eradicanginsulinsliding...
TRANSCRIPT
Eradica'ng Insulin Sliding Scales
How to manage diabetes in admi/ed pa1ents
Diabetes: Common in inpa'ent popula'on
• In USA, diabetes affects 10.8% of adults>20yo 23.1% of adults>60yo • 26% of hospitalized pa1ents have known diabetes with an addi1onal 12% having hospital or stress induced hyperglycemia • Diabetes increases the risk for disorders that predispose to hospitaliza1on (e.g. CVD, infec1on, CVA, demen1a)
Why are we doing a less than good job?
• Most admissions for diabe1cs are not directly related to the metabolic state • Diabetes management is rarely the primary focus of care • Glycemic control is oRen not adequately addressed • Sliding scale insulin has been used for a long 1me, it is simple, we are all resistant to change
Why should we care?
o Glycemic control has been shown to significantly impact morbidity and mortality especially in: • Cri1cally ill and ICU pa1ents • Surgical pa1ents, esp. CABG surgery • Acute CVA and acute MI
o Be/er glycemic control results in shorter hospital stays o Some USA evidence for cost savings as well
Sliding Scale History
• Introduced in 1934 by Elliot Joslin and was based on glycosuria • Samples of urine were boiled in a copper sulfate solu1on (Fehling’s solu1on) • No glucose-‐blue (no insulin) • Li/le glucose-‐green (5 units) • Moderate glucose-‐yellow (10 units) • Large glucose-‐orange (15 units)
• Original sliding scale was referred to “Rainbow Coverage”
Evidence??
• Medical ar1cles have ques1oned Sliding Scale Insulin (SSI) since 1970 • 52 trials from 1966-‐2003 showed NO trials demonstra1ng a benefit from SSI compared to other methods • The largest prospec1ve study in 1997 showed hyperglycemic rates 3X higher with SSI, higher rates of hypoglycemia and longer hospital stays • Evidence of effec1veness of SSI is lacking aRer more than 40 years of use
Examples:
How the literature describes SSI:
• “paralysis of thought” • “ac2ons without benefits”
• “relic of the past” • “recipe for diabe2c instability”
• “mindless medicine” • “nonsense”
• “Death to sliding scale” • “Myth or insanity”
Why doesn’t it work?
• In a sliding scale system, insulin is administered based on glucose levels done AC meals and Qhs • This is NOT an accurate predic1on of the amount of insulin needed • It is a reflec1on of the effect of the PREVIOUS dose of insulin • SSI is REACTIVE – it responds to hyperglycemia aRer it has occurred • It especially fails Type I diabe1cs who must never be without insulin, even when their glucose is “normal”
Example of pa'ent switched from sliding scale to basal/bolus insulin:
So, what do we do?
• Cri1cally ill, ICU, post MI/CVA, pre-‐opera1ve, sep1c • IV insulin
• Non cri1cally ill, not well controlled, or not ea1ng • Basal/bolus or “physiologic” insulin regimen
• Non diabe1c with hyperglycemia (likely to be temporary) • Classic sliding scale for PRN insulin
• Stable pa1ent who is ea1ng and well controlled at home • Con1nue home meds and/or insulin
Basal/Bolus Insulin regimen
3 Components: • Basal insulin (to inhibit hepa1c gluconeogenesis) • Nutri1onal insulin (to deal with meal1me glucose metabolism) • Correc1onal insulin (to provide real-‐1me insulin adjustment) Targets: • Premeal <7.8 mmol/l • Any <10 mmol/l • Never <5 mmol/l
Step 1: calculate total daily dose of insulin
• If pa1ent is well controlled, use home dose BUT consider decreasing by 20-‐25% • If not controlled or “new” hyperglycemia: • 0.3 units per kg (underweight, old, frail) • 0.4 units per kg (normal weight) • 0.5 units per kg (overweight) • 0.6 or more units per kg (obese, glucocor1coids, hx of insulin resistance)
Step 2: Basal insulin
HALF of total daily dose is to be given as long-‐ac1ng basal insulin • NPH or Levemir every 12 hours • Lantus every 24 hours
Step 3: Nutri'onal insulin
HALF of daily dose given in 3 equal por1ons as short-‐ac1ng insulin 0-‐15 minutes before meals: • Regular insulin (Humulin R, Novolin ge, Toronto) • Insulin lispro (Humalog) • Insulin aspart (NovoRapid)
**If pa1ent misses a meal, dose should not be given** **If pa1ent is fas1ng, this is excluded altogether**
Step 4: Correc'onal insulin
Blood Glucose Insulin sensi2ve (units) Standard (units) Insulin resistant (units)
8.3-‐11.0 mmol/l 1 1 2
11.1-‐13.8 mmol/l 2 3 4
13.9-‐16.6 mmol/l 3 5 7
16.7-‐19.4 mmol/l 4 7 10
> 19.5 mmol/l 5 + call MD 8 + call MD 12 + call MD
sensi1ve=<40 units/day, standard=40-‐80 units/day, resistant=>80 units/day
Oral hypoglycemic agents:
If pa1ent is not ea1ng or intake is very low, hold ALL PO diabe1c meds. Otherwise: • Mesormin: should almost always be held, esp. with any impaired renal or hemodynamic func1on (cardiac, renal or respiratory failure; dehydra1on, sepsis, urinary obstruc1on, pre-‐surgery or radiocontrast studies) • Sufonyureas associated with severe and prolonged hypoglycemia, also should almost always be held • The rest are OK but only if the pa1ent is ea1ng!