1. Module 41 Module 4 Pharmacologic Management of Hyperglycemia in the Hospital Part 1: Understanding How to Use Insulin Diabetes Special Interest Group Georgia Hospital Association

2. Module 42 Learning Modules Module no.Topic 1Hyperglycemia and hospital outcomes 2Challenges and opportunities for care improvement 3Initial recognition, triaging, and management 4Pharmacologic management: Insulin 1 5Pharmacologic management: Insulin 2 6Review of policies and procedures 7Getting patients ready for discharge

3. Module 43 Summary Thus Far Hospital hyperglycemia is associated with poorer patient outcomes Treating hospital hyperglycemia improves patient outcomes There is room to improve care at most hospitals Recognize and treat hyperglycemia early

4. Module 44 Recall our model of hyperglycemia care in the hospital Admission First 24 hours Recognition and triage Initial treatment plan Continued care Ongoing monitoring Education Treatment adjustment Discharge planning What therapy? What is the follow-up? Do patients know what to do? Education provided? This module will focus on how to provide ongoing care for patients with hyperglycemia in the hospital

5. Module 45 Objectives Review treatment of inpatient hyperglycemia Discuss principles of insulin therapy Review how to calculate insulin doses Describe how to adjust insulin therapy

6. Module 46 Continuing Care Actions Evaluate bedside glucose values daily Adjust therapy if needed Assess patient knowledge and obtain diabetes education consult if indicated Document in progress notes: –The problem of diabetes and hyperglycemia –Whether diabetes is controlled or uncontrolled (that’s how our coders bill)—if you have to change therapy, it is probably uncontrolled –Any changes in therapy

7. Module 47 Treating Inpatient Hyperglycemia What should we use? Concerns about oral hypoglycemic agents –Little data on outcomes in the hospital –Slow onset of action –Limited dose titration Concerns over specific agents –Sulfonylureas—worries over inpatient cardiovascular outcomes and hypoglycemic events when meals are missed –Metformin—concerns over lactic acidosis, creatinine should be less than 1.4, must be held when contrast studies performed –TZDs—fluid retention, contraindicated if LFTs are elevated

8. Module 48 Treating Inpatient Hyperglycemia Is there any role for oral agents in the hospital? Situations where we use oral agents –Patients already on oral agents admitted for short stays (e.g. elective surgical procedures) –Rehab patients who have recovered from their acute illness Insulin is the favored drug for treatment of acutely ill inpatients with hyperglycemia.

9. Module 49 Advantages of Insulin Therapy in the Hospital Adaptable to: –Rapidly changing clinical situations that affect glucose levels –Various forms of nutritional support NPO IV dextrose Total parenteral nutrition Enteral feeding Eating

10. Module 410 Three components of insulin therapy Basal (long-acting) insulin: component needed to prevent gluconeogenesis and ketogenesis Meal (Prandial) Bolus insulin: component that covers meals and other carbohydrate sources Corrective insulin: component needed to cover unexpected glucose excursions (e.g. from stress) –Can be pre-calculated and written as algorithm –Not the same as “sliding scale” –Tries to account for individual insulin sensitivity

11. Module 411 4:0016:0020:0024:004:00 8:00 12:008:00 Time Glargine or Detemir Aspart, Lispro or Glulisine Plasma glucose Aspart, Lispro or Glulisine This approach is adopted from experience in the outpatient setting Concept of basal-bolus (or basal-prandial) insulin therapy

12. Module 412 Corrective vs. Sliding Scale What’s the difference? Similarities –Treat hyperglycemia before or between meals or when intermittently eating –Dose finding strategy Contrasts –Corrective dose insulin is based on estimate of patient’s insulin sensitivity –Sliding scale Typically written then not modified Treats glucose “after the fact”—not preventive Can result in rapid changes in glucose

13. Module 413 Sliding scale alone is ineffective as a means to treat inpatient hyperglycemia Scheduled insulin preferred: one that includes basal, mealtime and correctional doses Gearhart Fam Pract Res J 14:1994Queale et. al. Arch Intern Med 157:1997 Compared to scheduled therapy Sliding scale = More hypoglycemia Sliding scale = Poorer glucose control

14. Module 414 Effectiveness of Basal-Bolus Insulin Day 1Day 2Day 3 42 y/o man with no prior h/o of diabetes admitted with necrotizing fasciitis of arms and started on steroids—developed hyperglycemia Day 4Day 5 Mean = 285 mg/dl Mean = 200 mg/dl Sliding Scale onlyBasal-Bolus Hyperglycemia did not improve until basal-bolus insulin started

15. Module 415 59 year –old woman with h/o diabetes admitted with brain mass and put on steroids Mean 289 mg/dl Mean 191 mg/dl Sliding Scale onlyBasal-Bolus Effectiveness of Basal-Bolus Insulin Hyperglycemia did not improve until basal-bolus insulin started Day 1Day 2Day 3Day 4Day 3

16. Module 416 InsulinTrade nameOnsetPeakDuration of action RegularN.A.0.52 – 56 -10 LisproHumalog5 min12 - 4 AspartNovolog10 min1 – 33 – 5 GlulisineApidra5 -15 min12 - 4 GlargineLantus2 hN.A.~ 24 DetemirLevemir0.8 – 2 h3-9 h< 24 NPHN.A.1 – 2 h4 – 1216 – 24 Commonly Used Insulin Formulations

17. Module 417 Estimate total daily dose = 0.5 x wt. in kg Wt. is 100 kg; 0.5 x 100 = 50 units per day Basal dose = 50% of total dose at HS 0.5 x 50 = 25 units at HS Bolus doses = 50% of total dose 0.5 x 50 = 25 divided by 3 = ~8 units ac Add a correctional insulin program Initiating Basal-Bolus Insulin Therapy for Type 2 Insulin Requiring Patients

18. Module 418 Initiating Basal-Bolus Insulin therapy The previous slide shows just one way to get started Different people may calculate doses or distribute prandial insulin differently Conservative total daily dose estimate for Type 1 patients could be 0.3 x wt. in kg Ultra conservative total daily dose estimate for Type 1 renal impaired or emaciated patients could be 0.2 x wt. in kg Remember: You won’t go wrong as long as you reevaluate the effect of treatment every day and make necessary changes

19. Module 419 Step One: Calculate the Correction Factor (CF) The correction factor is the estimated drop in glucose when 1 unit of rapid-acting insulin is given Use 1700 Rule to estimate the CF CF = 1700/total daily dose (TDD or the total number of units of all insulin given in 24h) Ex: Scheduled insulin: Glargine 26 units + Novolog 8 units prior to each meal ≈ 50 units TDD CF = 1700/50 CF = 30 meaning that 1 unit will lower the BG ~ 30 mg/dL How do you calculate the correction bolus?

20. Module 420 Another Way to Calculate the CF 3000 _______________________ Patient’s weight in kilograms

21. Module 421 Example: –Current BG:250 mg/dL –Target BG: 120 mg/dl –Correction Factor: 30 mg/dL Current BG - Ideal BG Glucose Correction Factor 250 - 120 30 = 4 units How much insulin would you give if the glucose was 250 mg/dL? Step Two: Calculate the Correction Bolus Based on a CF of 30, you (or the patient) would have to give 4 units to bring the glucose down to the desired target Calculating the Correction Bolus

22. Module 422 Using the Correction Bolus For example: You have a 23 year old woman with Type 1 diabetes. She takes 30 units of Lantus at bedtime and 5 units of Apidra with each meal. Her CF is 30 and her target glucose is 120. Her pre-lunch glucose is 250 mg/dL. In order to correct to 120, she will need to take 5 units to cover the meal plus an additional 4 units to correct for the pre-meal hyperglycemia.

23. Module 423 How does the CF concept work in the hospital? The concept of the CF works well if a patients are knowledgeable and can do their own care—typical outpatient scenario In the hospital—patients are sick and often cannot participate in their own diabetes management In the hospital, we use correctional insulin to try to achieve a target range, rather than a target value.

24. Module 424 Some Hospitals Use a Corrective Insulin Algorithm GlucoseMildModerateAggressive 70-150000 151-200024 201-250258 251-3004812 301-35061116 351-40081420 Mean Estimated. CF 422314 In this algorithm, the hospital does not use a CF approach in its insulin scales, but if you use the CF approach, estimated CFs are shown above The above is often a good place to start, but what if it doesn’t work? How do you calculate your own scale?

25. Module 425 Calculating Corrective Insulin Algorithm To calculate your target value, find the midpoint using the lower and upper bounds of your target range Ex: (70 + 150)/2 =110 = your target value Start with a CF of 30 To calculate the corrective insulin amount for each range, find the midpoint using the lower and upper bounds of the glucose range Ex: (151 + 200)/2 =175 Correction for range = (175-110)/30 = 2 units

26. Module 426 Insulin Regimens and When to Use Them RegimenExamples of when to useInsulin Corrective onlyIntermittent hyperglycemia Dose finding strategy in patient with moderate hyperglycemia (140 – 199 mg/dL) Rapid Acting Basal + Corrective Patient not eating 24h enteral feeding Long acting at HS + Corrective NPH B.I.D. + Corrective Basal + CorrectiveDose finding strategy in patient who is eating very little and nurses do not know how to adjust meal bolus based on amount of carbohydrate consumed at meal Rapidly changing stressors Long acting + Rapid Acting Basal + Prandial + Corrective Stable patient who is eating or nurses know how to adjust meal bolus based on amount of carbohydrate consumed (rapid acting insulin can be administered immediately after the meal instead of before) Long acting + Aspart

27. Module 427 Inpatient Glucose Control Categories in Non-ICU patients Average Daily Glucose (mg/dL) Category of Glucose Control Action <70HypoglycemiaInvestigate and remove cause Consider de-intensifying therapy 70 - 140GoalMaintain therapy 141 - 199FairConsider intensifying therapy  200 PoorDefinitely intensify therapy Be prepared to intensify daily until target achieved

28. Module 428 Titration Guidelines for Specific Time Zones Pre-breakfast BG > 140  long-acting dose 10% Pre-breakfast BG < 70  long-acting dose 10% Pre-lunch BG > 140  rapid-acting breakfast dose 10% Pre-lunch BG < 70  rapid-acting breakfast dose 10% Pre-dinner BG > 140  rapid-acting lunch dose 10% Pre-dinner BG < 70  rapid-acting lunch dose 10% Pre-bedtime/snack >140  rapid-acting dinner dose 10% Pre-bedtime/snack < 70  rapid-acting dinner dose 10%

29. Module 429 Guidelines for Insulin Increase All Pre-Prandial Glucose Values% Increase Total Daily Insulin 70 - 1400 141 - 19910 200 - 24920 250 - 29930 300 - 34940 >350Insulin infusion

30. Module 430 IV Insulin Infusion Data IV insulin infusion data can be used for dose finding. This will be discussed in another module.

31. Module 431 Titration Precautions and Considerations Fractions of Units In general, it is not recommended to round up when fractions of units are being considered. For example rounding 0.5 to 1.0 may drop an insulin resistant patient’s BG 10 mg/dL while a patient that is very sensitive to insulin might experience a 40 mg/dL drop in BG from the same 0.5 unit dose.

32. Module 432 Additional Considerations in an Imperfect World Patient and Staff Compliance Additional considerations before titrating include assessing the patient and staff for compliance with diet, testing and medication administration. The dose you prescribed may have been correct but: The patient may have consumed more carbs than you prescribed (Is the diet order correct? Are family members bringing food to the patient? Is the patient consuming snacks between meals?) An informed patient is part of the healthcare team. The BG may have been checked after the meal instead of before The insulin may have been given late, early, or not at all.

33. Module 433 Communicate, Communicate, Communicate! Team work is required to control hyperglycemia in the hospital. Communicating with patients and staff may identify and overcome the barriers to control. Not only does the physician need to order the correct insulin but also dietary needs to provide the proper carb count per meal, the patient needs to avoid carb intake between meals, the BG needs to be checked pre-prandial, the nurse needs to administer the correct dose at the right time. The nurse needs to notify the physician when a dose has been missed in order to avoid unsafe titration increases.

34. Module 434 Don’t ignore hyperglycemia The higher the glucose levels, the more frequent the monitoring Initiate or change treatment when glucose is high All hyperglycemia responds to insulin unless the patient is coding Summary General Rules for Hospital Management of Hyperglycemia