1. Inpatient Hyperglycemia Management

2. Inpatient Hyperglycemia: General Points
Avoid the temptation to “ignore” the patient’s diabetes
Try to distinguish type 1 and type 2 diabetes. Patients with type 1 diabetes will require at least some basal insulin at ALL times, even when NPO.
Assess pre-admission medications and recent glycemic control.
Diet should be individualized, based on body weight and other comorbidities. Consider a nutrition services consult.

3. General Points, continued
Order fingerstick glucose monitoring 4 times daily in all patients with diabetes (pre-meal and hs if eating; q6h if NPO) for at least the first 48 hours
Glucose targets in non-pregnant, non-ICU patients should be mg/dl, with glucose readings before meals. *
Revise insulin doses every 1-2 days based on results of fingerstick glucose testing.
* Current position statements suggest premeal targets <110 mg/dl, and
< 180 mg/dl at all other times for non-ICU patients

4. Blood Glucose Targets Labor and Delivery Critical Care Units
100 mg/dl
Critical Care Units
110 mg/dl
Non-Critical Care Units
mg/dl pre-meal (midpoint 110 mg/dl)
180 mg/dl maximal
American Diabetes Association, 2005

5. Glucose Measurements The standard measure is venous or plasma glucose
Whole blood glucose is 12-15% less than venous glucose, and may be influenced by hematocrit
Arterial blood is 7% greater that venous blood, with less of a difference in fasting or postabsorptive states
Capillary (fingerstick) blood is similar to arterial blood
From a practical standpoint, capillary blood or arterial blood are used for glucose measurements in hospital, and in a fasting state, are sufficiently close to venous measurements to guide therapy

6. General Points, continued
Do NOT leave patients on regular insulin “sliding scale” as the ONLY form of treatment.
Try to approximate the at home regimen as long as possible BEFORE discharge
Utilize the admission as a teaching opportunity for those patients who lack knowledge about their diabetes. Consider Diabetes Education consultation.

7. For patients treated with oral agents prior to admission:
NPO, well-controlled on oral hypoglycemic agents (OHA):
D/C OHA and use TEMPORARY insulin “sliding scale”
NPO, well-controlled on oral agent that does not result in hypoglycemia:
D/C metformin
Thiazolidinediones may be continued
D/C alpha-glucosidase inhibitors

8. For patients treated with oral agents prior to admission:
NPO, poorly controlled on OHA:
Use insulin. “Sliding scale” can be used for hours. If it is clear that patients will require insulin on discharge, proceed with the addition of a long/intermediate-acting insulin

9. For patients treated with oral agents prior to admission:
Eating, well-controlled on OHA or other oral agent:
Continue OHA
D/C metformin if unstable, in CHF, dehydrated or with impaired renal function
Continue thiazolidinediones
Continue alpha-glucosidase inhibitors

10. For patients treated with oral agents prior to admission:
Eating, but poorly controlled on oral agents:
Consider adding a second agent, HOWEVER, since this often takes weeks to optimize, it is usually preferable to proceed with insulin therapy.

11. For NPO insulin-treated patients:
Type 1 DM
Consider using an iv insulin infusion. (This technique is underutilized in hospital)
Alternatively, give 1/2-2/3 of intermediate/long-acting insulin + “sliding scale”
Unless markedly hyperglycemic, provide D5W
Check BG every 6 hours (q 1-2 hours on iv insulin)
NOTE: Insulin is NEVER to be stopped entirely in patients with type 1 diabetes.
Type 2 DM
Insulin-treated patients may demonstrated excellent control when diet restricted alone, and may require only “sliding scale”
Alternatively, give ½ of long/intermediate-acting insulin + “sliding scale”
Unless markedly hyperglycemic, provide D5W with insulin
Check BG every 6 hours
NOTE: Significantly insulinopenic patients are more easily managed as if they had type 1 diabetes, i.e., with iv insulin

12. For insulin-treated patients who are eating:
Continue usual insulin regimen.
It may be desirable for the knowledgeable and skilled patient to perform diabetes self-management while in hospital.

13. Fingerstick Glucose Monitoring
Perform 4 times daily (ac and hs) for patients on most insulin regimens.
Perform 1-2 times daily for patients on oral agents or only one insulin injection, if in good control.
Fingerstick glucose should be recorded on a bedside log, along with the corresponding insulin administered (all types of insulin)

14. Hypoglycemia orders: Patient alert and cooperative: Non-alert patient:
Give 15 gm CHO
4 oz juice/soda is 15 gm carbohydrate
3-2.5 inch graham crackers is 15 gm carbohydrate
Recheck in 15 minutes, repeat until glucose > 70 mg/dl
Non-alert patient:
Give 25 gm dextrose iv (1/2 amp D50W) or 1 mg glucagon im (if no venous access). Recheck glucose after 5-10 minutes, retreat as necessary.
If severe, or related to OHA or long-acting insulin, consider iv dextrose as D5W or D10W.
Investigate cause and modify treatment regimen as indicated.

15. Think Twice When Ordering “Sliding Scales”
Regular insulin “sliding scale” should be discouraged as the sole diabetes treatment in hospitalized patients, since it does little more than respond in a belated fashion to poor glycemic control.
Instead, treatment of hyperglycemia in a proactive fashion is preferred, with use of long-acting insulins in combination with short and rapid acting insulins, i.e., physiologic insulin replacement.
In certain patients who are NPO, or in those in whom it is difficult to predict requirements, “sliding scale” for hours is acceptable. Patients with severe insulin deficiency (all type 1 and some type 2 patients) must also be provided basal insulin replacement.

17. Peri-Op Orders: General Points
Type 1 diabetes:
Patients need insulin at ALL times, even NPO.
Place on iv insulin
If on HS insulin glargine, this can be given as usual
Type 2 diabetes:
Hold OHA, metformin, and alpha-glucosidase inhibitors on the day of procedure. Hold sustained release metformin the day before.
Thiazolidinediones can be given, if pills allowed.
If on insulin, give ½ of intermediate insulin (NPH) in the morning, or continue insulin glargine OR

18. Intravenous Insulin Infusion
Indications:
Diabetic ketoacidosis*
Hyperosmolar hyperglycemic state*
Uncontrolled diabetes despite subcutaneous insulin
Total parenteral nutrition (TPN)
Patients with type 1 diabetes who are NPO, perioperative, in labor and delivery
Any patient post-MI with hyperglycemia
Any ICU patient with hyperglycemia
* Should NOT use preprinted iv insulin orders. See Diabetes Care 2004;27(1):S94

19. Continuous Intravenous Insulin
Discontinue previous insulin orders (there may be overlapping basal insulin)
Carbohydrate is to be given at the same time
Enteral feeding
CVN
D5W 0.45 NS

20. Continuous Intravenous Insulin
Insulin infusion is Regular insulin 100 units/100 ml of Sodium Chloride 0.9 %
(1 unit of insulin/1 ml of NS)
Target blood sugar can be specified but is recommended to be mg/dl

21. Dose Adjustments
Four algorithms with insulin infusion rates for blood sugar ranges are used to determine dose adjustments
To make a dose adjustment you need to know
Algorithm being used
Current blood sugar
Previous blood sugar

22. Dose Adjustments
The previous blood sugar compared with the current blood sugar may determine the need to
Move up to the next higher algorithm (e.g., from algorithm 2 to algorithm 3) or
Down to the next lesser algorithm (e.g., from algorithm 2 to algorithm 1)

23. Dose Adjustments
Current blood sugar and where it is located in the algorithm being used may determine the dose adjustment
Blood sugar of 126 mg/dl in algorithm 2 is a rate of 1.5 units/hour
If the blood sugar is greater than 140 mg/dl and it is increasing, it will be necessary to move up to the next higher algorithm

24. Rate Adjustment Criteria
Previous Blood Sugar
Current Blood Sugar
Adjustment
Greater than 200 mg/dl
Decreased by at least 60 mg/dl
Stay in the same algorithm; adjust rate as per algorithm
Does not decrease by at least 60 mg/dl (or is increasing)
Move up to the next higher algorithm; adjust rate as per algorithm

25. Rate Adjustment Criteria
Previous Blood Sugar
Current Blood Sugar
Adjustment
mg/dl
Decreased by at least 30 mg/dl
Stay in same algorithm; adjust rate as per algorithm
Does not decrease by alt least 30 mg/dl (or is increasing)
Move up to the next higher algorithm; adjust rate as per algorithm

26. Rate Adjustment Criteria
Previous Blood Sugar
Current Blood Sugar
Adjustment
Any value
Decreased by more than 100 mg/dl in one hour
Move down to the next lesser algorithm; adjust rate as per algorithm; if already in algorithm 1, decrease the infusion by half

27. Rate Adjustment Criteria
Current Blood Sugar
Adjustment
Blood sugar less than 70 mg/dl
STOP THE INFUSION. Recheck blood sugar every 15 minutes. Resume insulin infusion at the next lesser algorithm when the glucose is greater than 110 mg/dl. If already using algorithm 1, decrease the infusion by half.
The half life of intravenous insulin is 5-10 minutes.

28. Rate Adjustment Criteria
Current Blood Sugar
Adjustment
Blood sugar less than 50 mg/dl
STOP THE INFUSION. If patient alert and able to take fluids , give 15 grams of carbohydrate orally. If patient confused or unconscious, or NPO, give 25 ml of 50 % Dextrose IV. Recheck blood sugar every 15 minutes. Repeat oral carbohydrate or IV 50% Dextrose every 15 minutes until blood sugar is greater than 70 mg/dl. Resume insulin infusion at the next lesser algorithm when the glucose is greater than 110 mg/dl. If already using algorithm 1, decrease the infusion by half.

29. Scheduled Subcutaneous Insulin Orders
Pre-meal or bolus insulin
Insulin type
Number of units
Basal insulin

30. Scheduled Subcutaneous Insulin Orders
Pre-meal correction insulin algorithms based on insulin sensitivity
Low dose algorithm for patients who require up to 40 units of insulin /day
Medium dose algorithm for patients requiring of insulin/day
High dose algorithm for patient requiring over 80 units of insulin/day
Individualized algorithm for correction may be written instead

31. Scheduled Subcutaneous Insulin Orders
Targets are specified
Frequency and timing of blood sugar checks are to be specified
Point-of- care test results done within 30 minutes are used to determine correction dose
Correction doses are given pre-meal only
Aspart or lispro 5-15 minutes before the start of the meal
Regular 30 minutes before the start of the meal

32. The Goal of Insulin Therapy is Physiologic Replacement
American Diabetes Association (2003). Insulin therapy in the 21st century. Alexandria, VA: ADA.

33. Starting Insulin in the Newly Diagnosed Patient
Calculate the total daily dose*
Determine basal insulin requirement
40 to 50% of total daily dose
Determine the mealtime insulin requirement
50 to 60% of total daily dose
Determine the correction dose
Based on estimate of insulin sensitivity
* Total daily dose can be estimated based on iv requirements or weight

34. Transition From IV to SQ Insulin
IV insulin covers basal insulin requirements in the NPO patient
Example: iv dose is 2 units/hour
Basal requirements: 2 u/h x 24 hrs= 48 units
48 u x 80% = 38 units basal sq insulin dose
Food requirements equal basal requirements when eating:
38/3 = 13 units with each meal
Correction requirements are based on the “1700 rule”*
1700 / total daily dose or 1700/76 = ~25 (1 u lowers glucose 25 mg/dl)
Regimen: 13 u rapid acting insulin analog before meals
38 u insulin glargine at bedtime
premeal correction: 1 u for every 25 mg/dl above target
* The “1700 rule” is simply an observation that estimates insulin sensitivity

35. Total Daily Dose Based on Weight
Patient Description
Insulin (units/kg.day)
Trained athlete
0.5
Mod. active man
0.6
Sedentary man; 1st trimester of pregnancy
0.7
Mod. stressed man; 2nd trimester of pregnancy
0.8
Severely stressed man; 3rd trimester of pregnancy
0.9
Systemic bacterial infection; full term pregnancy
1.0
Severely ill man

36. Subcutaneous Insulin Dose Based on Weight
Example:
70 kg man x 0.6 u/kg = 42 units total daily dose
Basal insulin = 42 x 50% = 21 units
Food insulin = 21/3 = 7 units with each meal
Correction insulin = 1700/42 =~40
Suggested insulin regimen:
7 units rapid acting insulin analog each meal
21 units insulin glargine at bedtime
Premeal correction insulin 1 unit for every 40 mg/dl above target

37. Remember…
Aggressive glycemic control in hospitalized patients improves clinical outcomes.
Management of diabetes in an inpatient setting requires familiarity with the use of both iv and sc insulin, both in intensive care units and on general nursing units.
The time-honored traditions of “sliding scale” insulin, and of withholding insulin for procedures and euglycemia should be buried along with fractional urine testing.

38. Remember… Most hospitalized patients are discharged
Inpatient diabetes treatment should transition smoothly to outpatient management
Think ahead; plan early
? Dietary consultation
? Diabetes education consultation
? Endocrinology consultation