hyperglycemia in hospitalized patients robert j. rushakoff, md professor of medicine university of...

Hyperglycemia in Hospitalized Patients

Robert J. Rushakoff, MDProfessor of Medicine

University of California, San Francisco

[email protected]

•Strategies For Implementing Change•Nuts and bolts of management

Strategies For Implementing Inpatient Glycemic Control

www.rushakoff.com

www.endotext.com

ucsfinpatientdiabetes.pbworks.com

What is inpatient diabetes care?

Diabetes as a Secondary Diagnosis

Inpatient Diabetes Goals

Who Cares

Just get patient home

Sliding Scales are fine

Avoid that scary hypoglycemia


Normal glucoses for everyone

A high glucose means failure

Sliding Scales are banned

Some hypoglycemia is acceptable


Appropriate Glucose Control Based on

physiology and outcome studies

Care of the Hospitalized Diabetic Patient Goals for Inpatient

management Evidence, if any, for

stated goals Methods to Achieve

Glucose Goals Insulin order forms NPO patients Patients eating TPN and

hyperalimentation

Special Situations Glucocorticoids

Implementation Cases

Target Glucose Levels

Alive

No DKA or Hyperosmolar Coma


Diabetes Care 31:238–239, 2008

Quantifying the Impact of a Short-IntervalInterruption of Insulin-Pump Infusion Sets

on Glycemic Excursions

Occasional hypo- and hyperglycemia


No hypo- or hyperglycemia

•Prevent fluid and electrolyte abnormalities secondary to osmotic diuresis•Improve WBC function•Improve gastric emptying•Decrease surgical complications•Earlier hospital dischange

•Decreased post-MI mortality

•Decreased post-CABG morbidity and mortality


Normal Glucoses

Decreased Morbidity and Mortality


Problems With High Glucoses

Increased InfectionsEarly postoperative glucose control predicts nosocomial

infections rate in diabetic patients

Pomposelli et al: J Parenteral Ent Nut. 1998; 22:77-81

• Relative risk for “serious” postop infections increased to 5.7 when glucose >220 mg/dl

Increased InfectionsPerioperative Glycemic Control and the Risk of

Infectious Complications in a Cohort of Adults with Diabetes

Golden et al: Diabetes Care, 22:1408, 1999

411 diabetics who underwent CABGLeg and chest wounds, pneumonia and UTI

Relative Odds of Wound Infections

121-206 -------207-229 1.17230-252 1.86253-353 1.78

(p<0.05 for upward trend)

Glucose and post-CABG morbidity and mortality

Diabetes and Coronary Artery Bypass Surgery. An examination of perioperative glycemic control and

outcomes

Diabetes Care 2003; 26:1518-1524

•Retrospective Review of 291 patients surviving 24 h post op

•40% with retinopathy, nephropathy or neuropathy Inpatient Complications

For each 1 mmol/l (18 mg/dl) increase in postop day 1 over 6.1 mmol/l (110 mg/dl), a 17% increase risk of complications

HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH INCREASED MORTALITY

IN ICU

Falciglia et al: ADA Scientific Meetings, 2006, late breaking abstracts

Retrospective Review of 216,000 critically ill patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati

Hyperglycemia was an independent predictor of mortality starting at 111 mg/dl.

Effect was greatest with acute myocardial infarction, unstable angina, and stroke heart attack - 1.6-5 time a stroke it raised risk from 3.4 to 15.1 times unstable angina it raised risk from 1.7 to 6.2 times

HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH INCREASED MORTALITY

IN ICU

Falciglia et al: ADA Scientific Meetings, 2006, late breaking abstracts

Retrospective Review of 216,000 critically ill patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati

A significant but weaker effect was seen in patients with sepsis, pneumonia, and pulmonary embolism. Hyperglycemia was not found to be associated with mortality in diseases such as COPD and hepatic failure.

In diabetes patients, the increase in mortality risk was

not seen until mean glucose was >146 mg/dl

Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes

Retrospective Review Hyperglycemia in 38%

26% known diabetes 12% no known diabetes

MortalityNew hyperglycemia 16%Known Diabetes 3%Nondiabetics 1.7%

J. Clin Endocrinol. 2002;87:978-982.

TPN: Adverse OutcomesHyperglycemia Is Associated With Adverse Outcomes in

Patients Receiving Total Parenteral Nutrition

Cheung et al: Diabetes Care, 28:2367-2371, 2005

Risk of complications in relation to mean daily blood glucose level

OR (95% CI) P

Any infection 1.40 (1.08–1.82) 0.01

Septicemia 1.36 (1.00–1.86) 0.05

Acute renal failure 1.47 (1.00–2.17) 0.05

Cardiac complications 1.61 (1.09–2.37) 0.02

Death 1.77 (1.23–2.52) <0.01

Any complication 1.58 (1.20–2.07) <0.01

<124mg/dl<6.9 mmol/l

(OR)

124-1406.9-7.8

140-1647.9-9.1

>164>9.1

OR P OR P OR P

Any infection 1 1.3 0.71 2.8 0.08 3.9 0.02

Septicemia 1 0.8 0.73 1.0 1.0 2.5 0.17

Acute renal failure

— 1 — 14.8 0.02 10.9 0.03

Cardiac complications

1 1.1 1.0 4.9 0.17 6.2 0.11

Death 1 1.0 1.0 3.4 0.18 10.9 <0.01

Any complication

1 1.2 0.76 4.1 0.01 4.3 <0.01

Risk of Complications by glucose level quartile after adjusting for age, sex and presence of preexisting diabetes

Cheung et al: Diabetes Care, 28:2367-2371, 2005

Intervention Studies

Decreased post-CABG morbidity and mortality

Intensive Intervention by a Diabetes Team Diminishes Excess Hospital Mortality in Patients with diabetes who

undergo CABG

Kalin et al. Diabetes Suppl. 47:A87 1998

Diabetes team followed patientPerioperative IV insulin infusionAlgorithm based SQ premeal insulin

Mortality during CABG 1993-96

Relative risk

National 1.46Beth Israel 1.02

Decreased post-MI mortalityEffects of insulin treatment on cause-specific one year mortality and morbidity in diabetic patients with acute

myocardial infarction. DIGAMI Study Group.

Malmberg et al. Eur Heart J 1996

PeriMI IV insulin infusionAlgorithm based SQ premeal insulin for 1 year

Mortality (%)

1 year 3.4 years

Control 26 44

Insulin 19 33

DIGAMI Design 620 patients

MI within 24 hours Previous known DM with glucose > 11 mmol/l (198

mg/dl) or glucose > 11 mmol/l without known DM Exclusion: (50% of 1240 were excluded)

To sick for consent Unable to manage multidose insulin

Usual acute CCU MI care Treatment group

Infusion for >24 hours (until stable) , then 3 months multiple shots insulin

J Am Coll Cardiol 1995;26:57-65

DIGAMI2 (European Heart J. Prepublication Feb

2005)

Group 1 – IV insulin then long term SQ insulinGroup 2 – IV insulin then standard treatmentGroup 3 – Standard treatment

Mortality

Decreased InfectionsInsulin infusion improves neutrophil function in diabetic

cardiac surgery patients.

Rassias AJ, Marrin CA, Arruda J, Whalen PK, Beach M, Yeager MP. Anesth Analg 1999;

88:1011-6.

Perioperative IV insulin infusion

Neutrophil phagocytic activity

% baseline Control 47

Insulin 75

Decreased InfectionsGlucose control lowers the risk of wound infection in diabetics

after open heart operations

Zerr et al: Ann Thoracic Surgery, 1997, 63:356-61 Furnary et al. Annals of Thoracic Surgery 1999, 67:352-60

Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021

Perioperative IV insulin infusionProtocol to maintain glucoses <200

Incidence of Deep Wound Infections (%)

19971999 Routine Control 2.4 2.0“Tight” Control 1.5 0.8

Decreased InfectionsGlucose control decreases mortality in diabetics after open heart

operations

Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021

0

2

4

6

8

10

12

14

16

<150 150-175 175-200 200-225 225-250 >250

Mo

rtal

ity

(%)

Cardiac-relatedmortality

Noncardiac-related Mortality

0.9%1.3%

2.3%

4.1%

6.0%

14.5%


Intensive Insulin Therapy in Critically Ill Patients.

Van den Berghe G, Wouters P, Weekers F, et al. N Engl J Med 2001; 345:1359-1367.

Patients (all) on mechanical Ventilation in ICU

Randomly assigned to IV insulin maintaining glucoses between 80-110 mg/dl or conventional treatment (iv insulin if glucose >215 mg/dl then maintain glucose between 180-200.)

% given Insulin 24 hour dose AM glucose

Intensive 99 71U 103

Conventional 39 33U 153






12 month mortality

Intensive 4.6%

Conventional 8.6%

Main effect on patients in ICU >5 days






Intensive Treatment reduced:•In hospital mortality 34%•Sepsis 46%•Need for dialysis 41%•Number of transfusions 44%

Decreased Morbidity and Mortality Post-op received high dose glucose - 200-300 g in 24 hours All adults receiving mechanical ventilation who were admitted

to intensive care unit 63% had cardiac surgery

59 percent had undergone coronary bypass surgery, 27 percent valve replacement, and 14 percent a combined procedure


Whole glucose, so Plasma range would be: 90-123 mg/dl

Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery

Patients: Adults with and without diabetes who were

undergoing on-pump cardiac surgery. Primary outcome: composite of death, sternal

infections, prolonged ventilation, cardiac arrhythmias, stroke, and renal failure within 30 days after surgery. Secondary outcome measures were length of stay in the intensive care unit and hospital.

Intervention: continuous insulin infusion to maintain intraoperative

glucose levels between 4.4 (80 mg/dL) and 5.6 mmol/L (100 mg/dL) (n = 199)

not given insulin during surgery unless glucose levels were greater than 11.1 mmol/L (>200 mg/dL).

Both groups were treated with insulin infusion to maintain normoglycemia after surgery. Ann Int Med. 2007 146: 233-243

Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery

The groups had the same risk for perioperative adverse events (risk ratio, 1.0 [95% CI, 0.8 to 1.2]).

The intensive treatment group had more strokes (8 vs. 1) and more deaths (4 vs. 0) than the conventional treatment group.

Ann Int Med. 2007 146: 233-243

Van den Berghe, G. et al. N Engl J Med 2006;354:449-461

Kaplan-Meier Curves for In-Hospital Survival

Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis: VISEP trial Multicenter, two-by-two factorial trial

537 patients 18 academic tertiary hospitals in Germany

Patients with severe sepsis receive either intensive

insulin therapy to maintain euglycemia or conventional insulin therapy and either 10% pentastarch, a low-molecular-weight hydroxyethyl starch (HES 200/0.5), or modified Ringer's lactate for fluid resuscitation.

The rate of death at 28 days and the mean score for organ failure were coprimary end points.

The trial was stopped early for safety reasons

Brunkhorst F et al. N Engl J Med 2008;358:125-139

Intensive Insulin Therapy and Pentastarch Resuscitation in

Severe Sepsis

Kaplan-Meier Curves for Overall Survival

Blood Glucose According to the Type of Insulin Therapy


Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis

Findings similar to second study by Van den Berghe et al Nonsignificant differences in the rates of death at 28 days and at 90 days in

the intensive-therapy group and the conventional-therapy group Increase in hypoglycemic episodes the same:

VB: 18.7% vs. 3.1% VSEP: 17.0% vs. 4.1%

Hypoglycemia the same: VB: (32 mg and 31 mg per deciliter, respectively; P=0.50 VISEP: 31 mg and 28 mg per deciliter, respectively; P=0.30

Glucose levels the same: VB: 111±29 mg and 153±31 mg per deciliter, respectively VISEP: 112±18 mg and 151±33 mg per deciliter, respectively

Taken together, these studies establish that intensive insulin therapy has no measurable, consistent benefit in critically ill patients in a medical ICU, regardless of whether the patients have severe sepsis, and that such therapy increases the risk of hypoglycemic episodes.


GluControl Study Anticipated 3500 subjects to be randomized

80-110 vs 140-180 mg/dl Stopped because of safety concerns 1082 subjects recruited.

80-110 140-180

Glucose 118 144

ICU Mortality 17% 15%

Hospital Mortality

25% 21%

28 day Mortality

20% 16%

Hypoglycemia 8.6% 2.4%

Mortality with glucose <40

32.6% 53.8%

Intensive versus Conventional Glucose Control in Critically Ill Patients

The NICE-SUGAR Study Investigators

N Engl J MedVolume 360(13):1283-1297

March 26, 2009

Study Overview

• In this study, adults who were expected to require treatment in the intensive care unit on 3 or more consecutive days were randomly assigned to undergo intensive blood glucose control (target range, 81 to 108 mg per deciliter [4.5 to 6.0 mmol per liter]) or conventional blood glucose control (180 mg per deciliter [10.0 mmol per liter])

• The primary end point was death from any cause within 90 days after randomization

• Intensive glucose control increased mortality among the patients

NICE- SUGAR: Data on Blood Glucose Level, According to Treatment Group

The NICE-SUGAR Study Investigators. N Engl J Med 2009;360:1283-1297

NICE-SUGAR: Probability of Survival and Odds Ratios for Death, According to Treatment Group

The NICE-SUGAR Study Investigators. N Engl J Med 2009;360:1283-1297

AACE Position Statement: Hospital Glycemic Goals

Intensive Care Units: Intensive Care Units: 110 mg/dL110 mg/dL

Non-Critical Care Units:Non-Critical Care Units:

Pre-Prandial Pre-Prandial 110 mg/dL110 mg/dL

Max. Glucose Max. Glucose 180 mg/dL180 mg/dL

2009 Inpatient Glucose Goals

How to Obtain “Tight” Control

Bedside glucose monitoring IV insulin drips Diabetic Flow sheets Discourage the use of traditional

Sliding Scale insulin

INSULIN

SLIDING

SCALE

Roller Coaster Effect of Insulin Sliding Scale

Mr. And Mrs. XXXXX are admitted for spring fever.

Mr. XXXXX has Type 2 diabetes and takes a total of 75 Units insulin per day (2 shots). Glucoses at home are “poorly controlled.”

Mrs. XXXXX also has Type 2 diabetes but she has good control taking about 25 units of Lispro premeal and 40 Units glargine at night.

Fingerstick qid with regular insulin SQ coverage:

FSBG Action

< 50 1 amp D50 iv and call HO

51-80 give juice and repeat in 0.5-1 hr

81-200 no coverage

201-250 3U regular insulin SQ




>400 12U regular insulin SQ, call HO

INSULIN

SLIDING

SCALE

Insulins Available in the US

Types andPreparations

Action profile (h)

Onset Peak DurationRapid-acting

Lispro/aspart/ glulisine 0.25 0.5-1.5 3-5Regular 0.5 2-5 6-8

Intermediate-actingNPH 1-2 4-12 18-26U-500 1-3 6-12 12-18

Long-actingGlargine 1.5 ---- 24Detemir 1 ---- 23

Insulin: Use and Adjustments

Types andPreparations

Timing

Injection Glucose check

Rapid-actingLispro/aspart/ 10 min premeal 2 hour post meal glulisine and before next mealRegular 30 min premeal before next meal

Intermediate-actingNPH Morning Pre-dinner

Night Fasting

Long-actingGlargine/detemir PM Fasting

Insulin and Glucose Patterns

Polonsky, et al. N Engl J Med. 1988;318:1231-1239.

100

200

300

400Glucose Insulin

06001000 18001400 02002200 0600

Time of Day

06001000 18001400 02002200 0600

Time of Day

20

40

60

80

100

120

B L SB L S

Normal

mg

/dL

U/m

L

Relative Insulin Level

Time

Breakfast12pm Lunch Dinner

Insulin Regimens


Time

Breakfast12pm

AM NPH

Lunch Dinner

Insulin Regimens


Time

Breakfast

BID lispro/aspart

Lunch Dinner

Long analogue

12pm

Lispro/aspart

Insulin Regimens


Time

Breakfast

TID lispro/aspart and hs NPH

Lunch Dinner

NPH

Lispro/aspart

12pm

Insulin Regimens


Time

Breakfast

TID lispro/aspart and ultralente

Lunch Dinner

Lispro/aspart

12pm

ultralente

Insulin Regimens


Time

Breakfast12pm

PM glargine

Lunch Dinner

glargine

Insulin Regimens


Time

Breakfast

TID lispro/aspart/glulisine and hs glargine

Lunch Dinner12pm

glargine

Lispro/aspart/

glulisine

Insulin Regimens


Time

Breakfast

Insulin pump

Lunch Dinner12pm

Lispro/aspart

Insulin Regimens

Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT 2 Trial)

Prospective, multicenter, randomized trial to compare the efficacy and safety of a basal-bolus insulin regimen with that of sliding-scale regular insulin (SSI)

Type 2 diabetes. 130 insulin-naive patients were randomized to receive glargine and glulisine (n = 65) or a standard SSI protocol (n = 65).

Glargine was given once daily and glulisine before meals at a starting dose of 0.4 units · kg–1 · day–1 for blood glucose 140–200 mg/dl or 0.5 units · kg–1 · day–1 for blood glucose 201–400 mg/dl. SSI was given four times per day for blood glucose >140 mg/dl.

Diabetes Care 30:2181-2186, 2007

Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT 2 Trial)

Diabetes Care 30:2181-2186, 2007

Changes in blood glucose concentrations in patients treated with glargine plus glulisine (•) and with SSI (○). *P < 0.01; ¶P < 0.05.Changes in blood glucose concentrations in patients treated with glargine plus glulisine (•) and with SSI (○). *P < 0.01; ¶P < 0.05.

Current Insulin Order Forms Adult

DKA Adult SQ Insulin – Patient

eating Adult SQ Insulin – NPO,

TPN, Tube Feeding IV insulin – ICU protocol IV insulin – Med-Surgical

Unit protocol Adult Insulin pump

Patient waver form to use pump

Adult SQ insulin algorithm for NPO patients**

OB-GYN SQ Insulin – Patient

eating Pump Form**

Pediatrics SQ Insulin – Patient

eating Pump Form** DKA** IV insulin**

** major update or under development** major update or under development

Subcutaneous Insulin Order Sheet

Introduction

Subcutaneous Insulin Order Sheet : - PATIENT EATINGCheck blood glucose and give insulin before meals, bedtime, and 2 A.M.1.Discontinue previous SQ insulin order.2.If patient becomes NPO for procedure/stops eating:

•HOLD nutritional dose of Aspart•Give correctional dose of Aspart if BG >130 mg/dL•Give Glargine dose. If BG has been <70 mg/dL in last 24 hours, call MD to consider adjusting Glargine dose•Call MD for SQ insulin NPO orders if patient on 70/30, NPH insulin or has been NPO for >12 hours.

BASAL AND NUTRITIONAL INSULIN DOSE (IN UNITS)Patient Eating TIME Breakfast Lunch Dinner Bedtime

Aspart (Novolog)Nutritional Dose

NPH

Glargine (Lantus)

Novolog Mix 70/30

Subcutaneous Insulin Order Sheet : Meal time insulin adjustments

B. Meal Time CORRECTIONAL Insulin with ASPART. Check box to choose scale. Add or subtract from nutritional dose of aspart

Blood Glucose Range SensitiveBMI less than 25 and/or <50 units per day

AverageBMI 25-30 and/or 50-90 units per day

Resistant BMI >30 and/or >90 units per day

Custom

<70 mg/dl

Once BG≥100mg/dl give

Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats.

2 units less 3 units less 4 units less _____units less

70-100 mg/dl 2 units less 2 units less 3 units less _____units less

101-130 mg/dl Give nutritional dose of Aspart as in # 1A above

131-150 mg/dl +0 unit +1 units +2 units +_______units

151-200 mg/dl +1 units +2 units +3 units +_______units





Over 400 mg/dl +6 units +12 units +18 units +_______units

Subcutaneous Insulin Order Sheet : Bedtime and 2am insulin adjustments

Shown below is the section C the page for “patients eating”. The area indicates the orders for supplemental insulin that should be given at bedtime and/or 2am. Aspart insulin is to be used at these times. These testing times are important not just for checking for high glucoses but also to monitor and treat low glucoses. These checks are also important in helping to adjust the overall insulin doses.

C. BEDTIME AND 2AM BLOOD GLUCOSE CORRECTIONAL INSULIN WITH ASPART IF BG ≥ 200mg/dl

BG Range: Default Value Or Custom

200-250 mg/dL 1 unit

251-300 mg/dL 2 units

>300 mg/dL 3 units

Subcutaneous Insulin Order Sheet : - NPO, Tube Feeds or TPN

1. NPO _____________________ (start date / time)TPN continuous cycle _______________TUBE FEED continuous cycle ______________

1.Check blood glucose and give insulin every 4 hours.

2.Discontinue previous SQ insulin order.3.If patient becomes NPO for procedure/stops eating:

• Hold nutritional does of Aspart• Give correctional dose of Aspart if BG>130 mg/dl• Give Glargine dose. If BG has been less than 70 mg/dl in last 24 hours, call MD to consider adjusting

glargine dose.

4.If TPN/Tube Feed interrupted >30 minutes, hand D10W at rate of Tube Feed/TPN

A. BASAL AND NUTRITIONAL INSULIN DOSE (IN UNITS) BLOOD GLUCOSE TIME 6:00 10:00 14:00 18:00 22:00 02:00Aspart (Novolog)Nutritional Dose 5 5 5 5 5 5

Glargine (Lantus) 24

Subcutaneous Insulin Order Sheet : q4hour correctional dosing for NPO, Tube Feeds or TPN

q4hour correctional insulin options are shown. Here correctional insulin is generally used to add or subtract insulin from the q4hour nutritional insulin ordered in section A. There are times it can be used even if no standing q4hour dose is written.





Custom

<70 mg/dl


Treat for hypoglycemia per protocol (see order #6). Once BG ≥100 mg/dl, give Aspart with following change when patient eats.2 units less 3 units less 4 units less _____units less










The final section of the both forms of the order sheets describes the treatment for hypoglycemia. The key item is that when a person can eat, the hypoglycemia is treated by oral glucose.

Low Glucose Reading

3. For BG <70 mg/dl, use Hypoglycemia Protocol below:For patient taking PO, give 20 g of oral fast-acting carbohydrate: 4 glucose tablets (5 grams glucose/tablet) -OR- Give 6 oz. fruit juice Give 25 ml of D50 IV push If patient cannot take PO Check fingerstick glucose every15 minutes and repeat above treatment until BG is ≥100 mg/dl.

Transition from IV to SQ Insulin

Take 80% of last 24 h insulin infusion

Basal: ½ of the value

premeal: ½ of the value divided for the meals

Example: 1.5 units per hour = 36U

36 x .8= 29

Basal: 30x.5=15

premeal: 30x.5=15 5 per meal






Custom

<70 mg/dl













A. BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose before meal, bedtime and 2am. • If patient becomes NPO HOLD nutritional dose of Aspart and give correctional dose of Aspart if BG >130 mg/dl• If patient is NPO >4 hours call MD for IV Dextrose order

Patient Eating TIME Breakfast Lunch Dinner Bedtime

Aspart (Novolog)Nutritional Dose 5 5 5



What to do if unclear how much the patient will eat? What if transition to clear liquids?

1.Basal calculation remains unchanged

2. Premeal 0-50% of calculated dose






Custom

<70 mg/dl






















Custom

<70 mg/dl

















Glucose 140 255 180 150

Insulin 5 A(5+0) 8 A(5+3) 6 A(5+1)

15 glargine

Change for next day would be increase in Breakfast and lunch Aspart

Patient on Insulin who is Eating

Patient on 40Uam,30Upm of 70/30

Poorly controlled, 80kg

30 U glargine

10U aspart/humalog premeal

Easy method:

Choose the U/kg (.3 to .5 U/kg)



If on premixed insulin changing to MDI:

Basal: ½ of the total dose

premeal: ½ of the total dose divided for the meals

Patient on Diet or Oral Agents who is Eating

Depending on which oral agents – may or may not be continuing- - - -

Pharmacologic Classes of Agents to Control Hyperglycemia in Type 2 Diabetes

Thiazolidinediones—e.g., rosiglitazone, pioglitazone

Class

Biguanides—e.g., metformin

Alpha-glucosidaseinhibitors—e.g.,acarbose & miglitol

Insulin

Insulin secretagogues—e.g., sulfonylureas (glyburide, glipizide); repaglinide

Bind to peroxisome proliferator activated receptor-gamma (PPAR) in muscle, fat and liver to decrease insulin resistance

Stimulate pancreatic -cells to increase insulin output

Target liver to decrease glucose production

Inhibit intestinal enzymes that break down carbohydrates, which delays carbohydrate absorption

Target insulin-sensitive tissue to increase glucose uptake

Action

Pharmacologic Classes of Agents to Control Hyperglycemia in Type 2 Diabetes

Thiazolidinediones—e.g., rosiglitazone, pioglitazone

Class

Biguanides—e.g., metformin

Alpha-glucosidaseinhibitors—e.g.,acarbose & miglitol

Insulin

Insulin secretagogues—e.g., sulfonylureas (glyburide, glipizide); repaglinide

Takes 2-3 weeks to see initial effect. Effects continue for weeks or months after discontinuation of medication. Issues with fluid retention, CHFKeep in mind the metabolic t1/2 of each drug

Withhold in conditions predisposing to renal insufficiency and/or hypoxia

CV collapse

Acute MI or acute CHF

Severe infection

Use of iodinated contrast material

Major surgical procedures

In case of hypoglycemia(due to sulfonylurea or insulin treatment)

Glucose (dextrose) must be administered

Sucrose and complex carbohydrates should not be administered

Special Considerations

Patient on Diet alone or Oral Agents who is Eating

Day 1 – Use Correctional dosing only

Base on BMI, anticipated sensitivity

Patient on Diet alone or Oral Agents who is Eating





Custom

<70 mg/dl
















Glargine (Lantus)

Glucose 140 255 180 190

Insulin 1 A(0+1) 6 A(0+6) 2 A(+2)

0 glargine

Change for next day:

•FBS >130 so start basal insulin at .1 to .3 U/kg

•Preprandial >130 so start premeal insulin

Patient Scheduled for NPO Procedure

Patient is scheduled for a CT scan and is NPO tomorrow morning. Glucoses at what would be breakfast time is 240. Orders are as follows. What should be done with the insulin?

Patient on Insulin who is Eating





Custom

<70 mg/dl















Aspart (Novolog)Nutritional Dose 21 14 19Glargine (Lantus) 65

Glucose 240

Insulin 6 A(0+6)

65 glargine

Tube Feeds

Method 1:

Take the last 24 hour insulin infusion

Basal: 24 hour total/2

Aspart: 24 hour total/10 givenq4h

Example: 2 units per hour – 48U

Basal: 48/2=24U glargine

aspart: 48/10=4.8 (5 U aspart q4h)

Method 2:

Similar to Method 1 – just using a higher proportion of basal insulin

Method 3:

If no IV – just use 1 unit per 6-10g CHO to start and calculate as per #1

Tube Feeds

2. BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Hold nutritional dose of Aspart if patient becomes NPO or tube feed held but give correctional insulin if required

Tube Feeds TIME 8 a.m. 12 p.m. 4 p.m. 8 p.m. 12 a.m. 4 a.m.


Aspart (Novolog) 5 5 5 5 5 5

NPH


Novolog Mix 70/30

Tube Feeds





Custom

<70 mg/dl













A. BASAL AND NUTRITION INSULIN DOSE (IN UNITS): Check blood glucose every 4 hours. • If tube feed held or patient becomes NPO, HOLD nutritional dose of Aspart and give correctional dose of Aspart if

BG >130 mg/dl• If patient is NPO >4 hours call MD for IV Dextrose order• Give insulin at start of tube feed

BLOOD GLUCOSE TIME 8:00 12:00 16:00 20:00 24:00 04:00Aspart (Novolog)Nutritional Dose 5 5 5 5 5 5Glargine (Lantus) 24

Glucose 140 255 180 260

Insulin 6 A(5+1) 11 A(5+6) 7 A(5+2) 11 A(5+6)

24 glargine

Change for next day would be increase in glargine

Glucocorticoids and Diabetes

Peripheral Peripheral TissuesTissues(Muscle)(Muscle)

GlucoseGlucose

LiverLiver

Impaired insulin Impaired insulin secretionsecretion

Increased glucose Increased glucose productionproduction

postreceptor postreceptor defectdefect

InsulinInsulinresistanceresistance

PancreasPancreas

Glucocorticoids and Diabetes:

Breakfast DinnerLunch Breakfast

Glucose

Bedtime



Glucose

Bedtime

Typical sliding scale insulin



Glucose

Bedtime

Revved Up sliding scale insulin



Glucose

Bedtime

NPH and

Regular



Glucose

Bedtime

Increase NPH and

Regular






Custom

<70 mg/dl

















Glucose 151 220 340 350

Insulin 12 A(10+2) 14 A(10+4) 18 A(10+8) 3A(+3)

15 glargine

Change for next day would be increase Aspart

Breakfast: 16units; Lunch 18 units; Dinner 18 units

Committee Members Physicians: Endocrinologist, Hospitalist Clinical Nurse Specialists: Diabetes, education Nurses: ICU Manager, at least one manager from

medical floor (or their representative) Clinical Pharmacist Administration presence – from level of quality

assurance or similar title Discharge Coordinator – not required for initial

discussions and implementation, but needed later Nutritional services – not required for initial design

and implementation of forms.

TASKS Formulary

Clean up insulin Clean up oral agents

Nursing Issues Policy on IV insulin use Policy on frequency of glucose monitoring

Forms Design forms

IV insulin forms SQ insulin forms ?DKA treatment forms

Other Committees To be Conquered Pharmacy and Therapeutics

Formulary issues Oral agents Insulins Insulin Forms – iv, sq

Forms Insulin forms – iv, sq

Quality Improvement Need buy in at this level to achieve

administrative support

Other People To be Conquered Smaller Hospitals

CEO Chief of Staff

Larger Institutions Chairs of Medicine, Surgery Heads of training programs from Medicine,

Surgery Chief of Staff, Chief Medical Officer, CEO Chairs of other Departments Chief Residents Dean for Education

Implementation Smaller Hospitals

Entire Institution Larger Institutions

? One unit at a time ? One service at a time

Make certain forms are available Unit clerks must be aware!!!! If orders written in ER, forms must be in ER If forms not available, this will fail.

UCSF Implementation Nursing Education

Diabetes Nurse Specialist Intranet Training

Physician Training Small group sessions Internet training

Question 1: Transition from IV to SQ Insulin

The IV rate has been changing, what do you use to base the conversion rate on?

The idea is to take the most recent steady rate and use that as the rate for the previous 24 hours. Thus for this patient, for 6 hours it has been at 1.8 units per hours, so that will be the rate used to calculate a 24 hour dose.

Question 1: Transition from IV to SQ Insulin

Take 80% of last 24 h insulin infusion



Example: 1.8 units per hour = 43.2U

43 x .8= 34

Basal: 34x.5=17

premeal: 34x.5=17 6 per meal






Custom

<70 mg/dl






















Custom

<70 mg/dl
















NPH) 17





Custom

<70 mg/dl


Treat for hypoglycemia per protocol (see order #3). Once BG ≥100 mg/dl, give Aspart with following change when patient eats.2 units less 3 units less 4 units less _____units less










Case 2: SQ Insulin Adjustments





Insulin 11 A(9+2) 16 A(12+4) 15 A(15+0)

42 glargine

Breakfast: 179; Lunch 202, Dinner 105 bedtime 143

Change for next day

Breakfast: 12A, 46 G; Lunch 12A; Dinner 15A

Case 3: Patient Starting Insulin





Custom

<70 mg/dl
















Glargine (Lantus)

5’7”, 270 lb, glucose 279, HgA1c 8.9

There is no perfect formula, the idea is to start with a reasonable choice and make quick adjustments

This patient is sick, obese, insulin resistant to begin with. Would be reasonable to use .5 U/kg and give ½ as basal and ½ split for premeal. Thus: 279/2.2= 122.7 kg 122x .5= 61 So about 30units basal and 10 units premeal.






Custom

<70 mg/dl


















Case 4: Patient NPO for short time





Custom

<70 mg/dl















Aspart (Novolog)Nutritional Dose 14 14 14Glargine (Lantus) 55

Glucose 240

Insulin 6 A(0+6)

55 glargine






Custom

<70 mg/dl

















Glucose 151 220 340 360

Insulin 6 A(5+1) 7 A(5+2) 9 A(5+4) 3A(+3)

20 glargine

Change for next day would be increase Aspart

Breakfast: 10units; Lunch 10 units; Dinner 9 units

Case 6: Tube Feeds





Custom

<70 mg/dl















BLOOD GLUCOSE TIME 8:00 12:00 16:00 20:00 24:00 04:00Aspart (Novolog)Nutritional Dose

Glargine (Lantus)

Patient is being started on Tube feeding. It would be easiest to titrate insulin using in IV drip, but you decide to just use SQ insulin. You are starting continuous feedings of ensure at 60 ml/hour. Ensure has .175 g CHO/ml (hint – 10.5 g/hour, 252g/24 hours). Write some orders

Tube Feeds

Use 26 units for 24 hours

Basal: 24 hour total/2

Aspart: 24 hour total/10 givenq4h

Example:

Basal: 26/2=13U glargine

aspart: 26/10=2.6 (3 U aspart q4h)

If no IV – just use 1 unit per 6-10g CHO to start

1U/10g= X U/256 g (basically 256/10 for those of you sleeping by now)- for 26 units of insulin in 24 hours.

Case 6: Tube Feeds





Custom

<70 mg/dl















BLOOD GLUCOSE TIME 8:00 12:00 16:00 20:00 24:00 04:00Aspart (Novolog)Nutritional Dose 3 3 3 3 3 3Glargine (Lantus) 13

hyperglycemia in hospitalized patients robert j. rushakoff, md professor of medicine university of...

Documents

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