Pharmacy Protocol for Insulin Dosing in the Hospitalized Patient CPS Annual Meeting 2017 Demonstrating Value through Medication Management ‘Best Practices’ Pharmacy Protocol for Insulin Dosing in the Hospitalized Patient

Manny Saltiel, Pharm.D, FASHP, FCCP Regional Vice President, Clinical Summit Health Care Comprehensive Pharmacy Services, White Mountains, Arizona

There are no conflicts of interest to declare. Faculty Disclosures There are no conflicts of interest to declare.

Learning Objectives Differentiate between basal-bolus and sliding scale insulin dosing regimens Explain the rationale for each component of a comprehensive pharmacy-based protocol for insulin dosing

Summit Healthcare, Show Low, Arizona 89 beds 12 ICU beds Non-teaching

Polling question Which of the following is an ultra-rapid acting insulin product? Lispro Detemir Glargine Insulin NPH

Polling question - answer Which of the following is an ultra-rapid acting insulin product? Lispro Detemir Glargine Insulin NPH

Onset, Peak, and Duration of Insulins Insulin product Onset Peak Duration Lispro (Humalog) 10-15 min 15-120 min < 5 hr Aspart (Novolog) Glulisine (Apidra) 5 hr Regular (R) 30-60 min 2-3 hr 6-8 hr NPH (N) 2-4 hr 6-10 hr 10-165 hr Glargine (Lantus) No peak 20-24 hr Detemir (Levemir) 1 hr 70%/30% aspart protamine/aspart 30 min 2-12 hr 10-16 hr Adapted from Kapustin JF. Uncomplicating Insulin Therapy. Strategies for initiation in patients with type 2 diabetes. Last updated on: October 9, 2012. http://nurse-practitioners-and-physician-assistants.advanceweb.com/Features/ Articles/Uncomplicating-Insulin-Therapy.aspx. Viewed June 26, 2017

Polling question Which of the following is a reason to convert prescribing habits from sliding scale insulin (SSI) to basal-bolus insulin (BBI)? BBI produces lower mean glucose levels SSI produces a “roller coaster” effect BBI is associated with fewer hypoglycemic episodes All of the above

Polling question - answer Which of the following is a reason to convert prescribing habits from sliding scale insulin (SSI) to basal-bolus insulin (BBI)? BBI produces lower mean glucose levels SSI produces a “roller coaster” effect BBI is associated with fewer hypoglycemic episodes All of the above

Basal-Bolus versus Sliding Scale Retrospective study of type 2 diabetes mellitus (T2DM) 202 patients (247 admissions) Basal-bolus insulin (BBI) associated with: Lower fasting blood glucose  Lower mean glucose levels throughout severe/acute hyperglycemia   Huri HZ et al. PLoS One. 2014 Sep 2;9(9):e106505. doi: 10.1371/journal.pone.0106505.

Basal-Bolus versus Sliding Scale “The principal difference between the two strategies is that sliding-scale insulin does not deliver adequate glycemic control to patients and addresses hyperglycemia after it has occurred; whereas, a basal–bolus regimen is directed at preventing hyperglycemia.” Badlani S et al. Evidence for Basal–Bolus Insulin Versus Slide Scale Insulin. Current Emergency and Hospital Medicine Reports. March 2014, Volume 2, Issue 1, pp 26–34.

Basal-Bolus versus Sliding Scale Image from www.slideshare.net/stewardv/denver-melanie-education-slides

Basal-Bolus versus Sliding Scale – Barriers to Change Tradition/historical practice Fear of hypoglycemia  Unaware of problems associated with sliding scale insulin (SSI) Unwilling to make changes to therapies initiated by another physician Image from www.conviva.com/category/service-providers. www.conviva.com/wp-content/uploads/2015/11/people-pushing-ott-elephant.jpg

Basal-Bolus versus Sliding Scale – Barriers to Change Jennette Larsen BSN RN CDE hired as Diabetes educator Based on current best-practice, sought to convert physician practice from SSI to BBI Two years of physician and nursing education

Basal-Bolus versus Sliding Scale – Barriers to Change Saying no to positive change can be a mistake Image from http://steenschledermann.wordpress.com/2014/05/17/square-or-round-wheels

Pharmacist-Based Insulin Protocol Breakthrough – Develop Pharmacist-Based Insulin Protocol (modeled after a protocol used by a colleague of hers)

Educational Competency Checklist Define type 2 and type 1 diabetes mellitus (T1DM), delineate potential difference in insulin needs Identify onset, peak, and duration of lispro, glargine, regular, 70/30 and NPH insulin Calculate correct transition doses from mixed insulin to basal-bolus insulin

Educational Competency Checklist Correctly calculate transition dose from IV to SQ insulin Correctly calculate insulin doses for insulin-naïve patient (transition from PO diabetes mellitus medications to SQ insulin) Assess patient and use correct calculations to determine total daily insulin dose based on patient-specific needs

Educational Competency Checklist Based on patient presentation, choose appropriate correction scale Identify correct blood glucose targets for non-critically ill and critically ill hospitalized patients Differentiate the need for basal vs. bolus dose adjustment

Educational Competency Checklist Identify potential confounding factors in HbA1c results, point of care blood glucose results Identify concurrent factors that may affect insulin dosing, i.e., renal, liver failure, age, nutritional status, steroid use, weight, previous insulin dose, etc.

Per-pharmacy protocol began mid 2/17 Results Per-pharmacy protocol began mid 2/17 N=88 N=78 N=91 N=85 N=91 N=77 N = number of patients on insulin Percentages are number of hypoglycemic episodes (<70 mg/dL) / patients on insulin per month

Take-Home Pearls Are you still using sliding scale insulin? Does your hospital have a Diabetes Instructor with whom you can partner? What is you hypoglycemic episode rate? Can you take on a pharmacy-based insulin management program?

Questions / Discussion Manny Saltiel, Pharm.D, FASHP, FCCP Regional Vice President, Clinical Comprehensive Pharmacy Services Summit Health Care