1. Correction Insulin for Inpatient Hyperglycemia Estelle Lin June 2012

2. Case Vignette 45 year old obese female with DM type II is admitted for acute nausea, vomiting, and epigastric pain. CT Abdomen with IV contrast demonstrates acute pancreatitis. Her diabetes is usually controlled on metformin 1000mg BID and glyburide 10mg BID. Admission BMP shows a random glucose of 240. How do you manage her hyperglycemia? A. Continue home regimen B. Continue home glyburide and discontinue metformin C. Start sliding scale insulin D. Start correction insulin

3. Learning Objectives Appreciate difference between sliding scale insulin vs correction insulin Understand optimal glycemic control goals in ICU vs non ICU settings Review the pharmacokinetics of different insulin preparations Learn how to use correction insulin and initiate insulin therapy on UCI wards

4. The problem with sliding scale insulin Time0700 Break- fast 08001200 Lunch 13001700 Dinner 18002100 Blood Glucose 275350400250 Sliding scale 6 units 10 units 12 units 6 units Sliding Scale Insulin - Treats hyperglycemia with only short/rapid acting insulin without long-acting basal insulin - Reactive therapy given AFTER meal - Treats current hyperglycemia, does not prevent future hyperglycemia - Can cause large swings in glucose levels throughout day Typical day battling hyperglycemia

5. Correction Insulin –It is both a concept AND includes a correction scale insulin –Treats current hyperglycemia with the goal of preventing further hyperglycemic events during the hospital course –Administer correction scale insulin BEFORE the meal using a rapid or short acting insulin –For patients already receiving scheduled rapid acting insulin AND scheduled long acting insulin, this is an additional correction scale to treat hyperglycemia –For patients whose primary oral anti-hyperglycemic therapy has been discontinued, this is the initiation of a correction scale to control hyperglycemia and if needed, the initiation of long acting insulin

6. A better day when using correction insulin Time0700EAT08001200EAT13001700EAT18002100 Blood Glucose 170275210350250400250 Sliding Scale 610126 Correct- ion Scale 2 unit s 4 units 6 units Sliding scale: 34 units of rapid/short acting insulin administered Correction scale: 18 units of rapid/short acting insulin Remember, it is the concept of correction insulin we want to practice. If this patient remains hyperglycemic, initiate longer acting insulin therapy

7. AACE/ADA Consensus Statement on Management of Inpatient Hyperglycemia BG goalsAvoidTips MICU140-180<110If >180, initiate IV short acting insulin General Wards Pre-meal <140 Random <180 <100In glucocorticoid therapy, initiate accuchecks for 48 hours and then initiate insulin therapy as appropriate Avoid routine use of corrective insulin at bedtime unless continuous nutrition/TPN

8. Rapid (Prandial, Bolus) Short (Prandial, Bolus) Intermediate (Basal) Long (Basal)

9. Correction Insulin Tips Start withIf uncontrolled add On insulin at home (DM I, some DM II) NPO*Home basal insulin*Correctional scale insulin Eating*Home basal insulin (reduce 50%) *Home prandial insulin (reduce doses by 25-50%) *Correctional scale insulin Not on insulin (pre-DM, DM II) NPOStop all oral anti-hyperglycemics. Start correctional scale *Basal insulin EatingCautiously use oral anti- hyperglycemics OR Start *basal, *prandial, AND *correctional scale insulin *Basal insulin *Prandial insulin *Correctional scale

10. Current UCI Glycemic Monitoring Protocol UCI is aggressively pursuing the concept of correction insulin and preventing hyperglycemia. Many more patients will be initiated on insulin therapy When to pursue insulin therapy All DM I Most DM II receiving medication treatment Uncontrolled hyperglycemia > 180 (2 episodes in 24 hours) If unsure, then monitor qAC/qHS glucose monitoring for 24 hours and then continue if BG > 180

11. How to Initiate Insulin Therapy (if not already on insulin OR if uncontrolled diabetes) Regimen Tracts DoseLow (DM I, Lean DM II) Standard (Normal weight DM) Moderate (Overweight DM) Aggressive (Obese DM) Total Daily Dose (TDD) 0.3 units/kg/day 0.4 units/kg/d0.5unit/kg/d0.6unit/kg/d Basal½ TDD Prandial½ TDD divided into 3 meals Correction Scale Yup, they will also receive this too It should be the same rapid/short acting insulin as used for prandial insulin See next page

12. Correction Scale with Meals Regimen Tracts DoseLow (DM I, Lean DM II) Standard (Normal weight DM) Moderate (Overweight DM) Aggressive (Obese DM) Total Daily Dose (TDD) 0.3 units/kg/d0.4 units/kg/d0.5unit/kg/d0.6unit/kg/d 161-2001 units2 units3 units4 units 201-2502 units4 units5 units6 units 251-3003 units6 units7 units8 units

13. Insulin Dose Adjustment for CKD No dose adjustment if GFR >50 Use 75% of baseline insulin dose if GFR 10-50 Use 50% of baseline insulin dose if GFR <10 Example: At home takes 40 units of glargine qHS If GFR 30: give 30 units of glargine qHS If GFR <10: give 20 units of glargine qHS

14. Long Beach VA Guidelines on Adjustment of Insulin If glucose above target, increase insulin doses by 10-20% (2-5 units) every 1-2 days Once patient clinically stable on insulin regimen, d/c correctional insulin and check glucose 2 hours after meals (target BS <150 two hours after a meal) How to Adjust: Patient on NPH/Regular insulin regimen If fasting glucoses elevated, increase evening NPH If pre-lunch or 2 hr post breakfast elevated, increase AM pre-breakfast regular If pre-dinner or 2 hr post lunch elevated, increase AM NPH If bedtime or 2 hr post-dinner elevated, increase pre-dinner regular May need bedtime snack once glucoses are well controlled

15. Long Beach VA Guidelines on Adjustment of Insulin Patient on Lantus with Regular/Aspart insulin: If fasting elevated, increase Lantus If pre-lunch or 2 hr post breakfast elevated, increase pre-breakfast regular/Aspart If pre-dinner or 2 hr post lunch elevated, increase pre-lunch regular/Aspart If bedtime or 2 hr post-dinner elevated, increase pre-dinner regular/Aspart If all glucoses elevated, may need to increase all insulins

16. Case Vignette 45 year old obese female with DM type II is admitted for acute nausea, vomiting, and epigastric pain. CT Abdomen with IV contrast demonstrates acute pancreatitis. Her diabetes is usually controlled on metformin 1000mg BID and glyburide 10mg BID. Admission BMP shows a random glucose of 240. How do you manage her hyperglycemia? A. Continue home regimen B. Continue home glyburide and discontinue metformin C. Start sliding scale insulin D. Start correction insulin

17. Case Vignette Answer: D Answers A and B incorrect because patient likely to be NPO Answer C, sliding scale insulin is no longer in favor. CORRECT ANSWER(S) Option 1: Initiate insulin therapy (basal, prandial, corrective scale) on admission Option 2: Start q6 accuchecks with correction scale (regular insulin is commonly used). Correct BS per Aggressive Regimen since is obese DM type II BS 160-200 – 4 units BS 201-250 – 6 units, etc. If BS is still >180 after 1-2 days, then initiate longer insulin therapy (basal, prandial, corrective scale). Note Option 2 less preferable because random BS>180 and requires high doses of PO meds already so odds are she will have uncontrolled hyperglycemia

18. Last Question 55 year old male with DM I comes from with cough and fevers with poor PO intake. Admitted for treatment of pneumonia. He normally takes 20 units glargine qHS and 6 units aspart with each meal. How would you manage his blood sugar? A. Continue home regimen B. Give 10 units glargine qHS and 2 units aspart qAC C. Give home glargine dose only D. Give home aspart doses only

19. Correct Answer is B Patient likely can eat, albeit he may eat less in setting of illness and restrictive hospital diets. He is DM type I so he needs continuous insulin coverage. The safest option is to decrease his insulin doses by 25-50% and monitor. His goal BS is a FBG <140 and random BS <180. If he continues to experience hyperglycemia, then do the following. Basal insulin: uptitrate the glargine or redose based on a TDD of 0.3units/kg/day Prandial insulin: uptitrate the aspart or re-dose based on a TDD of 0.3 units/kg/day Initiate correction scale: Give additional aspart for BS >160.

20. Take Home Points Correction insulin is a concept to prevent hyperglycemia. It may include the initiation of insulin therapy (basal insulin, prandial insulin, AND correction scale) Correction scale insulin is given before a meal, whereas sliding scale insulin is given after a meal Avoid hypoglycemia. A safe inpatient BS goal is no lower than 100 Avoid severe hyperglycemia. A good target is a random BS <180 Reassess insulin needs after any change in nutritional status (NPO, PO, tube feeds)

21. Easy self-directed learning materials American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Diabetes Care June 2009 32(6) 1119 Intensive insulin therapy in critically ill patients. NEJM 2001; 345(19): 1359 Management of Hyperglycemia in the Hospital Setting. Inzucci et al. NEJM 2006; 355: 1903-1911 The Nice-Sugar study investigators: Normoglycemia in Intensive Care Evaluation Survival Using Glucose Algorithm Regulation Intensive vs conventional glucose control in critically ill patients. NEJM 2009; 360:1283 UpToDate “Management of DM in hospitalized patients” and “General Principals in Insulin Management.” Accessed on June 11, 2012. UCI Inpatient Glycemic Monitoring and Treatment Guidelines. 2012