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Some Factors Destabilizing Glucose Control during Hospitalization

Internal Medicine Resident’s Fundamentals of Medicine Lecture Series Managing Diabetes Mellitus in Hospitalized Patients Steven Ing, MD MSCE Division of Endocrinology, Diabetes and Metabolism 7/26/2010. Some Factors Destabilizing Glucose Control during Hospitalization.

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Some Factors Destabilizing Glucose Control during Hospitalization

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  1. Internal Medicine Resident’s Fundamentals of Medicine Lecture Series Managing Diabetes Mellitus in Hospitalized PatientsSteven Ing, MD MSCEDivision of Endocrinology, Diabetes and Metabolism7/26/2010

  2. Some Factors Destabilizing Glucose Control during Hospitalization Stress of illness, surgery Glucocorticoid therapy IV dextrose, TPN Decreased physical activity Stopping DM medications Decreased caloric intake Continued sulfonylurea Inappropriate “sliding scale” insulin “Tight” control Glucose ↑ ↓ Glucose

  3. Nuts & Bolts: 10 Ten List • Diet-controlled T2DM • T2DM: what to do with oral DM meds • What are the Glycemic Targets in Hospitalized Patients? • When to Consider IV Insulin Therapy • How to Calculate an Initial Basal Insulin Dose (and transitioning from IV insulin) • How to Manage Basal Insulin Dosing in Patients Already on Insulin • How to Calculate an Initial Prandial Insulin Dose • How to Individualize the Premeal “Correction Dose” • When and Which Diabetes Consultant • Discharge Orders

  4. 1. Diet-controlled T2DM • Who have minor surgery, imaging, procedure, or non-critical acute illness that is expected to be short-lived • will not usually need specific anti-hyperglycemic therapy • Monitor glucose to detect serious hyperglycemia (e.g. steroids in COPD exacerbation) • Insulin therapy should be instituted if the preprandial blood glucose concentration >200 mg/dL • Inform patient that insulin may not be necessary after the episode is over

  5. 2. T2DM: What to do with oral meds • Sulfonylureas • glipizide (Glucotrol) • glyburide (Diabeta, Micronase, Glynase PresTab) • glimepiride (Amaryl) • Meglitinides • repaglinide (Prandin) • netaglinide (Starlix) • Biguanide • metformin (Glucophage, Glucophage XR, Fortamet, Glumetza, Riomet) • Metaglip, Glucovance • Thiazoladinediones • rosiglitazone (Avandia): Avandaryl, Avandamet • pioglitazone (Actos): Duetact, Actoplus Met • Alpha-glucosidase inhibitors • acarbose (Precose) • miglitol (Glyset)

  6. Metformin • Contraindicated if hemodynamic status or renal function is impaired or threatened • Acute cardiac or pulmonary decompensation • Surgery (with potential compromise of circulation) • Acute renal failure • IV iodinated contrast studies (with potential for contrast-induced ARF) • Dehydration • Sepsis • Should be held at least temporarily in most hospitalized acutely ill patient until renal function and circulation can be established, e.g. 48 hours after IV contrast

  7. Thiazoladinedione (TZD) • Associated with edema, fluid retention • Contraindicated in advanced heart failure (NYH class III, IV) • If there is question of ventricular dysfunction during hospitalization, hold TZD until the situation is clarified • Since the anti-hyperglycemic effect extends for several weeks after discontinuation, temporary interruption should have little effect on glucose lowering effect

  8. Sulfonylureas • Associated with hypoglycemia that may be severe and prolonged • Changes in renal function may increase the risk for hypoglycemia (decreased clearance) • Consider discontinuation during the hospitalization in the patient with erratic meal schedules and missed meals to lower the likelihood of hypoglycemia

  9. Meglitinides • repaglinide (Prandin) • netaglinide (Starlix) • Non-sulfonylurea insulin secretagogues • Prandial administration • Shorter duration of action • Theoretical advantage in hospitalized patients, but should also be used cautiously

  10. Newer Diabetic Meds • exenatide (Byetta) • GLP-1 analog • ↑ insulin, ↓ gastric emptying, ↓ appetite, ↓ glucagon • Nonformulary, SQ injection • Hold as inpatient • sitagliptan (Januvia) • DPP4 inhibitor, oral • OK to continue except in ARF • Janumet = Januvia + metformin • Saxagliptan (Onglyza) • pramlintide (Symlin) • Amylin analog • ↓ gastric emptying, ↓ appetite, ↓ glucagon • Nonformulary, SQ injection • Hold as inpatient

  11. 3. What are the Glycemic Targets in Hospitalized Patients? AACE Guidelines • ICU: 140-180 mg/dL • Noncritical care: < 140 mg/dl preprandial < 180 mg/dL postprandial • Values > 180 mg/dL indicate need to monitor glucose levels more frequently to determine the direction of any glucose trend and the need for more intensive intervention OSU ICU: 110-150 Noncritical care: 110-180 American Association of Clinical Endocrinologists. Available at: http://www.aace.com/pub/ICC/inpatientStatement.php.

  12. Insulin Therapy in Managing Hospitalized Persons With Diabetes • Intravenous insulin • continuous variable-rate infusion • regular insulin • Subcutaneous Insulin • basal/bolus therapy • long-acting and rapid-acting insulin

  13. 4. When to Consider IV Insulin Therapy • Diabetic ketoacidosis (DKA) • Hyperglycemia hyperosmolar state (HHS) • Critical care illness • Myocardial infarction (MI) or cardiogenic shock • Postoperative period following heart surgery • Labor and delivery • NPO status in Type 1 diabetes • General pre-, intra-, and postoperative care • Organ transplantation • Total parenteral nutrition • Exacerbated hyperglycemia during high-dose glucocorticoid therapy • Dose-determining strategy prior to initiation of subcutaneous insulin American Association of Clinical Endocrinologists. Available at:http://www.aace.com/pub/ICC/inpatientStatement.php.

  14. IV Insulin Protocol • When to initiate: • consider initiating if 3 consecutive accuchecks or blood glucose values > 200 mg/dL and if NPO >24 hours • Insulin solution: • regular insulin 100 units in 100 ml of 0.9% saline • piggy-backed with D5W • If initial glucose > 250 mg/dl: start D5W @ 25 ml/hr and increase to 100 ml/hr after glucose drops below 250 mg/dl. • If initial glucose < 250 mg/dl: start D5W @ 100 ml/hr

  15. IV Insulin Protocol • OSU target glucose range: 110 -150 • Assessment: • Serum or capillary glucose q1 hour • May transition to q 2 hours if glucose values are within goal range x 3 consecutive measurements • Convert back to q1 hour for major change in clinical condition or with any measurement out of goal range • For patient who is eating, provide prandial rapid-acting insulin

  16. IV Insulin Protocol • STEP 1: Consider consulting the Diabetes Team 292-3800 • STEP 2: Patient must receive dextrose CONTINUOUSLY during insulin infusion • STEP 3: Measure the patient's serum or capillary glucose q1 hour. • STEP 4: Initiate insulin infusion at 2 units/hr • STEP 5: Monitor glucose and adjust the insulin infusion rate as directed in following table • STEP 6: Frequency of glucose checks can be reduced to q2 hours. Convert back to q1 hour for major change in clinical condition or with any measurement out of goal range • STEP 7: Rate of decline of glucose should not be > 100 mg/dl/hour

  17. Insulin Drip Guideline

  18. OSU IV Insulin Protocol:Doctor-initiated and Nurse-driven

  19. IV Insulin: Miscellaneous • If patient is eating on IV insulin, cover mealtime carbohydrates • On order set for CHO:insulin ratio, delete the correction factor • When transitioning off IV to basal insulin, overlap by 6 hours • E.g. 9 PM give lantus, 3AM stop insulin drip • Lantus typically but not necessarily at HS • Lowering insulin rate @ 0/hr ≠ stop insulin protocol

  20. 5. How to Calculate an Initial Basal Insulin Dose: Converting from insulin drip Take 80% of insulin drip rate in fasting patient with stable glucose e.g. IV insulin rate @ 2 units/hr for past 8 hours 2 Units/hr x 24 hr x 0.8 = 38 Units glargine

  21. Example: IV to SQ Insulin

  22. Insulin Glargine

  23. 6. How to Manage Basal Insulin Dosing in Patients Already on Insulin • Patients already on basal insulin, continue some basal insulin • Food intake is diminished or stopped completely, • if glucose is well controlled in hospital, continue Rx • If hyperglycemic, can increase basal • if you suspect patient is on too much basal and too little bolus, decrease lantus 20%, decrease NPH 50% • NPO for test/procedure • Decrease prior PM glargine, detemir or NPH by 20% • Decrease AM NPH by 50% • After test/procedure, resume usual evening if eating

  24. 6. How to Manage Basal Insulin Dosing in Patients Already on Insulin (cont’d) • Insulin requirements often higher due to illness: infection, MI, steroids • Consider IV insulin, until glucose reasonably stable • If basal insulin requirement was high (e.g. 100 U/day), IV insulin rate should be higher (e.g. 5 U/hr) • Adjust basal insulin (often upwards) based on prior day’s glucose data • Basal insulin requirement changes with improvement of stress state, caloric intake, steroid dose, etc.

  25. 7. How to Calculate an Initial Bolus Insulin Dose 1. Prandial dose • Insulin:carbohydrate ratio • E.g. 1:15 = 1 unit lispro per 15 gm carbs, or 1:10, 1:20, etc. • Pro: flexible • Con: requires carbohydrate counting and calculation • Fixed dose insulin • E.g. 5 units each meal • Ideally accompanied by fixed carbs each meal (essentially same as insulin:carb ratio) 2. Correction factor • needed for either method • corrects for current glucose level, i.e. “Sliding Scale”

  26. 10 Carbs(grams) = 1 unit insulin Std: 10 Carbs(grams) = 1 unit insulin Low: 20 Carbs(grams) = 1 unit insulin High: 5 Carbs(grams) = 1 unit insulin

  27. “Sliding Scale” Insulin Alone Is Discouraged (in insulin-requiring diabetic) • “Sliding Scale” is considered anti-intellectual • Sliding scale only without basal insulin results in high rates of hyperglycemia, hypoglycemia, or iatrogenic diabetic ketoacidosis in hospitalized patients with T1DM American Association of Clinical Endocrinologists. Available at:http://www.aace.com/pub/ICC/inpatientStatement.php.

  28. Carbohydrate Counting • Grams of carbohydrates are listed on the menu tray ticket • PCA/Nurse • calculate total carbs eaten • calculates prandial insulin dose • determines correction factor insulin dose • gives insulin as soon as possible post-meal • At home patients take insulin pre-meal

  29. 8. How to Individualize a Premeal “Correction Factor”? “Standard Dose” Algorithm Individualized Dose Algorithm

  30. Nursing Documentation Insulin I:Cho+Cfact Lispro Sub Q Qachs Must document against all occurrences regardless of whether product given or not given.

  31. 1) Document administration time/date Insulin I:Cho+Cfact Lispro Sub Q Qachs Cho(grams): B.S.(mg/dl) I:Cho(unit)+Cfact(Unit) 2) In “VS/Lab info” document grams of carbs eaten and premeal glucose e.g. 30:151 3) In “Rate/Dose” document units given for carb intake and units given per Correction factor. e.g. 3+1

  32. Insulin I:Cho+Cfact Lispro Sub Q Qachs Insulin I:Cho+Cfact Lispro Sub Q Qachs Insulin I:Cho+Cfact Lispro Sub Q Qachs RN # 1 (user id = RNCHEM) documents administration 3+1 = units given for I:Cho and Correction factor 30:151 = Cho (grams) and B.S. (mg/dl) Select F12 Save

  33. Insulin I:Cho+Cfact Lispro Sub Q Qachs Cho(grams): B.S.(mg/dl) Ins:Cho(unit)+Cfactor(Unit) • Document actual Admin Tm/Dt blood sugar checked • In VS/Lab info document Cho intake in grams and Correction factor (Blood Glucose in mg/dl) i.e. 0:100 • In Rate/Dose document units given per I:Cho intake and units given per Correction factor. i.e. 0+0 • Select F5 Not Admin

  34. Insulin I:Cho+Cfact Lispro Sub Q Qachs * Indicates Not Admin 0+0 = units given for I:Cho and Cfactor 0:100 = Cho (grams) and Cfactor (mg/dl) Select F12 Save

  35. Adjusting Insulin Doses Organize data into table: glucose, carbs, insulin by meal each day

  36. 9. When and Which Diabetes Consult? • Staff Nurse • Review insulin self-administration: syringe and pen devices • Provide basic survival skills: video, written materials • Review DM regimen and insulins • CAPI: #15 Patient Care  Teaching/Educate  Self Injections or Diabetic Teaching (enter specific info into comments field, e.g. “video/book review” • Nutritionist: • Provide carbohydrate counting education • Review ADA diet • CAPI: #13 Anc Services • Diabetes Clinical Nurse Specialist (C.N.S.) • Complex patient • Newly diagnosed diabetic • Needle phobia • Insulin pump • Review blood glucose monitoring technique • CAPI: #13 Anc Services

  37. INSULIN PENSQuick, Discreet, and Convenient

  38. 10. Discharge Orders: Basics • Insulin plus Supplies • Ketostix • BD Ultra-Fine Insulin Syringes size: 1 ml (100 units), 0.5 ml (50 units), 0.3 ml (30 units) 100-count box, refills x ___ • BD Ultra-Fine Syringe Needles, 31 gauge x 5/16” (8 mm), 100-count box, refills x ___ • Pen insulin: 1 box of 5 cartridges (300 ml per cartridge) • BD Ultra-Fine Pen Needles, 100-count box, refills x ___ • 31 gauge x 5/16” (8 mm) - short • 31 gauge x 3/16” (5mm) - mini • Glucometer • Lancets: BD Ultra-Fine Lancets, 33 gauge, 100-count box, refills x ___ • Test strips for glucometer: sig, #, refills

  39. Diabetes Med Set: ease of use for DI At discharge generate prescription/med list Select “Add/Modify Discharge Meds”

  40. Diabetes Med Set: Ease of Use at Discharge Select “New Med”

  41. Diabetes Med Set: Ease of Use at Discharge Select “Med Sets”

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