1. Diabetes Management in Hospital November 16, 2003 Endocrine Fellows Conference Paul C. Davidson, MD, FACE Atlanta Diabetes Associates Atlanta, Georgia

2. Diabetes in Hospitalized Patients 6 Million US Hospitalizations 15% of Admissions 24 Million Hospital Days 20% of All Hospital Days 36% First Diagnosed in Hospital 66% No Documentation by Physician 27% Labeled Hyperglycemia 2% Diagnosis on Face Sheet

3. Diabetes in Hospitalized Patients 1997 Costs $ 23,500 Each Diabetes Patient vs.$ 23,500 Each Diabetes Patient vs. $12,200 for Non-Diabetes Patient $12,200 for Non-Diabetes Patient 60% of All Diabetes-Related Costs60% of All Diabetes-Related Costs Only 5% DKA, HHNKCOnly 5% DKA, HHNKC 48% Diabetes Complications48% Diabetes Complications 52% Other Conditions52% Other Conditions

4. Impairment of Phagocytic Function Bybee, 1964 Short, Transient Hyperglycemia Abnormalities in granulocyte adherence, chemotaxis, phagocytosis, bacterocidal function. Bybee, 1964; Hill, 1974; Chase, 1981; Rosenberg, 1990 Effects of Hyperglycemia Infectious Disease

5. Global Perspectives Effect of Underlying Diabetes Impact of Acute Diabetic State Stress Response Counter Regulatory Hormones Epinephrine, Glucagon, Cortisol, GH Glucose Toxicity Increased Glucose, FFA, Ketones Acidosis: Lactic or Ketosis Mechanism of Progressive Insulin Resistance Diabetes in Hospitalized Patients. Pathophysiology

6. Role of Insulin and Glucose in Acute MI Insulin l Anti-inflammatory –Acute Reduction CRP l Anti-thrombotic –Profibrinolytic Suppresses PAI-1 l Suppresses FFA –Preserve Endothlium l Suppresses MMPs –Prevents Rupture Glucose l l Pro-inflammatory l l Pro-thrombotic l l Induces MMPs (Matrix Matalloproteinases) –Mediates Plaque Rupture Dandona Diab Care 2003

7. Detriments: Decreased Appetite Meals Held or Delayed Decreased Activity Oral Agents Stopped Insulin Held Sliding Scale Insulin Only for Extreme BGs Benefit: Detecting Hyperglycemia Effects of Hospitalization on Diabetes Management

8. Missed Opportunities: To Reduce Hospital Morbidity and Mortality To Initiate Interventions to Delay Long-term Complications Diabetes in Hospitalized Patients. Diabetes in Hospitalized Patients. Failure to Treat Hyperglycemia

9. Diabetes in Hospitalized Patients. Psychology l Patients expect good glycemic control as part of hospital care l They strive for recommended goals at home l Difficult to understand staff’s casual approach to BG’s >150

10. Diabetes in Hospitalized Patients. Clinical Risks High-risk for Bacterial Infection –Surgery –Catheters –Intravenous Access –Anesthesia Problems with wound healing Problems with tissue and organ perfusion

11. Infections in Diabetes l One BG >220 mg/dl results in 5.8 times increase in nosocomial infection rate l Two hours hyperglycemia results in impaired WBC function for weeks Pomposelli, New England Deaconess, J Parenteral and Enteral Nutrition 22:77-81,1998

12. Side Effects of BG >200 mg/dl l Reduced Intravascular Volume l Dehydration l Electrolyte Fluxes l Impaired WBC Function l Immunoglobulin Inactivation l Complement Disabling l Increased Collagenase, Decreased Wound Collagen

13. Evidence for Immediate Benefit of Normoglycemia in Hospitalized Patients l Numerous Publications on in Vitro Evidence –Neutrophil Dysfunction –Complement Inhibition –Altered Redox State (Pseudohypoxia) –Glucose Rich Edema as Culture Media l Recent Outcome Studies Supporting Good Glucose Control in Hospital Setting l Reduction in CRP

14. Open Heart Surgery in Diabetes John Hopkins l 24.3% with infections l BG divided into quartiles Relative Odds Q1 121-206 20.1% Q2 207-229 21.6% 1.17 Q3 230-252 29.8% 1.86* Q4 252-352 25.7% 1.72* Golden SH Diabetes Care 22: 1408, 1999 * P < 0.01

15. Admission glucose values >108 mg/dl IV Insulin with Bypass Surgery Hospital mortality identical Diabetics and Non-diabetics (1.75% vs. 1.71%) Usual Diabetic Mortality 50% Higher CABG in Diabetes Kalin 1998

16. 623 Hyperglycemic Patients Mortality and Stroke Severity Increase Linearly with BG BG >144 mg/dl in First 24 Hours Double Mortality Risk Stroke in Diabetes Weir

17. Diabetes with Steroid Therapy Piedmont Hospital 1998 l Problem Noted by DRC Case Managers –Frequency of Hyperglycemia in “Non- Diabetic” Patients –Prevalence Among Steroid Treated –No Systematic Plan of Response –Frequency of Discharge “Out-of-Control” The Dark Side of Corticosteroids

18. Diabetes with Steroid Therapy Piedmont Hospital 1998 Chart Review by Terry Kaplan RN

19. Diabetes with Steroid Therapy Piedmont Hospital 1998 Opportunity for Improvement 59%

20. Classical Diabetes Management Typical A1c 9% l The daily dosage of insulin is divided –2/3 in the morning and 1/3 in the evening. –Two thirds NPH and 1/3 Regular. l Results –70/30 Insulin (The insulin for the retarded) –No Patients to Goal!

21. Sliding Scale Insulin Five Units for Each Plus on bid Urine Testing Table of BG Ranges and R Doses Correction Bolus Formula – (BG-Target BG) / CF No Benefit When Used Without Basal Insulin Three Times More Hyperglycemia Compared to Standing Dose NPH Queale, 1997

22. Methods For Managing Hospitalized Persons with Diabetes l Continuous Variable Rate IV Insulin Drip Major Surgery, NPO, Unstable, MI, DKA, Hyperglycemia, Steroids, Gastroparesis, Delivery, etc l Basal / Bolus Therapy (MDI)

23. Continuous Variable Rate IV Insulin Davidson 1982 l Give continuous rate of Glucose in IVF’s l Mix Drip with 125 units Regular Insulin in 250 cc NS l Starting Rate: Units / hour = (BG – 60) x 0.02 l Check glucose hourly and adjust l Change Multiplier to keep in desired range –100 to 140 mg/dl

24. Continuous Variable Rate IV Insulin l Adjust Multiplier to obtain glucose in target range If BG not decreasing > 50 mg/dL and > 140 mg/dL, increase by 0.01 If BG < 100 mg/dL, decrease by 0.01 If BG 100 to 140 mg/dL, no change in Multiplier l If BG is < 80 mg/dL, Give D50 cc = (100 – BG) x 0.4 l Once eating, continue drip till 2 hour post SQ insulin

25. Glucommander AN ADAPTIVE, COMPUTER-DIRECTED SYSTEM FOR IV INSULIN, SHOWN TO BE SAFE, SIMPLE, AND EFFECTIVE IN 120,618 HOURS OF OPERATION l Invented in 1984 Davidson and Steed l Based on 17 Year Experience with a Computer Based Algorithm for the Administration of IV Insulin l Developed for Marketing by MiniMed and Roche l GMS System l Shelved Pending FDA Approval of IV Use of Insulin l Useful and Safe for Any Application of IV Insulin

26. Glucose Management System

27. Intravenous Insulin with Severe Illness Three major recent studies DIGAMI: Prospective Randomized Study of Intensive Insulin Treatment on Long Term Survival After Acute Myocardial Infarction in Patients with Diabetes Mellitus Malmberg, et al. BMJ. 1997;314:1512-1515. Portland: Continuous Insulin Infusion Reduces Mortality in Patients with Diabetes Undergoing Coronary Artery Bypass Grafting Fumary et al J Thorac Cardiovasc Surg 2003;123:1007-21 Leuven: Intensive Insulin Therapy in Critically Ill Patients Van den Berghe et al N Engl J Med 2001; 345: 1359-67

28. DIGAMI Study Diabetes, Insulin Glucose Infusion in Acute Myocardial Infarction l Acute MI With BG > 200 mg/dl l Intensive Insulin Treatment l IV Insulin For > 24 Hours l Four Insulin Injections/Day For > 3 Months l Reduced Risk of Mortality By: 28% Over 3.4 Years 51% in Those Not Previous Diagnosed Malmberg BMJ 1997;314:1512

29. Cardiovascular Risk Mortality After MI Reduced by Insulin Therapy in the DIGAMI Study Malmberg, et al. BMJ. 1997;314:1512-1515. All Subjects (N = 620) Risk reduction (28%) P =.011 Standard treatment 0.3.2.4.7.1.5.6 01 Years of Follow-up 2345 Low-risk and Not Previously on Insulin (N = 272) Risk reduction (51%) P =.0004 IV Insulin 48 hours, then 4 injections daily 0.3.2.4.7.1.5.6 01 Years of Follow-up 2345 6-11

30. Open Heart Surgery in Diabetes Portland St. Vincent Medical Center Perioperative Blood Glucose Furnary et al, The 34th Meeting of The Society of Thoracic Surgeons New Orleans, LA January 26, 1998

31. Mortality of DM Patients Undergoing CABG Fumary et al J Thorac Cardiovasc Surg 2003;123:1007-21

32. ICU Survival l 1548 Patients l All with BG >200 mg/dl l Randomized into two groups –Maintained on IV insulin –Conventional group (BG 180-200) –Intensive group (BG 80-110) l Conventional Group had 1.74 X mortality Van den Berghe et al, NEJM 2001;345(19):1359

33. ICU Survival Conventional Intensive Mean AM BG 153 103 % Receiving Insulin 39% 100% BG < 40 mg/dl 6 39 Van den Berghe et al, NEJM 2001;345(19):1359 No serious hypoglycemic events

34. ICU Survival Intensive Therapy (80 to 110 mg/dL) resulted in: l 34% reduction in mortality l 46% reduction in sepsis l 41% reduction in dialysis l 50% reduction in blood transfusion l 44% reduction in polyneuropathy Van den Berghe et al, NEJM 2001;345(19):1359

35. P=0.000 9 P=0.026 BG<110 110<BG<150 BG>150 ICU Mortality Effect of Average BG Van den Berghe et al (Crit Care Med 2003; 31:359-366)

36. All three have IV insulin protocols Complex Require ICU housing Specially trained nurses Dedicated supervision Consequently not widely accepted IV Insulin Based Studies DIGAMI, Portland, Leuven

37. 1. Start Portland protocol during surgery and continue through 7 AM of the third POD. Patients who are not receiving enteral nutrition on the third POD should remain on this protocol until receiving at least 50% of a full liquid or soft American Diabetes Association diet. 2. For patients with previously undiagnosed DM who have hyperglycemia, start Portland protocol if blood glucose is greater than 200 mg/dL. Consult endocrinologist on POD 2 for DM workup and follow-up orders. 3. Start infusion by pump piggyback to maintenance intravenous line as shown in Appendix Table 1. 4. Test blood glucose level by finger stick method or arterial line drop sample. Frequency of blood glucose testing is as follows: a. When blood glucose level greater than 200 mg/dL, check every 30 minutes. b. When blood glucose level is less than 200 mg/dL, check every hour. c. When titrating vasopressors, (eg, epinephrine) check every 30 minutes. d. When blood glucose level is 100 to 150 mg/dL with less than 15 mg/dL change and insulin rate remains unchanged for 4 hours (“stable infusion rate”), then you may test every 2 hours. e. You may stop testing every 2 hours on POD 3 (see items 1 and 8). f. At night on telemetry unit, test every 2 hours if blood glucose level is 150 to 200 mg/dL; test every 4 hours if blood glucose level is less than 150 mg/dL and “stable infusion rate” exists. 5. Insulin titration according to blood glucose level is performed as follows a. When blood glucose level is less than 50 mg/dL, stop insulin and give 25 mL 50% dextrose in water. Recheck blood glucose level in 30 minutes. When blood glucose level is greater than 75 mg/dL, restart with rate 50% of previous rate. b. When blood glucose level is 50 to 75 mg/dL, stop insulin. Recheck blood glucose level in 30 minutes; if previous blood glucose level was greater than 100 then give 25 mL 50% dextrose in water. When blood glucose level is greater than 75 mg/dL, restart with rate 50% of previous rate. c. When blood glucose level is 75 to 100 mg/dL and less than 10 mg/dL lower than last test, decrease rate by 0.5 U/h. If blood glucose level is more than 10 mg/Dl lower than last test, decrease rate by 50%. If blood glucose level is the same or greater than last test, maintain same rate. d. When blood glucose level is 101 to 150 mg/dL, maintain rate. e. When blood glucose level is 151 to 200 mg/dL and 20 mg/dL lower than last test, maintain rate. Otherwise increase rate by 0.5 U/h. f. When blood glucose level is greater than 200 mg/dL and at least 30 mg/dL lower than last test, maintain rate. If blood glucose level is less than 30 mg/dL lower than last test (or is higher than last test), increase rate by 1 U/h and, if greater than 240 mg/dL, administer intravenous bolus of regular insulin per initial intravenous insulin bolus dosage scale (see item 3). Recheck blood glucose level in 30 minutes. g. If blood glucose level is greater than 200 mg/dL and has not decreased after three consecutive increases in insulin, then double insulin rate. h. If blood glucose level is greater than 300 mg/dL for four consecutive readings, call physician for additional intravenous bolus orders. 6. American Diabetes Association 1800-kcal diabetic diet starts with any intake by mouth. 7. Postmeal subcutaneous Humalog insulin supplement is given in addition to insulin infusion when oral intake has advanced beyond clear liquids. a. If patient eats 50% or less of servings on breakfast, lunch, or dinner tray, then give 3 units of Humalog insulin subcutaneously immediately after that meal. b. If patient eats more than 50% of servings on breakfast, lunch, or supper tray, then give 6 units of Humalog insulin subcutaneously immediately after that meal. 8. On third POD, restart preadmission glycemic control medication unless patient is not tolerating enteral nutrition and is still receiving an insulin drip. Portland Protocol Furnary et al J Thorac Cardiovasc Surg 2003;123:1007-21

38. Complexity versus Simplicity. Arterial BG q 1-2 hours, then q 4 hours if stable. If BG >220 give 4 units/hr. If BG >110 mg/dl give 2 units/hr.. If F/U BG in 1-2 hours >140 mg/dl Increase insulin 1-2 units/hr.. If F/U BG in 1-2 hours 121-140 mg/dl increase insulin 0.5-1 unit/hr.. If F/U BG 110-120 mg/dl increase insulin 0.1-0.15 units/hr.. If BG 81-110 mg/dl then do not change.. If BG decreases >50% decrease insulin 50%.. If BG 61-80 mg/dl decrease insulin “reduced as dictated by previous BG level.. Repeat BG in one hour.. If B 41-60 mg/dl discontinue insulin.. If BG >40 mg/dl give 10 Gm glucose IV. Repeat q 1 hr until BG 81-110 mg/dl.. If BGT decreases >20% in 81-110 mg/dl range decrease insulin 20%.. If patient transferred from ICU and insulin <2 units/hr, DC insulin.. If patient transferred from ICU and insulin >2 units/hr get endocrine consult. Van den Berghe Orders Glucommander Orders Requires ICU nurses trained in protocol and study physicianAdministered by floor nurse and any physician

39. Glucommander. Summary of Performance Glucose Averages for 3404 Patients Glucose mgm/dl 50 Percentiles 90 10 Hours Percentiles

40. A System for the Maintenance of Overnight Euglycemia and the Calculation of Basal Insulin Requirements in Insulin-Dependent Diabetics NEIL H. WHITE, M.D., DONALD SKOR, M.D., JULIO V. SANTIAGO, M.D.; Saint Louis, Missouri Ann Int Med 1982 ;97:210-214 Practical Closed Loop Insulin Delivery 1/slope = Multiplier = 0.02 0 1 2 3 4 5 6 0100200300400 Glucose (mg/dl) Insulin Rate (U/hr) INSPIRATION FOR GLUCOMMANDER

41. Historical Perspective l IV Insulin Algorithm –Insulin = (BG-60) x Multiplier l “White’s” Multiplier Not Applicable for Majority –Based on Type 1 Pediatric Pump Patients –IV Insulin Used Frequently in Stressed Type 2 Only 14% Stabilized at 0.02 Glucommander Multipliers N=2364 Runs White = 0.02

42. Glucommander 5802 Runs and 120,618 BG’s 1985-1998

43. Glucommander Principles Insulin Units / Hour Glucose mgm / dl

44. Hours Glucose Multiplier Insulin Glucose Typical Glucommander Run Hi Low

45. Glucommander Average and Standard Deviation of of All Runs 1985 to 1998; 5808 runs, 120,618 BG’s

46. Glucommander. Complete Data Set 1985 to 1998 Beyond Data Analyzed by Boehringer Manheim/MiniMed in 1995 13 years of data from Glucommander. 5802 Runs over 120,618 hours. Correction of hyperglycemia: Mean starting BG=259 mg/dL (SD 127). Mean stable <150 after three hours. Subsequent stability in target range for 60 hrs. 90% of patients achieved BG<180 within 8 hrs. Experience with Hypoglycemia:  BG’s <50 were 0.6% of total BG’s.  2.6% all runs had one BG <40. All were immediately corrected to 100 with IV glucose, insulin held 30 min, then modified.  No severe hypoglycemia.

47. Lauren <40 mg/dl 5.2% Hypoglycemia on Glucommander 5772 Runs

48. Glucommander. Correction of Hypoglycemia IV 50% Glucose: ( 100-BG) X 0.15 Grams Time (min) Glucose (mg/dl) N = 886

49. Conformity of Blood Glucose to Glucommander Target

50. IV Insulin Protocols l Correct with minimal insulin –Least reactive hypoglycemia –Cut insulin quickly l Correct hyperglycemia quickly –Limit intracellular dehydration –Start insulin aggressively l Avoid prolonged hyperglycemia –Less intracellular edema with correction l Many protocols in use –Few with outcomes ADA Diabetes Care 26:S109-S117,2003 Watts Diabetes Care 10:722-28,1987 Umpierrze Personal Commication Markovitz Endocr Pract 8:10-18,2002 Metchick Am J Med 133:317-323, 2002 Van den Berghe N Engl J Med 346:1586-8, 2002 Fumary J.Thor CV Surg 125:1007-1021, 2003

51. Glucommander Comparsion to Other Systems Insulin Units / Hour Glucose mgm / dl Glucommander 33 u ADA 38 u MARKS 52 u FUMARY 19 u METCHICK 37 u VAN DEN BERGHE 41 u IV DRIP 38 u UMPIERRZE 34 u MARKOVITZ 33 u WATTS 46 U LEVETAN 32 u

52. Insulin Units / Hour Glucose mgm / dl Glucommander 33 u ADA 38 u IV DRIP 38 u MARKOVITZ 33 u Glucommander Similar Systems Features in Common Early high dose Decrease in parallel with BG End up at common dose Similar total dose

53. Glucommander. Surgical Series Compared to Watts Algorithm Watts Glucommander Watts et al Diab Care 1987 10:722-728

54. Glucommander. Surgical Series Compared to Watts Algorithm Glucommander Watts

55. How has the Glucommander been used? l Treatment of ketoacidosis l Hyperosmolar non-ketotic state l Perioperative glucose management l Labor and delivery l Myocardial infarction l Critically ill patients in ICU l Hyperalimentation l Gastroparesis with intractable nausea and vomiting l Estimating a patient’s insulin sensitivity –A guide for dosing insulin Estimating total insulin dose, correction factor, CHO/Ins

56. Clinical Experience with Glucommander l Simple, safe, and effective method for maintaining glycemic control l Extensively studied l Standardized treatment method applicable in a wide variety of conditions l Available for review, www.glucommander.com l Opportunity to improve clinical outcome now not when and if

57. Hospital Diabetes Plan l NPO Pathway For All Diabetes Patients l Finger Stick BG ac qid on ALL Admissions l Check All Steroid Treated Patients l Diagnose Diabetes FBG >126 mg/dl Any BG >200 mg/dl Paul Davidson MD Atlanta Diabetes Associates

58. Hospital Diabetes Plan l Document Diagnosis in Chart l Hyperglycemia Is Diabetes Until Proven Otherwise l Bring to All Physician’s Attention l Note on Problem List and Face Sheet l Check Hemoglobin A1C l Hold Metformin; Hold TZD with CHF, Liver Dysfunction l Use Insulin in All Hospitalized Persons with Diabetes l Use Insulin in All Hospitalized Persons with Diabetes Continue for Course of Hospitalization Paul Davidson MD Atlanta Diabetes Associates

59. Hospital Diabetes Plan l Get Diabetes Education Consult l Instruct Patient in Monitoring and Recording See That Patient Has Meter on Discharge l Decide on Case Specific Program for Discharge l Arrange Early F/U with PCP Paul Davidson MD Atlanta Diabetes Associates

60. Hospital Diabetes Plan l Follow National Guidelines For Endocrinology Consults –Any Type 1 –Any Hypoglycemia Requiring Intervention –DKA or HHNC –Patient on Insulin Pump –Pregnant Diabetic –Glucocorticoid Therapy in Diabetes –Progressive Diabetic Complications –HbA1c >8%, Microalbuminuria >30 mg,LDL >130, HDL 400 mg/dl

61. l Treat Any Patient With BG > 150 With Insulin –Treat Any BG >150 with Rapid-acting Insulin (BG-100) / (7000 / wt #) –Treat Any Recurrent BG >200 with IV Insulin l If More than 0.5 u/hr IV Insulin Required with Normal BG Start Long Acting Insulin Protocol for Insulin in Hospitalized Patient

62. Prescription for insulin therapy includes: Basal Insulin (BI) Carbohydrate-to-Insulin Ratio (CIR) Correction Factor (CF) 1801 Records from Pump Patients Studied Data from best-controlled of 591 pump patients Analyzed for optimum parameters Resulting formulae used as model for others The Accurate Insulin Management (AIM) formulae The Accurate Insulin Management (AIM) Formulae

63. RESULTS

64. 125 100 75 50 25 Correction Factor 25 20 15 12 10 9 8 7 6 5 Carbohydrate to Insulin Ratio CF Curve AIM Nomogram Davidson et al Diab Tech Ther 2003 Vol 5 No 2 ( CIR = 2.8 Wt / TDD ) ( CF = 1700 / TDD ) Intial Dosing: Plot BW and 25 CIR for BI Plot BW and 12 CIR for TDD Plot BW and TDDfor CIR Plot TDD and CF curve for CF Follow-up Dosing: Change CF as above Change CIR by 20% toward CIR AIM 4 3 2

65. Protocol for Insulin in Hospitalized Patient l Daily Total: Pre-Admission dose or Weight (#) x 0.24 u –50% as Glargine (Basal) –~50% as Rapid-acting Insulin (Bolus) Give in Proportion to CHO Eaten, CIR 12Give in Proportion to CHO Eaten, CIR 12 l BG >150: (BG-100) / CF –CF = 7000 / Wt(#) l Do Not Use Sliding Scale As Only Insulin l Do Not Hold Insulin When BG Normal

66. Protocol for Insulin in Hospitalized Patient Treatment of Hypoglycemia l Any BG <80 mg/dl: D50 = (100-BG) x 0.4 ml IV l Do not treat with po CHO l Do Not Hold Insulin When BG Normal

67. Correction of Hypoglycemia with Glucose 100-BG X 0.2 Grams BeforeAfter Richardson Diabetes 1999 50:A200 100-BG X 0.15 Grams

68. Hospital Diabetes Plan Conclusions l Any BG >200 mg/dl Is Diabetes (Fasting >126 mg/dl) l Most Diabetes Is Type 2 l No BG >150 mg/dl Should Go Untreated l Most Hospitalized DM Patients Should Be on Insulin l IV Insulin is Most Effective, Efficient, Safest Rx in Acute Illness (Glucommander)

69. Hospital Diabetes Plan Hospital Diabetes Plan Conclusions 2 l Switch to Basal Insulin Glargine –IV Hourly Dose X 24 / 2 l DC IV Glucose l Feed and Give Rapid Acting Insulin p.c. –One Unit Per 12 Grams CHO l BG ac tid, hs, 3 am –Correct with Rapid Insulin (BG - 100) / 7000 / BW# l Type 2 Diabetics Are Resistant to Insulin Reactions l Treat Insulin Reactions in Hospital With IV Glucose l Do Not Be Hold Insulin for Normal BG, i.e. 80-120 l HbA1c Values >7% Indicates Sub-optimal Care

70. The Paradigm for the Millenium Hyperglycemia: A “Mortal” Sin A blood glucose over 110 in a hospitalized patient causes increased morbidity and mortality. In the 21st Century Neglecting BG >200 Is Malpractice

71. Conclusion All hospital patients should have normal glucose

72. Insulin The agent we have to control glucose only most powerful

73. QUESTIONS? l For a copy or viewing of these slides –Contact www.adaendo.com l How can I get use of Glucommander? – Available for review on internet, www.glucommander.com – Contact us: Glucommander@adaendo.com