting Insulin before meals: Nutritional Correction

7. Basal Bolus Insulin during hospitalization • .

8. Basal Bolus Insulin Rapid acting Analogs: Lispro (Humalog) Aspart (Novolog) Glulisisne (Apidra) Long acting Analogs (24 hours): Glargine (Lantus) Detemir (Levemir) Intermediate acting (12 Hours): NPH Short acting Regular Insulin is not recommended

9. Implementation of a Basal Bolus Plan. • Calculate: • Total Daily Dose of insulin (TDD) • Basal (Long Acting) insulin • Rapid Acting Insulin: Nutritional Correction

10. Prescription of insulin • Calculate the Total Daily dose of insulin (TDD). Patient weight in Kg x 0.4 • The TDD of insulin for a 70 Kg patient is 28 units.

11. Prescription of insulin • Basal insulin: Half of the TDD will be Long acting Insulin, one injection every 24 hours TDD of insulin 28 units for the 70 kg patient 14 units of Glargine/Detemir once a day • Nutritional insulin: The other half will be Rapid Acting insulin before meals 14 units of Lispro/Aspart/Glulisine One third (4 Units) before Breakfast, Lunch and Supper

12. Correction insulin • If the blood sugar before a meal is high, add extra units to the Rapid Acting Insulin dose. • Sugar 150-180 + 1 unit 181-210 + 2 units 211-250 + 3 units > 251 + 4 units

13. Basal Bolus prescription for a 70 Kg patient (Glargine and Lispro) • Example: • TDD: 0.4 x 70= 28 units/d • Basal:14 units of Glargine every 24 hrs • Nutritional: 14 units of Lispro in 24 hrs 4 units 10 minutes before B/L/S Lispro Correction: Blood Sugar before B/L/S: 150-180 + 1 unit 181-210 + 2 units 210-250 + 3 units > 251 + 4 units

14. Basal Bolus prescription for a 70 Kg patient (Glargine and Lispro) • Example: • TDD: 0.4 x 70= 28 units/d • Basal:14 units of Glargine every 24 hrs • Nutritional:14 units of Lispro in 24 hrs 4 units 10 minutes before B/L/S Lispro Correction: Blood Sugar before B/L/S: 150-180 + 1 unit 181-210 + 2 units 210-250 + 3 units > 251 + 4 units Test Blood Sugars before each meal and at bedtime. No Nutritional insulin if patient doesn’t eat. Only Correction insulin at meal times if patient is not eating. Rapid Acting Insulin at Bedtime is discouraged

15. Inpatient care of Diabetes Mellitus • Hyperglycemia and Hypoglycemia are associated with poor outcomes in hospitalized patients.

16. Non Critically Ill Patients • Premeal Blood Glucose targets < 140 mg/dL Avoid Hypoglycemia Stringent targets in stable patients Gentler targets in patients who are terminally ill or with severe comorbidities

17. Hyperglycemia in the critically ill. • One publication in 2001 indicated that intensive glycemic control ( target 80-110 mg/dL) was beneficial in a surgical Intensive Care Unit (1) (1) Van den Berghe G. Intensive insulin therapy in critically ill patients. NEJM, 2001;345:1359=1367

18. Hyperglycemia in the critically ill. • The tight glucose target (80-110 mg/dL) Is difficult to achieve Causes frequent Hypoglycemia • Repeat attempts to replicate the results failed, tight control in some cases caused an increased mortality (2), (3), (4) • Until further information is available glucose target for critical illness should be less stringent than 80-110 mg/dL • (1) Van den Berghe G. Intensive insulin therapy in critically ill patients. NEJM, 2001;345:1359=1367 • (2) Brunkhorst FM, Intensive insulin therapy and pentastarch in severe sepsis. NEJM 2009;360:15-139 • (3) Finfer F. Intensive vs conventional glucose control in critically ill patients. NEJM.2009;360;1283-1297 • (4) Van den Berghe G. Intensive insulin therapy in the medical ICU. NEJM 2006;354:449-461

19. Hyperglycemia in the critically ill. • Intravenous insulin therapy. Glycemia: 140 to 180 mg/dL Greater benefit at the lower end of this range In selected (surgical patients) lower ranges may be beneficial but target <110mg/dL is not recommended Avoid Hypoglycemia

20. Hospital issues • Over/undertreatment of Hyperglycemia is a major problem. • Education of Hospital personnel. • Use validated protocols • Caution interpreting glucose values if using Glucometers in patients with anemia, polycythemia or hypoperfusion. Validate with Laboratory Plasma Glucoses. • Always use common sense.

21. Discharge Planning • Start at the time of hospital admission • Patient Education • Plans for follow up and communication with outpatient providers.

23. .

24. Watch out !