1. Management of Diabetes Mellitus in the Hospital
Part 2
Kathleen Dungan, MD
Assistant Professor,
Division of Endocrinology, Diabetes and Metabolism

2. Objectives
Describe the pathophysiology and clinical significance of “stress hyperglycemia”.
Identify patients that require IV insulin.
Explain the difference between DKA and HNK.
Describe the initial therapy for DKA.
Understand how and when to discontinue IV insulin.
Be able to calculate daily adjustments in insulin dose.
Describe the pathophysiology and clinical significance of “stress hyperglycemia”.
Identify patients that require IV insulin.
Explain the difference between DKA and HNK.
Describe the initial therapy for DKA.
Understand how and when to discontinue IV insulin.
Be able to calculate daily adjustments in insulin dose.

3. Case 3: Post-Op Hyperglycemia
68 YOM with 20 year h/o T2DM is scheduled for elective cardiac catheterization due to abnormal stress test.
Home medications: Glargine 54 units QHS, Metformin 1000 mg BID, Glipizide 10 mg BID
Last A1c 7.5%
68 YOM with 20 year h/o T2DM is scheduled for elective cardiac catheterization due to abnormal stress test.
Home medications: Glargine 54 units QHS, Metformin 1000 mg BID, Glipizide 10 mg BID
Last A1c 7.5%

4. Post-op Quiz

5. Patient getting a procedure
In general, DO NOT hold basal insulin
May reduce 20-50% so that it accounts for 50% or less of the total daily dose
Premix insulin : reduce 50%
But, do hold meal insulin
*Under no circumstances should you completely withhold basal insulin from a patient with type 1 diabetes!
In general, DO NOT hold basal insulin
May reduce 20-50%
Premix insulin : reduce 50%
But, do hold meal insulin
*Under no circumstances should you completely withhold basal insulin from a patient with type 1 diabetes!

6. Case 3: Post-op Hyperglycemia
The patient is sent for CABG. Intra-operatively, an insulin drip is started.
Post-op Day 1
Extubated, pressors still running
Insulin drip running at 1-6 unit/hour , BG 100s-200s
Taking sips of fluids, ADA diet ordered
The patient is sent for CABG. Intra-operatively, an insulin drip is started.
Post-op Day 1
Extubated, pressors still running
Insulin drip running at 1-6 unit/hour , BG 100s-200s
Taking sips of fluids, ADA diet ordered

7. Transition to SQ Quiz

8. Predictors of Successful Cessation of Insulin Drip
Our patient
On drip at least 24 hours
Yes
DKA is resolved NA
Hemodynamically stable No
Extubated
Minimal rate (<4 unit/hr) and minimal changes for at least 6 hrs
BG controlled <150 mg/dl
Tolerating PO intake
CHART: Predictors of Successful Cessation of Insulin Drip
Am J Cardiol. 2006;98(4):

9. Case 3: Converting off the drip
Day 3:
Patient is off pressors, afebrile
Insulin drip running at 2 units/hr and stable.
BG s
Receiving Lispro SQ 1 unit/10 gm CHO
Day 3:
Patient is off pressors, afebrile
Insulin drip running at 2 units/hr and stable.
BG s
Receiving Lispro SQ 1 unit/10 gm CHO

10. Convert to SQ Quiz

11. Does the patient need basal insulin?
Yes
DKA or type 1 diabetes
Requiring >1 unit/hour
If not…
Check BG frequently once drip is stopped
Patient may need meal coverage or oral med
Yes
DKA or type 1 diabetes
Requiring >1 unit/hour
If not…
Check BG frequently once drip is stopped
Patient may need meal coverage or oral med

12. Conversion to SQ insulin
Basal insulin dose =
70% of total infusion requirements
Assumes that the drip is not being used for meal coverage
Compare to home dose of insulin
Continue IV insulin/IVF for 4-6 hours after the dose
Basal insulin dose =
70-80% of total infusion requirements
Assumes that the drip is not being used for meal coverage
Compare to home dose of insulin
Continue IV insulin/IVF for 4-6 hours after the dose

13. Physiologic Insulin Regimen
Bolus Insulin = prandial + correction dose 50
Insulin
(µU/mL) 25
Basal Insulin
Breakfast Lunch Dinner
150
Glucose
(mg/dL)
100
Prandial Glucose
IMAGE: Physiologic Insulin Regimen 50
Basal Glucose 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9
A.M.
P.M.
Time of Day

14. Physiologic Insulin Regimen 3 components
Examples
Basal
Long-acting insulin analogue
NPH
Continuous SQ rapid acting insulin analogue (pump)
IV insulin drip
Prandial
Rapid-acting insulin analogue
Regular insulin (tube feeds)
Correction (supplemental)
Prandial insulin above
CHART: Physiologic Insulin Regimen
BOLUS
Rapid acting insulin analogues: Aspart (Novolog), Lispro (Humalog), Glulisine (Apidra); Long acting insulin analogues: glargine (Lantus), detemir (levemir)

15. Mooradian, A. D. et. al. Ann Intern Med 2006;145:125-134
Insulin: The most effective therapy for hyperglycemia.
Insulin Preparations
Onset of Action
Peak Action
Duration of Action
BOLUS INSULIN
Regular
30 minutes
2-4 hours
6-10 hours
Lispro (Humalog)
Aspart (Novolog)
Glulisine (Apidra)
5-15 minutes
1-2 hours
4-6 hours
BASAL INSULIN
NPH
4-8 hours
10-20 hours
Glargine (Lantus)
Flat
~ 24 hours
Detemir (Levemir) ?
~ 24 hours*
CHART: Insulin: The most effective therapy for hperglycemia
*Detemir lasts 24 hours in most patients but is slightly shorter in duration than glargine.
Mooradian, A. D. et. al. Ann Intern Med 2006;145:

16. Steps to initiating SQ insulin
1. Calculate total daily insulin dose= unit/kg or based on insulin drip requirement
2. Basal = 50% of total daily dose
3. Prandial dose:
50% of total daily dose divided over meals
I:CHO
High=1u/5gm, Standard =1 u/10gm, Low=1 u/15 gm
Steps to initiat
Calculate total daily insulin dose= unit/kg or based on insulin drip requirementing SQ Insulin
2. Basal = 50% of total daily dose
3. Prandial dose:
50% of total daily dose divided over meals
I:CHO
High=1u/5gm, Standard =1 u/10gm, Low=1 u/15 gm
4. Add correction dose (drop in BG/unit):
High=1 unit/25 mg/dl above target, Standard=1unit/50 mg/dl, Low=1 unit/100 mg/dl
Target (when you start giving it)=default is 150 mg/dl
4. Add correction dose (drop in BG/unit):
High=1 unit/25 mg/dl above target, Standard=1unit/50 mg/dl, Low=1 unit/100 mg/dl
Target (when you start giving it)=default is 150 mg/dl

17. “Sliding Scale” Monotherapy
Without basal insulin, results in
Hyperglycemia
Hypoglycemia (possibly)
Iatrogenic DKA with Type 1 diabetes
Use of “Sliding Scale” Insulin Alone Is Discouraged
Traditional sliding scale insulin
Use of “sliding scale” insulin (regimens usually consist of regular insulin without any intermediate or long-acting insulin) is discouraged; evidence does not support this technique because it has resulted in unacceptably high rates of hyperglycemia, hypoglycemia, and iatrogenic diabetic ketoacidosis in hospitalized patients.
Plus, “Sliding Scale” is anti-intellectual:
Reactionary rather than anticipatory
American Association of Clinical Endocrinologists. Available at: Accessed March 17, 2004.

18. Measure FSG  give insulin
What is a sliding scale?
Measure FSG  give insulin
(usually qac+hs)
Standard Dose Algorithm Individualized Dose Algorithm
Premeal BG
Additional Insulin
1 unit
___ units
2 units
__ units
3 units
4 units
>349
5 units
> 349
CHART: What is a sliding scale? Measure FSG  give insulin

19. Why not sliding scale? “Typical sliding scale” “The better way”
Blood sugar before lunch 280
Blood sugar before lunch 280
Patient receives 6 U insulin sliding scale (correction factor), PLUS 5 U insulin for 75 g carb lunch
Patient receives 6 U insulin sliding scale, but then eats 75 g carb lunch!
Typical Sliding Scale
Blood sugar before lunch 280
Patient receives 6 U insulin sliding scale, but then eats 75 g carb lunch
Blood sugar before dinner 245!
The better way
Patient receives 6 U insulin sliding scale/correction factor PLUS 5 U insulin for 75g carb lunch
Blood sugar before dinner 124!!
Blood sugar before dinner 245!!
Blood sugar before dinner 124!!

20. Dose-finding strategy
Determine yesterday’s total insulin dose actually administered
Address hypoglycemia first
Adjust at least 10-20% based on the glucose
Determine yesterday’s total insulin dose actually administered
Address hypoglycemia first
Adjust at least 10-20% based on the g 20

21. Oral Agents in the Hospital
Often contraindicated
Slower onset of action
In some circumstances, patients can continue orals, with the following important caveats
Short hospital stay
Acceptable glycemic control
Meformin  probably contraindicated (risk of lactic acidosis)
Creatinine >
IV contrast
Symptomatic heart failure
Respiratory failure
Hepatic failure
TZDs (Glitazones)  contraindicated in CHF, very slow onset
Sulfonylureas  Risk of hypoglycemia
Often contraindicated
Slower onset of action
In some circumstances, patients can continue orals, with the following important caveats
Short hospital stay
Acceptable glycemic control
Meformin  probably contraindicated (risk of lactic acidosis)
Creatinine >
IV contrast
Symptomatic heart failure
Respiratory failure
Hepatic failure
TZDs (Glitazones)  contraindicated in CHF, very slow onset
Sulfonylureas  Risk of hypoglycemia

22. Treatment of Hypoglycemia
Do not overtreat!
PO route preferred
10-20 gms
IV dextrose
12.5 gms (1/2 amp D50)-full 25 gm
Double current dextrose infusion
Glucagon if no IV
Do not overtreat!
PO route preferred
10-20 gms
IV dextrose
12.5 gms (1/2 amp D50)-full 25 gm
Double current dextrose infusion
Glucagon if no IV

23. Iatrogenic hypoglycemia is usually predictable and preventable
Iatrogenic hypoglycemia is usually predictable and preventable. (Fischer)
PIE CHART: Iatrogenic hypoglycemia is usually predictable and preventable (Fischer)
Blue: Decreased intake of calories
Lt. Green: Adjustment of insulin dosage
Dk Green: Incorrect dose of insulin given
Gray: No cause identified
Reduce insulin, increase monitoring if
- Any form of carbohydrate is interrupted
- Declining renal or hepatic function
Reduce insulin, increase monitoring if
Any form of carbohydrate is interrupted
Declining renal or hepatic function

24. In summary
Management of diabetes in the hospital is aimed at achieving a nearly normal blood sugar
Think!!
Good BS management is possible in most patients with some careful consideration
Diabetes consult team is available for help (at least at OSU)
Management of diabetes in the hospital is aimed at achieving a nearly normal blood sugar
Think!!
Good BS management is possible in most patients with some careful consideration
Diabetes consult team is available for help (at least at OSU)

25. Please direct questions to: [kathleen.dungan@osumc.edu]

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