Stepwise approach to inpatient diabetes management Erin Keely

At the Ottawa Hospital: (From Test Strip Usage) On any given day, patients admitted to Ottawa Hospital have diabetes (25-30%)! On any given day, patients admitted to Ottawa Hospital have diabetes (25-30%)!

Impact of Diabetes on Length of Stay – The Ottawa Hospital Compiled by S. Brez, APN Endocrinology and Metabolism Specialty ALOS No DM (days) ALOS DM (days) CivicGeneralCivicGeneral General Medicine General Surgery Vascular Surgery10N/A21N/A Orthopedic Surgery Mean for Hospital661512

Increasing information on diabetes and cancer

Hyperglycemia in the Hospitalized Patient: Classification Diabetes Diabetes Previously Diagnosed – type 1 or type 2 Previously Diagnosed – type 1 or type 2 Previously Undiagnosed Previously Undiagnosed Confirmed after discharge Confirmed after discharge Secondary diabetes (glucocorticoids) Secondary diabetes (glucocorticoids) Hospital-related hyperglycemia Hospital-related hyperglycemia Reverts to normal after discharge Reverts to normal after discharge

Glycemic Targets in Hospitalized Patients Medical/surgical floors Medical/surgical floors mmol/L mmol/L Increase risk of infection if glucose > 12 mmol/l Glucosuria if >16-18 mmol/l

Potential Benefits of Improving Glucose Control in the Hospital Reduce mortality Reduce mortality Reduce morbidity Reduce morbidity Reduce costs of care Reduce costs of care Length of stay (LOS) Length of stay (LOS) Cost of inpatient complications Cost of inpatient complications Fewer rehospitalizations Fewer rehospitalizations

Goals of Inpatient Diabetes Management Avoid Hypoglycemia Avoid Hypoglycemia Avoid Hyperglycemia Avoid Hyperglycemia Assessment of Patient’s diabetes care Assessment of Patient’s diabetes care Assessment of Risk Factors Assessment of Risk Factors

Common Errors in Inpatient Glucose Management Admission orders Withdrawal or outpatient treatment regimen Failure to modify outpatient regimen Overly high glycemic targets Lack of therapeutic Adjustments Overuse of Sliding Scale!!!!

Classification of oral agents Insulin secretagogues Sulfonylureas Diabeta, diamicron (regular and MR) Amaryl Meglitinides Gluconorm Starlix Insulin sensitizers Metformin Glitazones Actos Avandia Incretins DPP-4 inhibitors GLP-1 analogues CHO absorption acarbose

Principles of InPatient Diabetes Management Type 1 different than type 2 Type 1 different than type 2 Be safe Be safe Be proactive Be proactive Try to continue pre-admission treatment Try to continue pre-admission treatment Unless NPO or decreased intake Unless NPO or decreased intake HgbA1c> 8.0 – 10 % HgbA1c> 8.0 – 10 % Glucose > mmol/L Glucose > mmol/L Frequent hypoglycemia Frequent hypoglycemia

Types of Insulin Two main manufacturers Novolin, Humulin duration of action rapidaspart, lyspo, apidra shortregular (toronto) intermediateNPH, lente Very long glargine, detemir

Action Profiles of Bolus & Basal Insulins Plasma Insulin levels Hours Note: action curves are approximations for illustrative purposes. Actual patient response will vary. regular 6-10 hours NPH 12–20 hours lispro/aspart 4–6 hours  BASAL INSULINS detemir ~ 6-23 hours (dose dependant) glargine ~ hours Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5):  BOLUS INSULINS

Expected insulin changes during the day Expected insulin changes during the day for individuals with a healthy pancreas. for individuals with a healthy pancreas. *Insulin effect images are theoretical representations and are not derived from clinical trial data. Basal-Bolus Approach therapy addresses: Bolus needs: Lispro, Aspart Basal needs: Glargine, Detemir, NPH Meal

Principles of insulin managment “Usual” = Proactive “Usual” = Proactive Basal Basal NPH NPH Levemir Levemir Lantus Lantus Meal-time Meal-time Regular Regular Novorapid Novorapid Humalog Humalog Pre-mixed Pre-mixed “Corrective” = Reactive “Corrective” = Reactive sliding scale sliding scale Amount depends on insulin sensitivity Amount depends on insulin sensitivity One size does not fit all!! One size does not fit all!! Use same type of insulin as meal-time Use same type of insulin as meal-time

So What to Do??

Diabetes Pocket Card

1. Is patient on diet/oral agents/insulin 2. Is patient going to eat, be NPO, tube/parenteral feeds 3. Look at glucose trends and adjust

Patient with Diet controlled diabetes Order: Blood glucose monitoring QID Blood glucose monitoring QID Consider doing a HgbA1c Consider doing a HgbA1c Consider oral hypoglycemic agent or insulin if blood sugars in hospital persistently >11.0 mmol/L Consider oral hypoglycemic agent or insulin if blood sugars in hospital persistently >11.0 mmol/L

Patient with diabetes on oral hypoglycemic agents Continue oral agents Continue oral agents Caution if on metformin or actos (pioglitazone) and renal, cardiac or hepatic dysfunction Caution if on metformin or actos (pioglitazone) and renal, cardiac or hepatic dysfunction If blood sugars persistently >10.0 mmol in hospital: If blood sugars persistently >10.0 mmol in hospital: Step 1: maximize oral agents, add another oral agent (from a different class) Step 1: maximize oral agents, add another oral agent (from a different class)  Step 2: if not at target, add insulin Step 2: if not at target, add insulin

Do not use Metformin: If congestive heart failure If renal failure If requiring a test with IV contrast dye Thiazolidinediones If Congestive Heart Failure

How to start Insulin Discontinue oral agents except metformin Discontinue oral agents except metformin Corrective sliding scale alone (if temporary) – if needs >8-10 units for longer than 48 hrs, consider starting “usual” insulin Corrective sliding scale alone (if temporary) – if needs >8-10 units for longer than 48 hrs, consider starting “usual” insulin Start “usual insulin” Start “usual insulin” basal – u/kg/day (either NPH split ac breakfast and supper) or levemir/lantus qhs basal – u/kg/day (either NPH split ac breakfast and supper) or levemir/lantus qhs Mealtime – u/kg/day (breakfast and supper if using NPH, all 3 meals if levemir/lantus) Mealtime – u/kg/day (breakfast and supper if using NPH, all 3 meals if levemir/lantus) Continue corrective scale Continue corrective scale

Why don’t sliding scales work? Action is Retrospective not Prospective Higher risk of Hyper and Hypoglycemia Threshold for insulin administration may be too high Sliding scales can be useful and effective if used appropriately (I.e. as supplemental insulin only) Same amounts given if eating meal or not

How to Use Sliding Scale Insulin Sliding scale insulin can be effective IF used appropriately Never use sliding scale alone (unless for 1 to 2 days to get idea of insulin requirements) Should be used in addition to oral agents or long acting insulin NEVER NEVER NEVER use sliding scale alone in patient with TYPE 1 DIABETES

Choosing a sliding scale

Total Daily Insulin Dose = Lantus 40 units + Novorapid 5 with meals = 40 units + 5 units x B, L, D = 55 units X X Correction Insulin

How do I change the scale? If patient hypoglycemic and needs less insulin, choose scale to the LEFT If patient hyperglycemic and needs more insulin, choose scale to the RIGHT

Patient on Insulin Determine if patient is Type 1 or Type 2!! If unsure treat as type 1 (i.e. needs insulin all of the time) Determine if patient is Type 1 or Type 2!! If unsure treat as type 1 (i.e. needs insulin all of the time) NEVER put a patient with type 1 Diabetes on sliding scale alone even if not eating NEVER put a patient with type 1 Diabetes on sliding scale alone even if not eating Insulin requirements may be more or less than as required as outpatient Insulin requirements may be more or less than as required as outpatient Likely needs long-acting insulin (unless Type 2 and sugars are excellent without it) Likely needs long-acting insulin (unless Type 2 and sugars are excellent without it)

Patient on Insulin Order Blood glucose monitoring QID Blood glucose monitoring QID Continue outpatient regimen unless contraindicated (patient not eating, Type 1 with DKA, etc..) Continue outpatient regimen unless contraindicated (patient not eating, Type 1 with DKA, etc..)

Patient on insulin and eating If HgbA1c < 8, continue preadmission If HgbA1c < 8, continue preadmission If HgbA1c > 8, or CBG > 10 If HgbA1c > 8, or CBG > 10 Start usual insulin Start usual insulin Use corrective scale Use corrective scale Adjust based on glucose pattern Adjust based on glucose pattern

Dosage Titration Practical Example Breakfast 8u H Lunch Dinner Bed 16u N Breakfast 8u H Lunch Dinner Bed 14u N First adjust insulin that caused the low blood glucose 2. Then adjust insulin that caused first high BG of the day

Pre-op Goal Blood sugar 6-10 mmol Start IV D5W at 75 to 100 cc/hour Start IV D5W at 75 to 100 cc/hour Previously on oral agents/diet Previously on oral agents/diet Hold oral agents if not eating Hold oral agents if not eating No basal insulin No basal insulin No meal-time insulin No meal-time insulin Corrective scale only Corrective scale only Previously on insulin Previously on insulin 1/2 – 2/3 usual basal insulin 1/2 – 2/3 usual basal insulin No meal-time insulin No meal-time insulin Corrective scale Corrective scale

NPO Patient with Diabetes on Oral Agents Hold oral agents: Humalog or NovoRapid sliding scale may be added q 4-6 h in case of hyperglycemia: Note: 1 unit of humalog usually decreases blood sugar by 2 to 3 mmol/L OR IV Insulin

NPO Patient with Diabetes on Insulin (2+ shots/day) Option 1: IV Insulin OR Option 2: Subcutaneous Insulin:

NPO Patient with Diabetes on Insulin (2+ shots/day): SC insulin option Order 70-80% of long acting insulin (will need for basal insulin requirements) Add sliding scale to control marked hyperglycemia Remember to order IV D5W to prevent catabolism

Patient with Diabetes on Feeds IF feeds are continuous, no previous insulin: IF feeds are continuous, no previous insulin: Put patient on basal insulin Put patient on basal insulin units/kg/day units/kg/day  Lanuts qhs or NPH q. 12 h Use corrective scale Use corrective scale If feeds stopped suddenly start D5W at 100cc/hr! If feeds stopped suddenly start D5W at 100cc/hr! IF feeds are continuous, previous insulin: IF feeds are continuous, previous insulin: 2/3 usual basal insulin 2/3 usual basal insulin No meal-time insulin No meal-time insulin Use corrective scale Use corrective scale If feeds stopped suddenly start D5W at 100cc/hr! If feeds stopped suddenly start D5W at 100cc/hr!

IF getting bolus feeds: IF getting bolus feeds: Basal- 0.2 u/kg/day or 2/3 usual basal Basal- 0.2 u/kg/day or 2/3 usual basal Give meal-time insulin before bolus feed (3-4 units rapid insulin before 250 cc feed) Give meal-time insulin before bolus feed (3-4 units rapid insulin before 250 cc feed) If feeds stopped suddenly start D5W at 100cc/hr! If feeds stopped suddenly start D5W at 100cc/hr!

Patient on TPN 2 options: 2 options: Insulin included in TPN Insulin included in TPN Subcutaneous insulin if needed Subcutaneous insulin if needed Start long-acting insulin at time when has TPN running (i.e. if receives overnight, start NPH when feeds start and titrate up) Start long-acting insulin at time when has TPN running (i.e. if receives overnight, start NPH when feeds start and titrate up)

How to control glucose levels on TPN Very poorly studied In the TPN bag or subcutaneous? If subcutaneous units/kg/day NPH q. 12 hr levemir/lantus q. 12 or 24 hr regular q. 6 h rapid q. 4 h If in TPN bag 0.1 units regular/gm of CHO plus s.c. sliding scale 3-6 gm/kg/day dextrose = gm 50% dextrose = units insulin in 24 hr supply Next day add 80% of insulin given as sliding scale to insulin bag

Assess Blood Glucoses at Daily, Adjusting Insulin Doses as Appropriate Blood glucose targets can only be achieved via continuous management of the insulin program Blood glucose targets can only be achieved via continuous management of the insulin program There is no “autopilot” insulin regimen for a hospitalized patient! There is no “autopilot” insulin regimen for a hospitalized patient!

Pre-Printed Insulin Orders

X X2

X 40 X 333

X X X

Consult Diabetes Specialty Team – RN +/- MD Insulin pump Insulin pump Severe or frequent hypoglycemia Severe or frequent hypoglycemia Poorly controlled prior to admission (eg. HbA1c>10%) Poorly controlled prior to admission (eg. HbA1c>10%) Unrecognized diabetes complications Unrecognized diabetes complications IS BEING D/C ON INSULIN AND WAS NOT ON INSULIN PRIOR TO ADMISSION – and PLEASE, not on day of d/c!! IS BEING D/C ON INSULIN AND WAS NOT ON INSULIN PRIOR TO ADMISSION – and PLEASE, not on day of d/c!!