1. Special Situations In The Management Of In-Patient Hyperglycemia

2. Special Situations Patients With Renal Failure
Patients Receiving Corticosteroids
Patients Receiving Tube Feeds
Causes of Hypoglycemia

3. 50% 50% The Basal/Bolus Rule In Treating Hyperglycemia
Bolus Or Prandial
Basal
50%
Insulin
Glucose
Breakfast
Lunch
Dinner

4. The Impact Of Renal Failure On In-Patient Hyperglycemia
Decreased Insulin Clearance
Decreased Gluconeogenesis
Both Will Increase The Risk Of Hypoglycemia

5. Renal Failure Insulin Stacking Glucose Bolus Basal Breakfast Lunch
Dinner

6. How Do We Prevent This?
Less Insulin

7. Calculating The Total Daily Dose In Patients With Renal Failure In Our Current Protocol?
If Patient Is New To Insulin And GFR Is < 20 mL/min/1.73m2
If Type 1 Or Unsure Whether Type 1 Or 2: Start At 0.3 Unit/kg (instead of 0.4 unit/kg in normal renal function)
If Newly Diagnosed: Start At 0.4 Unit/kg (instead of 0.6 unit/kg in normal renal function)
If Obese Type 2: Start At 0.6 Unit/kg (instead of 0.8 unit/kg in normal renal function)

8. Calculating The Total Daily Dose In Patients With Renal Failure In Our Current Protocol?
Is The Current Reduced Dose Of Insulin Appropriate?
Do We Need A Scale Where Total Insulin Dose Changes With Different Stages Of Renal Failure?

9. Our Protocol Reduce to 70% 15-29% Reduce to 50% <15 or Dialysis
30-50
No Change
>50
Total Insulin Dose
GFR

10. After Calculating The Total Daily Dose…..
50% As A Basal Dose Using a Long Acting Insulin
50% As A Bolus Dose Divided By 3 And Each ⅓ Is Given After Meal

11. Example
An 80 year old female with no known history of diabetes is admitted with vomiting and hypotension.
She developed new onset renal failure resulting from volume depletion.
She also developed new onset hyperglycemia in the mg/dl range.

12. Example The patient weighs 70 kg with a BMI of 27
Creatinine is 2.8 mg/dl
GFR= 19 ml/min/1.73 m2
Total Daily Dose If Renal Function Is Normal: 0.6 unit/kg= 42 units
Total Daily Dose Given Renal Failure: 42 X 70% = About 30 units
Basal Dose: 30÷2= 15 units
Prandial dose with each meal: 15÷3= 5 units

13. Example The patient weighs 70 kg with a BMI of 27
Creatinine is 1.7 mg/dl
GFR= 31 ml/min/1.73 m2
Total Daily Dose If Renal Function Is Normal: 0.6 unit/kg= 42 units
Total Daily Dose Given Renal Failure: 42 X 80% = About 34 units
Basal Dose: 34÷2= 17 units
Prandial dose with each meal: 17÷3= About 6 units

14. Example The patient weighs 70 kg with a BMI of 27
Creatinine is 3.3 mg/dl
GFR= 14 ml/min/1.73 m2
Total Daily Dose If Renal Function Is Normal: 0.6 unit/kg= 42 units
Total Daily Dose Given Renal Failure: 42 X 50% = About 21 units
Basal Dose: 21÷2= About 10 units
Prandial dose with each meal: 10÷3= About 3 units

15. Further Considerations
Dialysis Can Improve Insulin Sensitivity
Recognize Creatinine Level That May Appear “Within The Normal Range”
Recognize Rapid Changes In Glucose Levels

16. Special Situations Patients With Renal Failure
Patients Receiving Corticosteroids
Patients Receiving Tube Feeds
Causes of Hypoglycemia

17. The Impact Of Corticosteroids On In-Patient Hyperglycemia
Increased Insulin Resistance
Hyperglycemia Worse In The Postprandial Phase

18. Prevalence And Predictors Of Corticosteroid-Related Hospital Hyperglycemia
Retrospective Study
Patients Admitted During A 1 Month Period
Included Those Who Received Oral Or IV Corticosteroids Equal Or Higher Than 40 mg Prednisone For At Least 2 Days
Hyperglycemia Was Defined As BG > 200 mg/dl
Donithi A C et al. Endocrine Practice Vol 12, No

19. 64% Of Patients With A History Of Diabetes Had Hyperglycemia
Prevalence And Predictors Of Corticosteroid-Related Hospital Hyperglycemia
66 Patients
More Than 50% Of Those Without A Known History Of Diabetes Had Hyperglycemia
64% Of Patients With A History Of Diabetes Had Hyperglycemia
Donithi A C et al. Endocrine Practice Vol 12, No

20. Multiple Episodes of Hyperglycemia Were Seen, More With:
Prevalence And Predictors Of Corticosteroid-Related Hospital Hyperglycemia
Multiple Episodes of Hyperglycemia Were Seen, More With:
Known Diagnosis Of Diabetes
Longer Stay
Longer Duration Of Use Of Corticosteroids
Higher Illness Score And Co Morbidities
Donithi A C et al. Endocrine Practice Vol 12, No

21. 50% 50% The Basal/Bolus Rule in Treating Hyperglycemia Bolus Basal
Insulin
Glucose
Breakfast
Lunch
Dinner

22. The Basal/Bolus Rule In Treating Hyperglycemia With Corticosteroids
? 70%
>50%
Bolus
With Corticosteroids
Basal
<50%
Insulin
?30%
Glucose
Breakfast
Lunch
Dinner

23. Patients On Once A Day Corticosteroids
? 70%
>50%
Bolus
With Corticosteroids
Basal
20%
40%
40%
<50%
Insulin
?30%
Glucose
Breakfast
Lunch
Dinner

24. Example # 1
A Patient With No History Of DM Admitted With COPD Exacerbation
Started On Prednisone At 40 mg Once A Day
Developed Significant Hyperglycemia

25. Glucose Readings On 40 mg Of Prednisone
240 mg/dl
260 mg/dl
200 mg/dl
160 mg/dl
Bedtime
Before Dinner
Before Lunch
Fasting

26. Example # 1 The patient weighs 70 kg with a BMI of 25
His creatinine is 1.1 mg/dl
Total daily dose: 0.6 unit/kg= 42 units
Basal dose: 42 X1/3= 14 units
Bolus dose 42-14=28 units
Prandial dose with Breakfast: 28 X20%= 5-6 units
Prandial dose with Lunch And Dinner: 28 X 40%= units

27. Example # 2
A Patient With No History Of DM Admitted With COPD Exacerbation
Started On Prednisone At 40 mg Once A Day
Developed Hyperglycemia

28. Glucose Readings On 40 mg Of Prednisone
180 mg/dl
200 mg/dl
160 mg/dl
100 mg/dl
Bedtime
Before Dinner
Before Lunch
Fasting

29. NPH
With Steroids
Insulin
Glucose
Breakfast
Lunch
Dinner

30. NPH May Not Be Enough Alone……
With Steroids
Insulin
Glucose
Breakfast
Lunch
Dinner
Add Rapid Acting Insulin With Breakfast And Dinner

31. Other Options
Changing The Frequency Of Prednisone To Twice A Day (20 mg Twice A Day)
Changing To A More Long Acting Corticosteroid Like Dexamethasone
In This Case The Bolus Dose Should Be Divided By 3

32. Summary of Corticosteroids and In-Patient Hyperglycemia
Basal/Bolus Insulin With More Bolus Than Basal
Shorter Long Acting Insulin (Such As NPH) With Normal Fasting Glucose
Changing The Type or Frequency of Corticosteroids

33. Special Situations Patients With Renal Failure
Patients Receiving Corticosteroids
Patients Receiving Tube Feeds
Causes of Hypoglycemia

34. The Impact of Tube Feed on In-Patient Hyperglycemia
Continuous And Persistent Carbohydrate Absorption
Continuous And Persistent Hyperglycemia
The Basal/Bolus Rule Is Different…..

35. The Impact of Tube Feeding on In-Patient Hyperglycemia
Glucose No Tube
Feed
Breakfast
Lunch
Dinner

36. The Impact of Tube Feeding on In-Patient Hyperglycemia
Insulin
Glucose
Breakfast
Lunch
Dinner

37. = The Impact of Tube Feeding on In-Patient Hyperglycemia Basal Insulin
Total Daily Dose
Insulin
Glucose
Continuous Tube Feed

38. Calculating The Total Daily Dose In Patients On Continuous Tube Feed
Type 1 DM: O.5 unit/kg
Type 2 DM: 1 unit/kg
No Previous Diagnosis of DM: 0.8 unit/kg

39. Calculating The Total Daily Dose In Patients On Continuous Tube Feed
The Basal Dose Given As A Very Long Acting Insulin
First Dose Given Once The Tube Feed Starts

40. Patients on Continuous Tube Feed
Check Blood Glucose Every 6 Hours
Give Correction Factor Rapid Acting Insulin Based On An Algorithm

41. Correction Factor Dose
Low Dose
Total Insulin Dose <40 units/day
Medium Dose
Total Insulin Dose units/day
High Dose
Total Insulin Dose >80 units/day 9
>320 7 5 3 1 3 5
>320 4 3 2 1 5 7 9
>320 11

42. Patients on Continuous Tube Feed
Decrease Total Dose
By 10% If The Most Recent Glucose Level Was < 80 mg/dl
By 20% If The Most Recent Glucose Level Was < 60 mg/dl
Increase Total Dose
By Adding The Total Dose Of Correction Factor Insulin Needed The Previous Day

43. Example
A 60 year old patient with no history of diabetes is currently on continuous tube feed with no oral intake.
The patient is having significant hyperglycemia in the mg/dl range.
He has received a total of 30 units of rapid acting insulin.

44. Example The patient weighs 70 kg with a BMI of 27
His creatinine is 1.1 mg/dl
Total daily dose: 0.8 unit/kg= 56 units
Basal dose = Total Dose= 56 units
No Prandial Insulin
Correction Factor Algorithm is Medium Dose

45. Glucose Readings After Starting 56 Units Of Basal Insulin
175 mg/dl
3 units of Insulin
190 mg/dl
200 mg/dl
300 mg/dl
7 units of insulin
6 AM MN
6 PM
Noon
The Second Day, the Total insulin Dose Will Be Increased to 72 Units

46. The Next Day, the Total insulin Dose Will Be Decreased to 65 Units
Glucose Readings After Increasing The Dose to 72 Units Of Basal Insulin
78 mg/dl
0 units of Insulin
100 mg/dl
0 unit of Insulin
98 mg/dl
110 mg/dl
0 unit of insulin
6 AM MN
6 PM
Noon
The Next Day, the Total insulin Dose Will Be Decreased to 65 Units

47. Patients On Continuous Tube Feed But On General Diet
Calculating The Total Dose Is The Same
Divide The Total Dose By Six And Then Give That Amount As Bolus Insulin After Meals

48. Patients On Continuous Tube Feed And Liquid/Clear Diet
Non Caloric Liquid:
No Prandial Insulin
Carbohydrate-containing Liquid:
Give 1 Unit For Each 15 Gram Carbohydrate

49. BEWARE of HYPOGLYCEMIA
There is a risk of hypoglycemia if the tube feed is temporarily stopped.
Immediately initiate IV fluid to provide the patient with a minimum of 5 gm of glucose per hour.

50. BEWARE of HYPOGLYCEMIA
Basal Insulin Can Be Given As Two Or Three Doses Of NPH Insulin.
With NPH Insulin Risk Of Prolonged Hypoglycemia Is Less Should The Tube Feed Be Interrupted.

51. Once They Are Eating And The Tube Feed Will Be Stopped….
Divide The Total Dose In Half And This Will Be Basal Dose
Divide The Basal Dose In 3 And Give Each Third After A Meal

52. Tube Feed at Bedtime
Glucose
Breakfast
Lunch
Dinner

53. Tube Feed at Bedtime
Glucose
Breakfast
Lunch
Dinner

54. Tube Feed at Bedtime NPH Insulin Insulin Breakfast Lunch Dinner
Glucose
Breakfast
Lunch
Dinner

55. Tube Feed at Bedtime NPH Insulin Insulin Breakfast Lunch Dinner
Glucose
Breakfast
Lunch
Dinner

56. Example
A 20 year old male with a history of cystic fibrosis who is 4 days status post bilateral lung transplant.
He is on Prednisone at 60 mg a day.
He is also on tube feed overnight for about 10 hours.
He has no history of diabetes.

57. Glucose Readings 180 mg/dl 200 mg/dl 160 mg/dl 320 mg/dl Bedtime
Before Dinner
Before Lunch
Fasting

58. Options
Basal/Bolus (Very Long Acting Insulin and Rapid Acting Insulin)
If Still Hyperglycemia At Night, Add NPH With Tube Feeds
Divide The Prednisone Dose To Q 12 Hours

59. Glucose Readings 180 mg/dl 200 mg/dl 160 mg/dl 320 mg/dl Bedtime
Before Dinner
Before Lunch
Fasting
- The patient was started on two doses of NPH insulin twice a day.
- He eventually needed 25 units along with the tube feed and
16 units in the morning.

60. Special Situations Patients With Renal Failure
Patients Receiving Corticosteroids
Patients Receiving Tube Feeds
Causes of Hypoglycemia

61. Summary Patients with Renal Failure Patients on Corticosteroids
Patients Receiving Tube Feeds

62. Less Insulin Summary Patients With Renal Failure
Patients On Corticosteroids
Patients Receiving Tube Feeds

63. Summary More Bolus Insulin
Patients With Renal Failure
Patients On Corticosteroids
More Bolus Insulin
Remember The Role Of NPH Insulin In Some Patients
Patients Receiving Tube Feeds

64. Summary Basal Equals Total Dose
Patients With Renal Failure
Patients On Corticosteroids
Patients Receiving Tube Feeds
Basal Equals Total Dose
Remember The Role Of NPH Insulin In Some Patients
Beware Of The Hypoglycemia

65. Special Situations Patients with Renal Failure
Patients on Corticosteroids
Patients Receiving Tube Feeds
The Data on the Glycemic Management at Loyola

66. Why is it Important to Collect Data?
Identify Areas of Weakness
Improve The Insulin Protocols
Because We Have To!

67. Hospital Quality Measures
Developed to Assess Quality of Care at Hospitals
Several Associations Participate Like JCAHO and CMS
Include Several Areas that Reflect Adequate Care.

68. Hospital Quality Measures

69. Hospital Quality Measures

70. Hospital Quality Measures

71. Hospital Quality Measures

72. Hospital Quality Measures