1. Inpatient Glycemic Management
UCI Medicine- Inpatient Mini Lecture
Jodi Nagelberg, PGY2
April 2017

2. Learning Objectives Goals of glycemic management
Blood glucose monitoring
Insulin formulations
Calculating insulin regimens

3. Goals of Glycemic Management1
Avoid hypoglycemia 2
Avoid severe hyperglycemia 3
Ensure adequate nutrition 4
Ensure pre-discharge education
Hyperglycemia is an independent factor for mortality in cardiac, septic, and respiratory failure patients ↑ LOS, delayed extubation, ↑risk of perioperative complications
Glycemic control with intensive insulin therapy improves mortality and morbidity

4. Assessment: Criteria for Insulin Therapy
Oral medications and non-insulin injectables should be held and substituted with insulin therapy while in the hospital
Determine last dose of medications (oral/ injectable)
Determine diet status (i.e.-NPO, TPN, TF)
Contact endocrine fellow for patients with insulin pump

5. Clinical Considerations in Glycemic Management
DM1 vs. DM2
Current blood glucose levels
Prior treatment regimen
Comorbidities (i.e.- renal function)
Expected caloric intake

6. Inpatient Glycemic Target
mg/dL
Critically ill: NO firmly established targets via clinical trials, however TIGHT glucose control (i.e gm//dL) has NOT resulted in improved outcomes
Acute MI: suboptimal glycemic control and DM and non-DM patient associated with worse outcomes after acute MI (AHA guidelines)
NICE-SUGAR Study
§ Intensive control ( mg/dL) vs. Standard control ( mg/dL)
§  Intensive control of hyperglycemia is difficult without risk of hypoglycemia
§  Increase mortality in intensive group
Finfer S et al. N Engl J Med 2009;360:1283–1297

7. General Approach
Step 1: Stop oral hypoglycemic agents
Step 2: Calculate total daily dose
Step 3: Determine frequency of monitoring based on nutritional source
Step 4: Determine insulin formulation (basal + nutritional + correctional)
Step 5: Monitor blood sugars and adjust regimen
Step 2: ACCOUNT for home dose, renal function, nutritional source/ schedule, etc.)

8. Step 2: Calculating Insulin Dosage
Total daily dose (TDD)
(Weight in Kg) x (Correctional Factor)
BASAL
NUTRITIONAL
Breakfast
Lunch
Dinner
1/2
1/3
If patient is on insulin at HOME, give them 2/3 of their home dose (basal and nutritional) as they don’t eat the same foods in the hospital vs. at home
EXAMPLE:
75 Kg person
Standard correction: 0.4
Basal 15
Meals 5/5/5
How to calculate correctional factor comes next…

9. Total Daily Dose (TDD) Correctional Factor
LOW = 0.3 units/kg/day: very lean patient, on hemodialysis or very sensitive to insulin (hypoglycemic risk factors)
STANDARD = 0.4 unit/kg/day: patient with normal body habitus
MODERATE = 0.5 units/kg/day: overweight patient
AGGRESSIVE = units/kg/day: patient obese, on steroids, known to be insulin resistant
This is a prelude to next slide, HOW TO KNOW WHICH CORRECTIONAL FACTOR TO USE

10. Correction for Renal Impairment
GFR
% Reduction in Total Daily Units of Insulin
GFR>50
No correction
GFR 30-50
20% reduction
GFR < 30
30-50% reduction
Ex: If TDD = 100 by weight and patient has a GFR of 40  TDD = 80

11. Step 3: Blood Glucose Monitoring Schedule
Diet
Schedule
Oral Diet (TID meals)
TID AC & QHS
Bolus enteral feedings
Prior to each bolus & QHS
Tube feeds, TPN or NPO
Q6H (or Q4H if unstable sugars)
Insulin ggt
Q1H

12. Step 4: Insulin Categories
EVERY patient should have 3 insulin orders, EXCEPT CORRECTIONAL INSULIN alone is OK for:
Pre-diabetics
Borderline diabetic patients
Patients with good glycemic control just on oral medication
…because they still have enough endogenous insulin production to meet basal needs.
Insulin Type
Description
Example
Basal
Background insulin provided by intermediate or long acting insulin
Glargine (Lantus)
Detemir
Nutritional
Rapid acting insulin that is given with meals to mimic the body’s mealtime insulin secretions
Lispro (Humalog)
Aspart (Novolog)
Regular
Correctional (Sliding Scale)
Rapid acting insulin given at the time of blood sugar check to correct for hyperglycemia (frequently given with nutritional insulin)
NUTRITIONAL and CORRECTIONAL SHOULD BE THE SAME TYPE OF INSULIN
CHANGE COLOR OF SHPES AT BOTTOM
Basal
Nutri-tional
Correctional
Daily Insulin + + =

13. UCI Insulin Protocol: Basal+ Nutritional + Correctional
ALL patients should have 3 insulin orders: basal+ nutritional + correctional
(exceptions on previously slide in which case just ISS alone ok)
TDD: Total insulin requirement in a 24H period
This represents ONE EXAMPLE of possible insulin sliding scale
Note the different sliding scale based on regimen tract

14. Pharmacokinetics of Insulin Formulations
Here one can see the relative peak and durations of various insulin formulations
Adapted from
Hirsch, IB: Insulin Analogues. N Engl J Med 352:174–183; table on 177, 2005

15. Step 5: Monitor Blood Sugars and Adjust
If glucose >180 at any time (without risk of hypoglycemia), increase TDD by 10-20%
If glucose consistently > , increase TDD by 30%
If ANY hypoglycemia (BS<70 mg/dL), start D5 ½ NSS and reduce TDD by 20%
If glucose >180, can also take the total daily dose from the day before INCLUDING THE REQUIRED INSULIN SLIDING SCALE and redistribute this to with meals and basal so the TDD includes the ISS

16. Type of Insulin and Monitoring by Nutrition Source
Monitoring Interval
Insulin Type
Oral diet (TID meals)
AC + QHS
Basal: Long or intermediate
Nutritional: Short acting
ISS: Short acting
Bolus enteral feeds
Prior to each bolus + QHS
Continuous tube feeds/
TPN
Q6H (or Q4H if unstable sugars)
Basal: Long or intermediate acting
Nutritional: Regular Insulin
ISS: Regular Insulin
NPO (on D5/ D10)
Basal: long or intermediate acting
Nutritional: None
Insulin ggt
Q1H
Regular insulin only

17. Putting it all together…
Step 1: Discontinue oral hypoglycemic agents
Step 2: Calculate Total Daily Dose (TDD)
Step 3: Determine the distribution of the TDD calculated above based on the nutritional regimen
Eating or Bolus TF
1) Monitor: AC+QHS
2) Basal: Long acting
3) Nutritional: Short acting in 3 doses with each meal
4) Correctional: Short acting, AC
Continuous Infusion/ TPN
1) Monitor: Q6H
2) Basal: Long acting
3) Nutritional: Regular insulin
4) Correctional: Regular insulin
NPO (or nearly- CLD)
1) Monitor: Q6H
Low dose dextrose: (D5 1/2NS)
2) Basal: Long acting
3) Nutritional: none
4) Correctional: Short acting
Step 4: Re-evaluate and adjust TDD daily based on prior 24H
If glucose >180 at any time (without risk of hypoglycemia), increase TDD by 10-20%
If glucose consistently > , increase TDD by 30%
If ANY hypoglycemia (BS<70 mg/dL), start D5 ½ NSS and reduce TDD by 20%
Journal of Hospital Medicine Volume 4, Issue 1, pages 3-15, 12 JAN 2009 DOI: /jhm.391

18. CASE 1
Tom has Type 2 DM, weighs 88kg and is admitted for diabetic foot ulcer. He takes Metformin 1g bid, glipizide 10mg daily at home. He has a normal GFR. His HbA1c is 10% and his blood sugars since admission have ranged How do you manage his DM?

19. Case 1
Step 1: STOP his metformin and glipizide
Step 2: Calculate his TDD (can use correctional factor of 0.5 for overweight patient)
0.5 x 88kg = 44 units daily (normal GFR, no add’l reduction)
44 x 0.5 (or 0.4, consider comordibities) = 22 units basal and 22 units for meals
22/3 = ~7 units with each meal
Step 3: Frequency of monitoring based on his nutritional source
TID meals  check before meals (AC) + QHS
Step 4: Insulin formulation
Basal: 22u Glargine
Nutritional: 7u Lispro TID
ISS: Lispro TID + QHS
Step 5: Monitor for 24H period and increase or decrease TDD accordingly
Each order will have 2 types of insulin:
Basal: provides continuous insulin coverage to diminish BS swings
Nutritional: treats the anticipated BS increase with meals
Correctional: corrects current BS level
Nutritional and Correctional coverage should be the same type of insulin (both Lispro or both Regular)
Correction insulin is designed to be given independent of nutritional intake.
Also remember, studies have shown that the long acting insulins (glargine or levemir) plus the rapid acting insulins (aspart or lispro) mimic physiologic production of insulin better then any other combination (such as NPH, 70/30 combos).

20. Case 1: Learning Points
Hold oral DM meds when inpatient (minimize hypoglycemia, improve glycemic control)
DO NOT place diabetic patients only on Correctional Insulin (unless as specified elsewhere)
Use weight based method to get accurate insulin requirement
Adjust insulin dose for GFR:
GFR > 50, no correction
GFR 30-50, 20% reduction
GFR < 30, 30-50% reduction
Its ok to only use Correctional insulin for pre-diabetics or borderline diabetic patients bc they still have enough endogenous insulin production to meet basal needs; or in patients with good glycemic control just on oral medications

21. Case 2
Tom has Type 2 DM and was admitted for diabetic foot ulcer. Today is hospital day 3 and his blood sugars have been stable with Lantus 22u QHS, Lispro 7u TID and Lispro Correctional. Tomorrow he is having a L foot amputation. How should his insulin regimen be adjusted?
Meaning he will need to be made NPO

22. Case 2: Insulin Management in NPO Patient
Basal: Continue evening Lantus dose
Nutritional: Stop Lispro for nutritional insulin because patient is NPO
START IVFs (carbohydrate source): D5 or D10 (consider volume status and comorbidities, i.e.- CHF, ESRD)
ISS: Continue Lispro correctional coverage
…Remember though, Type I DM requires insulin AND carb source (D5 or D10) at all times (even when NPO, to prevent DKA). So if Type I diabetic is NPO, DO NOT hold basal insulin and DO start D5 or D10
Typically patients require 3 types of insulin orders: basal + nutritional + ISS
HOWEVER, when NPO, patient STILL REQUIRES basal AND a dextrose source AND ISS
Start D5 or D10 if carb source is interrupted (NPO). The infusion rate will have to take into account the patient’s general condition (CHF, cirrhosis)
Do not hold basal insulin if long acting (levemir or glargine)
1 L of D5 1/2NS provides less calories than a small candy bar (170 calories per L)

23. Case 3
Tom has Type 2 DM and was admitted for diabetic foot ulcer. Today is hospital day 3 and his blood sugars have been stable with NPH 22 units bid and Regular Correctional. Tomorrow he is having a L foot amputation. How should his insulin regimen be adjusted?
Same Tom, different regimen
HOW TO USE NPH/ REGULAR

24. Pharmacokinetics of Insulin Formulations
Here one can see the relative peak and durations of various insulin formulations
See NPH is NOT as long lasting as glargine
Adapted from
Hirsch, IB: Insulin Analogues. N Engl J Med 352:174–183; table on 177, 2005

25. Case 3: Management of NPH/ Regular in NPO Setting
Basal:
Continue evening NPH dose
Half morning NPH dose
START IVF (carbohydrate source): D5 or D10
Correctional: Continue Correctional insulin
Alternatively, On admission, change from NPH to Lantus for better glycemic control
NPH is intermediate acting  CONTINUE THE BASAL INSULIN SOURCE WHILE NPO
Regular: short acting

26. Case 4
Tom has Type 2 DM, admitted for diabetic foot ulcer and today is hospital day 3. He is treated with Humalog 7u TID & Lantus 22u nits QHS. Tom has pre- meal BS of 65 before lunch, but does not have any symptoms of hypoglycemia. What should you do?

27. Case 4: Management of Hypoglycemia
First: Treat hypoglycemia
If possible, give PO 1st (juice)
Treat SYMPTOMS, not just the number
15-15 rule
Treat with 15 grams of carbs and Recheck every 15 minutes, until blood glucose > 75 mg/dL
4 oz of juice/ 8 oz fat free milk = 15 grams of carbs
Second: Lower TDD of insulin
Tom has low pre-meal BG readings: confirm he ate breakfast
Decrease pre-meal regimen form 7 to 5 u TID (~10-20%)
Multiple different ways to change insulin regimen to manage hypoglycemia and prevent further
-One way is to lower TDD by 20%, or determine where specifically he has low BG and just lower the insulin reigmen affecting that low reading
-For example, a low pre-lunch lunch reading can be from a high pre-breakfast insulin dosing (see pharmacokinetics graph)

28. Case 5
Jerry is a 65 yo male who is receiving continuous TPN. He has a h/o DM, weighs 80kg and is on continuous TPN. His blood glucose readings have ranged , how do you manage his DM and hyperglycemia?

29. Case 5: TPN Management Monitoring: Q6H Insulin regimen:
Basal: Lantus 12u QHS
Nutritional: Regular 5u Q6H
Correctional: Regular insulin Q6H
Learning Points
For continuous feeds (TPN), check blood glucose levels Q6H
Regular correctional insulin preferred over rapid acting (Aspart/Lispro) because patient is not taking food in orally and regular lasts longer then rapid acting
Use weight based method. He weighs 80kg and 0.4 units/kg/day = 32 units total daily dose
You can do 40% long acting and use 60% as short acti

30. Inpatient Diabetes Management: Pearls
HOLD all oral DM meds and noninsulin injectable meds on admission
If patient is on insulin, give them 2/3 of their home dose (basal and nutritional) as they eat less inpatient vs. at home
Always account for renal function
When NPO, always give carb source (D5 D10 depending on overall fluid state)
Pt should be on same insulin for nutritional and correctional
Monitor daily and adjust as needed

31. References
Scott, Shruti. Inpatient Glycemic Management. UCI Mini-Lecture. 2013
American Diabetes Association. Diabetes Care Jan; 39(Supplement 1): S99-S