Glycemic Control In The Hospital Setting

LOYOLA UNIVERSITY MEDICAL CENTER Total Number of Beds 580 LOCATION: ICU # OF BEDS MICU 15 CCU 10 Heart Transplant Unit 10 CV Surgery ICU 21 Trauma Units 20 Surgical ICU 18 Neuro ICU 15 Burn ICU 15 Neonatal ICU 50 Pediatric ICU 14

Loyola Medical Center LOCATION: Non-ICU # OF BEDS IMC Cardiac & Angioplasty 28 Telemetry Unit 67 Bone Marrow 15 Pediatrics 32 Post partum 30 Labor and Delivery 15 Nursery 25 Rehab Unit 24 General Medicine 60 Hematology/Oncology 30 Orthopedic 19 Neurology, Neurosurgery and ENT 40 Surgery 32 Burn and Surgical Unit 21

Glycemic Control In The Hospital Setting  The Evidence For Tight Glycemic Control  The Achievement of Better Control: Strategies and Protocols

Insulin In The Hospital Setting Retrospective Studies

Hyperglycemia in the Hospital CABG  Tight Control  Hospital Mortality  50% Kalin. Diabetes. 1998;47:a87  Tight Control  Postop Infections  75% Golden SH, Et Al. Diabetes Care. 1999;22:  Tight Control  Sternal Wounds  60% Furnary AP, Et Al. Ann Thorac Surg. 1999;67:  Tight Control  Sternal Wounds  60% Zerr KJ, Et Al. Ann Thorac Surg. 1997;63: General Surgery  Hyperglycemia  Serious Infections  X 6 Pomposelli JJ, Et Al. J Parenter Enteral Nutr. 1998;12:

Effect of Continuous Insulin Infusion on Mortality Following CABG 3554 DM Patients Undergoing CABG From Jan to Dec Treated With: Subcutaneous Injection Group (SQI) (n=942) Received Insulin Q4h to Maintain BG <250 mg/dl Subcutaneous Injection Group (SQI) (n=942) Received Insulin Q4h to Maintain BG <250 mg/dl Continuous Infusion Group (n=2612) Continuous Infusion Group (n=2612) 1987 to 1991 Target BG of 220 mg/dl 1987 to 1991 Target BG of 220 mg/dl 1991 to 1998 Target BG of mg/dl 1991 to 1998 Target BG of mg/dl In 1999, Target Lowered to mg/dl In 1999, Target Lowered to mg/dl In 2001, Target Lowered to mg/dl In 2001, Target Lowered to mg/dl Furnary et al J Thoracic Cardiovasc Surg 2003;125:10073

Post-CABG Mortality by Diabetic Status Furnary et al J Thoracic Cardiovasc Surg 2003;125: % 2% 4% 6% 8% 10% Mortality CII DM Pts. Non-DM

Hyperglycemia in the Hospital Stroke  Hyperglycemia  Independent Determinent of Infarct Expansion Baird TA, et al. Stroke. 2003; 34:  Hyperglycemia  Hospital Mortality  X 2 Weir CJ, et al. BMJ. 1997; 314: Weir CJ, et al. BMJ. 1997; 314:  Hyperglycemia  Hospital Mortality  X 2 Jorgensen H, et al. Stroke. 1994; 25: Jorgensen H, et al. Stroke. 1994; 25:

Hyperglycemia In Critical Illness Targeting Risk? From The VA Inpatient Evaluation Center  From 177 ICUs In 73 VA Hospitals  216,000 Patients  Glycemia Independent Predictor Of Mortality Starting At 1 mg% Above Normal (Normal = mg%)  True In Medical, Surgical & Cardiac ICUs Falciglia, M. et al Annual Meeting of the American Diabetes Association, 2006

Hyperglycemia In Critical Illness Targeting Risk? From The VA Inpatient Evaluation Center Different Disease States Variably Affected Condition Risk Of Death* Condition Risk Of Death* Acute MI Acute MI Unstable Angina Unstable Angina Stroke Stroke Outcomes Worse In “Non-Diabetics” Falciglia, M. et al Annual Meeting of the American Diabetes Association, 2006 * Fold Increase

Insulin In The Hospital Setting Prospective Studies

DIGAMI Study 620 Randomized to 2 Groups At 19 Swedish Hospitals Control: Standard Coronary Care for Their Center Control: Standard Coronary Care for Their Center Intensive: Insulin-Glucose Infusion for >24 Hrs Intensive: Insulin-Glucose Infusion for >24 Hrs Target Serum Glucose 126 – 180 mg/dl Target Serum Glucose 126 – 180 mg/dl Multidose (4/day) Insulin for Minimum of 3 Months Following Discharge Multidose (4/day) Insulin for Minimum of 3 Months Following Discharge BMJ 314: , 1997

Cardiovascular Risk Mortality After MI Reduced by Insulin Therapy in the DIGAMI Study All Subjects (N = 620) Risk Reduction (28%) P =.011 Standard Treatment Years of Follow-up 2345 Low-risk; Not Previously on Insulin (N = 272) Risk Reduction (51%) P =.0004 IV Insulin 48 Hours, Then 4 Injections Daily Years of Follow-up 2345

Intensive Insulin Therapy in Critically Ill Patients Van Den Berghe, G et al. NEJM 345:

Intensive Insulin Therapy in Critically Ill Patients 1548 Mechanically Ventilated Patients in SICU 2 Glycemic Treatment Groups: Insulin Infusion to Keep Blood Glucose mg/dl Insulin Infusion to Keep Blood Glucose mg/dl Insulin Treatment Only If Blood Glucose >215 mg/dl to Maintain Glucose mg/dl Insulin Treatment Only If Blood Glucose >215 mg/dl to Maintain Glucose mg/dl van den Berghe G. N Engl J Med 2001; 345:1359 Glucose Achieved: Control 153 mg/dl Intensive 103 mg/dl

Intensive Insulin Therapy in Critically Ill Patients 87% Diagnosed With DM in the ICU 87% Diagnosed With DM in the ICU 13% Had Previous Dx of Diabetes Mellitus 13% Had Previous Dx of Diabetes Mellitus 5% Had Previous Insulin Treatment 5% Had Previous Insulin Treatment van den Berghe G. N Engl J Med 2001; 345:1359

Intensive Insulin Therapy in Critically Ill Patients  34% Decrease in In-Hospital Mortality  46% Decrease in Sepsis  41% Decrease in Renal Replacement Therapy  50% Decrease in Median Number of RBC Transfusions  44% Decrease in Critical Illness Polyneuropathy Van den Berghe G. N Engl J Med 2001; 345:1359

>14d in ICU >14d on Ventilator Peak Cr. >2.5 Hyperbilirubinemia ICU Sepsis Antibiotics >10d Polyneuropathy % of Patients Van den Berghe Morbidity Data Glucose Glucose Glucose Glucose

Lazar, H. et al Circulation 109: ,2004

Glucose Achieved: Control 267 mg/dl Intensive 134 mg/dl

The Effect of GIK Infusion For CABG in Type 2 Diabetes Lazar, et al: Circulation 109:1497, PacingA. FibInfectionTime on Vent (h) ICU Stay (h) Hospital Stay (Days) GIK n=72 No GIK n=69

And Now Van den Berghe -2 Van den Berghe, G. et al NEJM 354: , 2006

Intensive Insulin Therapy in the Medical ICU Greet Van den Berghe, M.D., Ph.D., Alexander Wilmer, M.D., Ph.D., Greet Hermans, M.D., Wouter Meersseman, M.D., Pieter J. Wouters, M.Sc., Ilse Milants, R.N., Eric Van Wijngaerden, M.D., Ph.D., Herman Bobbaers, M.D., Ph.D., and Roger Bouillon, M.D., Ph.D.

Intensive Insulin Therapy in Critically Ill Patients: Van den Berghe Patients in MICU 2 Glycemic Treatment Groups: Insulin Infusion to Keep Blood Glucose mg/dl Insulin Infusion to Keep Blood Glucose mg/dl Insulin Treatment Only If Blood Glucose >215 mg/dl to Maintain Glucose mg/dl Insulin Treatment Only If Blood Glucose >215 mg/dl to Maintain Glucose mg/dl van den Berghe G. N Engl J Med 2006; 354:449 Glucose Achieved: Control 153 mg/dl Intensive 111 mg/dl

With Intensive Insulin Therapy  Reduced Newly Acquired Kidney Disease  Earlier Weaning From Ventilator  Faster Discharge from ICU  Shorter Hospital Length of Stay Van den Berghe, G. et al NEJM 354: , 2006

The Two Van den Berghe Studies 45.9%10.6% % Mort >5 Days I 54.9%20.2% % Mort >5 Days C 37.3%4.6% % Mortality I 40%8% % Mortality C % Mortality C 239 APACHE II 111 mg% 103 mg % Glucose I 153 mg% Glucose C VB 2--MICU VB 1--SICU C- Control Group I- Intensive Group

New Trials On The Horizon…  NICE (NormoGlycemia In Intensive Care Evaluation: 4,000 Patients in 20 ICU’s In Australia & New Zealand  SUGAR (Survival Using Glucose Algorithm Regulation): Another 1,000 ICU Patients In Canada NICE + SUGAR = NICE-SUGAR

Insulin Therapy for Critically Ill Hospitalized Patients: A Meta-Analysis of Randomized Controlled Trials Pittas et al. Arch Intern med 164: , 2004 Combining Data From All Trials: Insulin Therapy Reduces Short-term Mortality By 15% (RR 0.85, 95% CI: ) SICU: RR 0.54, 95% CI: AMI: RR 0.84, 95% CI:

Is It Less Serious If a Patient Has Not Had a Previous Diagnosis of Diabetes?

Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes Question: Does Hyperglycemia, New or Established, Predict Mortality? Question: Does Hyperglycemia, New or Established, Predict Mortality? 2030 Consecutive Records of Adults Admitted to Georgia Baptist Hospital 2030 Consecutive Records of Adults Admitted to Georgia Baptist Hospital Hyperglycemia: FBG ≥ 126 mg/dl or Random Glucose ≥ 200 mg/dl Hyperglycemia: FBG ≥ 126 mg/dl or Random Glucose ≥ 200 mg/dl New Hyperglycemia 223 Pts. (12%) New Hyperglycemia 223 Pts. (12%) Umpierrez GR et al. J Clin Endocrinol Metab 2002; 87:978

Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes 1.7% 3.8% 16.0% 0% 5% 10% 15% 20% NormoglycemiaKnown DiabetesNew Hyperglycemia Umpierrez GR et al. J Clin Endocrinol Metab 2002; 87:978 Total Mortality

A Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes New Hyperglycemia Patients ~3 x’s As Likely to Be Admitted to ICU New Hyperglycemia Patients ~3 x’s As Likely to Be Admitted to ICU New Hyperglycemia Patients Had Twice the Length of Stay New Hyperglycemia Patients Had Twice the Length of Stay Umpierrez GR et al. J Clin Endocrinol Metab 2002; 87:978

There are other benefits…

Van den Berghe G. et al N Engl J Med 2001; 345:1359

Glycemic Management In The Hospital Financial Aspects Van den Berghe, G. et al Crit Care Med 34: , 2006

Glycemic Management In The Hospital Financial Aspects Van den Berghe, G. et al Crit Care Med 34: , 2006

Glycemic Management In The Hospital Financial Aspects Van den Berghe, G. et al Crit Care Med 34: , 2006 Euros Conventional 10,569 Intensive 7,931 Savings 2,638

Glycemic Control In The Hospital Setting The days of casual glycemic control for critically ill patients should be over!

Glycemic Control In The Hospital Setting  The Evidence For Tight Glycemic Control  The Achievement of Better Control: Strategies and Protocols

What Are The Treatment Goals?

Hospital Glycemic Goals Intensive Care Units: 110 mg/dL Non-Critical Care Units: Non-Critical Care Units: Pre-Prandial 110 mg/dL Pre-Prandial 110 mg/dL Max. Glucose 180 mg/dL Max. Glucose 180 mg/dL Endocrine Practice 10:77-82, 2004 Diabetes Care 27: , 2004 AACE Consensus Conference

Strategies and Protocols for Achieving Inpatient Glycemic Control

IV Insulin Infusion Protocols

The Ideal IV Insulin Protocol Easily Ordered (Signature Only) Easily Ordered (Signature Only) Effective (Reach Goal Quickly) Effective (Reach Goal Quickly) Safe (Minimal Risk Of Hypoglycemia) Safe (Minimal Risk Of Hypoglycemia) Easily Implemented Easily Implemented

IV Insulin Protocol Based On Insulin Sensitivity BGUnits/hrBGUnits/hrBGUnits/hrBGUnits/hr < 60 = Hypoglycemia <80Off<80Off<80Off<80Off >33028 > >36016 Algorithm 1Algorithm 2Algorithm 3Algorithm 4

IV Insulin Protocol Based On Insulin Sensitivity

< 70 Off Etc. Etc. Suppose The Patient Starts With BG = 254 mg/dl Insulin Drip Algorithm

Shifting Between Several Algorithms Makes It Possible To Discover The Insulin Requirement That Maintains Normoglycemia

Recommended IV Fluids To Prevent Hypoglycemia, Hypokalemia & Ketosis: Glucose: 5-10 gms/hour Glucose: 5-10 gms/hour Potassium: 20 meq/L Potassium: 20 meq/L The Primary Service Should Choose the Type and the Rate of the Fluid Depending on the Underlying Disease The Primary Service Should Choose the Type and the Rate of the Fluid Depending on the Underlying Disease

Other Protocols Exist  DIGAMI (Studied In Acute MI Setting)  Van den Berghe (Critical Care Setting)  Portland Protocol (Surgical Setting)  Markovitz (Postoperative Heart Surgery)  Yale Protocol (Medical Intensive Care Setting)  Glucommander.com; Endotool.com; Medicaldecisions.com (Critical Care & Non- Critical Care)

Life After The Drip…. Transition From IV to SQ Insulin In The Adult Patient

Physiologic Insulin Secretion : Basal/Bolus Concept Breakfast Lunch Supper Insulin (µU/mL) Glucose (mg/dL) Basal Glucose A.M.P.M. Time of Day Basal Insulin Prandial Glucose Prandial Insulin Suppresses Glucose Production Between Meals & Overnight The 50/50 Rule

Transition From IV to SQ Insulin In The Adult Patient  Basal Insulin  Bolus Insulin Prandial Insulin Prandial Insulin Correction Factor Insulin Correction Factor Insulin

Effective OnsetPeakDuration Lispro/Aspart/Glulisine <15 min1 hr3 hr Regular 1/2 -1 hr2-3 hr3-6 hr NPH/Lente 2-4 hr7-8 hr10-12 hr Ultralente4 hrVaries18-20 hr Insulin Glargine 1-2 hr Flat/Predictable24 hr Current Insulin Preparations

Onset Peak Effective Duration Lispro/Aspart/Glulisine <15 min1 hr3 hr Regular 1/2-1 hr2-3 hr3-6 hr NPH 2-4 hr7-8 hr10-12 hr Insulin Glargine 1-2 hrFlat24 hr Insulin Detemir hr * ~8-9 hr * Up to 24 hr * Current Insulin Preparations * Dose Dependent

Insulin Detemir Pharmacokinetics Plank, J et al Diabetes Care 28: , 2005

Transition to SQ: An Approach To Transition A Patient From An IV Insulin Infusion To SQ Insulin: Multiply Last Drip Dose By 20, And Give This Amount As Glargine Multiply Last Drip Dose By 20, And Give This Amount As Glargine Turn The IV Drip Off 2 Hours Later

Glucose Levels after Starting Lantus Lantus Group40%60%80% Glucose when Lantus given (mg/dl) Avg Glucose for 24h after Lantus started Glucose at time 6 hours Glucose at time 12 hours Glucose at time 24 hours Glucose level – next AM Any glucose < 50 mg/dl 1 (4.5%)2 (8.7%)0 Molich M, DeSantis A, 2005

Transition to SQ: An Approach To Transition A Patient From An IV Insulin Infusion To SQ Insulin: Multiply Last Drip Dose By 20, And Give This Amount As Glargine Multiply Last Drip Dose By 20, And Give This Amount As Glargine Turn The IV Drip Off 2 Hours Later

Transition to SQ: An Approach To Transition A Patient From An IV Insulin Infusion To SQ Insulin: Multiply Last Drip Dose By 20, And Give This Amount As Glargine Multiply Last Drip Dose By 20, And Give This Amount As Glargine Turn The IV Drip Off 2 Hours Later

 Example: Last Drip Dose Is 1.5 Unit/Hour; Give 1.5 X 20 = 30 units Of Glargine SQ; Discontinue Drip Two Hours Later This Is Basal Insulin This Is Basal Insulin

Adjust Basal Insulin By FBS: Decrease 4 U if FBS are below 60 mg/dL Decrease 4 U if FBS are below 60 mg/dL Decrease 2 U if FBS Is mg/dL Decrease 2 U if FBS Is mg/dL If FBS Is mg/dL, At Goal-No Change is Needed If FBS Is mg/dL, At Goal-No Change is Needed Increase 2 U If FBS Is 100 to 120 mg/dL Increase 2 U If FBS Is 100 to 120 mg/dL Increase 4 U If FBS Is 121 to 140 mg/dL Increase 4 U If FBS Is 121 to 140 mg/dL Increase 6 U If FBS Is 141 to 160 mg/dL Increase 6 U If FBS Is 141 to 160 mg/dL Increase 8 U If FBS Is 161 to 180 mg/dL Increase 8 U If FBS Is 161 to 180 mg/dL Increase 10 U If FBS Is > 180 mg/dL Increase 10 U If FBS Is > 180 mg/dL Or Adjust Based On Previous Days Correction Factor Doses

Transition From IV to SQ Insulin In The Adult Patient  Basal Insulin  Bolus Insulin Prandial Insulin Prandial Insulin Correction Factor Insulin Correction Factor Insulin

Onset Peak Effective Duration Lispro/Aspart/Glulisine <15 min1 hr3 hr Regular ½ -1 hr 2-3 hr3-6 hr NPH 2- 4 hr 7-8 hr10-12 hr Insulin Glargine 1-2 hrFlat24 hr Insulin Detemir hr * ~8-9 hr * Up to 24 hr * Current Insulin Preparations * Dose Dependent

When Patient Is Able To Eat, Add Rapid Acting Insulin For Mealtime Coverage Add Rapid Acting Insulin For Mealtime Coverage Rule Of Thumb: Rule Of Thumb: 50% Basal 50% Basal 50% Prandial, Divided Over 3 Meals 50% Prandial, Divided Over 3 Meals

Example: Patient Is On 30 units Glargine Daily; Give 10 units With Each Meal Of Lispro (Humalog), Aspart (Novolog), Or Glulisine (Apidra) This Is Prandial Insulin

Basal-Bolus Insulin Therapy: Glargine and Mealtime Rapid Acting SLBB Glulisine Lispro/Aspart/Glulisine HS Glargine Insulin Effect 30 units 10units

Transition From IV to SQ Insulin In The Adult Patient  Basal Insulin  Bolus Insulin Prandial Insulin Prandial Insulin Correction Factor Insulin Correction Factor Insulin

Correction Factor Dose, Added To Prandial Dose Low Dose Total Insulin Dose <40 units/day Medium Dose Total Insulin Dose units/day High Dose Total Insulin Dose >80 units/day 5 units >320 4 units units units unit Additional Insulin Premeal BG 9 units >320 7 units units units units Additional Insulin Premeal BG 11 units >320 9 units units units units Additional Insulin Premeal BG

What About Patients Admitted With Hyperglycemia On The Floor?

Sliding Scale Episodic Bolus Insulin WITHOUT WITHOUT Basal Insulin

Pitfalls of Sliding Scale Common Problems With SS Only  Is Reactive Rather Than Proactive  Often Mismatched With Changes In Patient’s Insulin Sensitivity  It Does Not Meet The Physiologic Needs Of The Patient  Leads To Insulin Stacking

Calculate Starting Total Daily Dose (TDD) Previous Total Daily Insulin Units Used or Previous Total Daily Insulin Units Used or 0.4 units/kg (Type 1 DM) 0.4 units/kg (Type 1 DM) 0.6 units/kg (New Onset Or Lean Type 2) 0.6 units/kg (New Onset Or Lean Type 2) 0.8 units/kg (Type 2 DM) 0.8 units/kg (Type 2 DM) This Is Very Conservative and Actual Needs May Turn Out to Be Substantially More Starting Basal-Bolus From Scratch

NPH or Combination Insulin Discontinue this while an inpatient Disadvantages Insulin peaks Less reliable timing Variation in food intake Often poorer control Conversion Add all doses of insulin total daily dose

Starting Basal-Bolus From Scratch Basal Insulin = ½ TDD Give All of Calculated Glargine Dose Q 24h Goal: FBS And Pre-Meal Glucose = mg/dl Bolus Doses = ½ TDD Prandial Dose + Correction Factor AFTER THE MEAL Goal: 2h Post-Prandial <180 mg/dl

Hypoglycemia: Most Frequent Causes  Not Lowering Insulin Dose For Decreased Caloric Intake  Interrupted Tube Feeding  Unrecognized Renal Insufficiency  Sulfonylurea’s In Addition To Insulin Very Rare:  Adrenal Insufficiency & Drugs

A Word About Oral Agents….

Therapy of Type 2 Diabetes Mellitus: Hospital Use of Oral Agents Not for Acute Illness With Variable Intake Secretagogues Can Give or Not Glitazones Hold for Acute Illness If Renal, Cardiac, or Liver Function Unstable, or Surgery, or Radiocontrast Metformin Not for Acute Illness With Variable Intake  Glucosidase Inhibitors

Common Errors in Glucose Management in Hospital Patients Discontinuing All Diabetes Medicines On Admission (Some Pills Must Be Stopped) Discontinuing All Diabetes Medicines On Admission (Some Pills Must Be Stopped) Setting High Glycemic Targets (>200 mg/dL) Setting High Glycemic Targets (>200 mg/dL) Not Changing Therapy With The Situation Or The Glucose Profile Not Changing Therapy With The Situation Or The Glucose Profile Overutilization Of Sliding Scale Insulin Overutilization Of Sliding Scale Insulin Underutilization Of Insulin Infusions and Basal Insulin Underutilization Of Insulin Infusions and Basal Insulin Metchick LN. Am J Med 2002; 113:317

Have A Discharge Plan

Admission HbA1C Very Helpful Admission HbA1C Very Helpful Can A Patient Go Back To Oral Agents At Discharge?

Admission HbA1C Very Helpful Admission HbA1C Very Helpful If Known Diabetic and Pre-Admission Control Acceptable  YES!!! If Known Diabetic and Pre-Admission Control Acceptable  YES!!! If > 7.5% on Maximum Oral Agents, If > 7.5% on Maximum Oral Agents, Needs Basal Insulin Needs Basal Insulin Can A Patient Go Back To Oral Agents At Discharge?

Natural History of Type 2 Diabetes Years of Diabetes Glucose (mg/dl) Relative Function (%) Insulin Resistance Insulin Level  -Cell Failure *IFG=impaired fasting glucose Fasting Glucose Post-meal Glucose Obesity IFG * Diabetes Uncontrolled Hyperglycemia

Glycemic Management Teams: Review Scheduled Insulin Orders Review Scheduled Insulin Orders Examine Bedside Glucose Levels To Assess Recent Responses To Treatment Examine Bedside Glucose Levels To Assess Recent Responses To Treatment Use These Responses To Revise Insulin Orders Use These Responses To Revise Insulin Orders

Glycemic Management Teams: Mild Hypoglycemia  Adjust Downward, Especially Rapid-Acting Analogue Mild Hypoglycemia  Adjust Downward, Especially Rapid-Acting Analogue Review Notes For Unusual Occurrences, i.e., Late Insulin, Decreased Caloric Intake, Physical Activity, Hypoglycemia Treatment Review Notes For Unusual Occurrences, i.e., Late Insulin, Decreased Caloric Intake, Physical Activity, Hypoglycemia Treatment Provide Provide Education/Inservice For Nurses, Pharmacists, Physicians & Physician Assistants Code and Bill Appropriately

Inpatient Diabetes Management: Is Cost a Barrier? Use of a Diabetes Management Team:  Reduction in LOS  Cost Reduction of $2353/ Patient  MICU: Annual Savings $40,000/ ICU Bed  SICU: Savings $3,000/Patient Inpatient Diabetes and Glycemic Control: A Call To Action Feb 7, 2006

Hospital Diabetic Management: Medical Benefits Unequivocal Medical Benefits Unequivocal Few Studies Address Optimal Method Few Studies Address Optimal Method Principles Borrowed From Outpatient Management Principles Borrowed From Outpatient Management Insulin Strategy Should Be Physiologic Insulin Strategy Should Be Physiologic  All Regimens Must Include Adequate Basal Insulin  Prandial and Correction Factor Team Approach Essential Team Approach Essential Financial Incentives Financial Incentives