in-hospital management of...

In-Hospital

Management of

Diabetes

Dr Benjamin Schiff

Assistant Professor McGill University

No conflict of interest to declare

CLINICAL SCENARIO

62 y/o male with hx of DM 2, COPD, and HT is admitted with 2

days of cough and fever

He is taking metformin, glyburide and saxigliptin

Home sugars usually in the 8-10 range (well controlled, as per

patient)

Patient is generally well, though appetite has been a bit

diminshed in the past 2-3 days

Random glucose on admission is 11.1, Cr is 70, eGFR of 80 ml/min

Treatment includes antibiotic, bronchodilators and oral steroids

How should you manage his diabetes?

Outline

Goals of therapy

Factors affecting glucose

Brief review of medications

Co-morbid conditions

Approach to management

Sliding scales

Steroids

Tips and Pitfalls

D/C planning

In-Hospital Hyperglycemia is

Common Approximately 1/3 of in-

patients have been

found to have

hyperglycemia

Many have pre-existing

diabetes prior to

admission

Hyperglycemia

Hyperglycemia

Increases risks

of postoperative

infections and delirium

Prolonged

hospital stay,

resource utilization

Increased renal

dysfunction and

renal allograft

rejection in

transplant

Adverse Effects of Hyperglycemia

In-Hospital Glycemic Targets

Patient Type Glucose Target

(mmol/L)

Therapy of

choice

Non-critically ill Fasting 5-8

Random <10

Pre-hospital

regimen OR

basal-bolus-

correction

Critically ill 8-10 IV insulin infusion

CABG intraop 5.5-10 IV insulin infusion

Other periop 5-10 As appropriate

CABG = coronary artery bypass graft; IV = intravenous; Intraop = intraoperative;

periop = perioperative

FACTORS INFLUENCING GLYCEMIC

CONTROL

Diet ( )

Mobility/Exercise

Acute illness

IV (D5W)

Artificial feeding (TPN)

Medications

Co-morbidities (renal failure, liver failure)

Medication Review: Metformin

First line in Type 2 Diabetes

Lactic Acidosis main concern

Liver disease; hold

Renal Failure (CrCL<30, or 30-60 and conditions

associated with hypoperfusion/hypoxemia);

hold or adjust dose

Acute and/or unstable CHF; hold

IV contrast: Hold before and 48hr post

Add another class of agent best suited to the individual (agents listed in alphabetical order):

Class RelativeA1C Lowering

Hypo-glycemia

Weight Effect in Cardiovascular Outcome Trial

Other therapeutic considerations Cost

-glucosidase inhibitor (acarbose)

Rare neutral to Improved postprandial control, GI side-effects

$$

Incretin agents:DPP-4 InhibitorsGLP-1R agonists

to RareRare

Neutral to

Neutral (alo, saxa, sita)Neutral (lixi)

Caution with saxagliptin in heart failureGI side-effects

$$$$$$$

Insulin Yes Neutral (glar) No dose ceiling, flexible regimens $-$$$$

Insulin secretagogue:Meglitinide

Sulfonylurea

Yes

Yes

Less hypoglycemia in context of missed meals but usually requires TID to QID dosingGliclazide and glimepiride associated with less hypoglycemia than glyburide

$$

$

SGLT2 inhibitors to Rare Superiority (empa in T2DM patients with clinical CVD)

Genital infections, UTI, hypotension, dose-related changes in LDL-C, caution with renal dysfunction and loop diuretics, dapagliflozin not to be used if bladder cancer, rare diabetic ketoacidosis (may occur with no hyperglycemia)

$$$

Thiazolidinediones Rare Neutral CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect

$$

Weight loss agent (orlistat)

None GI side effects $$$

2016

Types of Insulin

Insulin Type (trade name) Onset Peak Duration

Bolus (prandial) Insulins

Rapid-acting insulin analogues (clear):

• Insulin aspart (NovoRapid®)

• Insulin glulisine (Apidra™)

• Insulin lispro (Humalog®)

• Insulin lispro U200 (Humalog® 200 units/mL)

10 - 15 min

10 - 15 min

10 - 15 min

10 - 15 min

1 - 1.5 h

1 - 1.5 h

1 - 2 h

1 - 2 h

3 - 5 h

3 - 5 h

3.5 - 4.75 h

3.5 - 4.75 h

Short-acting insulins (clear):

• Insulin regular (Humulin®-R)

• Insulin regular (Novolin®geToronto)

30 min 2 - 3 h 6.5 h

Basal Insulins

Intermediate-acting insulins (cloudy):

• Insulin NPH (Humulin®-N)

• Insulin NPH (Novolin®ge NPH)

1 - 3 h 5 - 8 h Up to 18 h

Long-acting basal insulin analogues (clear)

• Insulin detemir (Levemir®)

• Insulin glargine (Lantus®)

• Insulin glargine U300 (Toujeo®)

• Insulin glargine (BasaglarTM)

90 min

90 min

Up to 6 h

90 min

Not applicable

Up to 24 h (detemir 16-24 h)

Up to 24 h (glargine 24 h)

Up to 30 h

Up to 24 h (glargine 24 h)

2016

Insulin Type (trade name) Time action profile

Premixed Insulins

Premixed regular insulin – NPH (cloudy):

• 30% insulin regular/ 70% insulin NPH

(Humulin® 30/70)


(Novolin®ge 30/70)


(Novolin®ge 40/60)


(Novolin®ge 50/50)

A single vial or cartridge contains a

fixed ratio of insulin

(% of rapid-acting or short-acting

insulin to % of intermediate-acting

insulin)

Premixed insulin analogues (cloudy):

• 30% Insulin aspart/70% insulin aspart protamine

crystals (NovoMix® 30)

• 25% insulin lispro / 75% insulin lispro protamine

(Humalog® Mix25®)

• 50% insulin lispro / 50% insulin lispro protamine

(Humalog® Mix50®)

Types of Insulin (continued) 2016

Renal Failure

Diabetic patients at risk, even if not

previously known RF

Common complication of acute medical

illnesses

Increases risk of hypoglycemia

Closely monitor renal function, reassess

management (diabetes meds, other

nephrotoxic medications, etc)

Liver Disease

Metformin and lactic acidosis

Risk of hypoglycemia (hepatic

gluconeogenesis)

Concomitant pancreatic dysfunction

(exocrine and endocrine)

Approach to Management

Complete Hx, including dietary history, home values

(if available), medications, diabetic complications

(RF)

Labs, including Urea, Cr, K+, and HgB A1C

Determine goals of glycemic control ("tight" vs

relaxed, short term vs long term)

Evaluate and anticipate impact of acute illness(es)

on glucose control and choice of medication

Management (cont’d)

Diabetic diet

Accuchecks (frequency and duration individualized)

Preference is to continue usual medications when

possible (including insulin)

Reassess management as clinical situation changes

”Judicious” use of sliding scale

Above all, avoid hypoglycemia (ensure protocol exists)

Insulin Sliding Scales Indications

On home insulin

NPO or variable PO intake

Artificial feeding (parenteral or enteral)

Acutely ill

Peri-operative

Co-morbities, especially liver disease, renal failure

Use of steroids

Sliding Scales

Short-acting insulin

Often QiD, but increased risk of hypoglycemia

overnight

Alternatively TiD AC meals +/- ½ dose at HS

Both CDA and ADA recommend against using

sliding scale alone (Reactive rather than proactive)

Total daily dosing used to covert to basal/bolus

4.0

10.0

Breakfast Lunch Dinner Bedtime

BG (mmol/L) Bolus insulin (U)

< 4 Call MD

4.1 – 10.0 0

10.1 – 13.0 2

13.1 – 16.0 4

16.1 – 19.0 6

> 19.0 Call MD

6.0

Bolus insulin QID

14.0

6.0

16.5

3.0

Sliding Scale alone

What do you do?

What do you do?

What do you do?

What do you do?

+4 U

0 U 0 U

+6 U

QID: four times daily; SSI: sliding-scale insulin; BG: blood glucose

Sliding Scale Insulin Alone Results

in Variable Glucose ControlBG (mmol/L)

BASAL + BOLUS + CORRECTION Results in

Smoother Glycemic Control

4.0

10.0

Breakfast Lunch Dinner Bedtime

BG (mmol/L) Bolus insulin (U)

< 4 Call MD

4.1 – 10.0 0

10.1 – 13.0 2

13.1 – 16.0 4

16.1 – 19.0 6

> 19.0 Call MD

6.0

12.0

6.0

Correctional Insulin AC meals

What do

you do?

What do you do?

What do

you do?

6+2 U

6+0 U

6U 6U

What do you do?

6+0 U

6.0

ROUTINE Bolus insulin

Basal

insulin6U

18 U

Routine Basal

Sliding Scales

I begin with basic sliding scale, and review the glycemic readings

Adjust the scale according to readings:

if glu 10.1-13 4 units

13.1-16 6 units

16.1-18 8 units

18.1-22 10 units

22.1-26 12 units

> 26 14 units

Next step(s) depend on anticipated duration of the need for thesliding scale

I don’t necessarily include “call MD”

Steroids

Variable effect on glycemic control

Can cause hyperglycemia in non-diabetics

Particular risk with Prednisone (effect can begin

to wear off after 12 hours)

Avoid HS insulin if taking qD steroids

Caution when changing from IV to PO

Can use qD N in AM

Helpful Tips

Ensure you know what the patient is actually taking, not

just what they were prescribed

Review accuchecks early in the day BEFORE long acting

insulins

Include in your orders fixed time(s) to reassess sliding scales,

accuchecks etc as a “forced” reminder

Err on the side of higher glucose values, especially if you

anticipate a short term admission (minimize risk of

hypoglycemia, improve patient comfort)

Unexpectedly high sugars may indicate occult infection

Pitfalls

Not reviewing the actual glucose readings

Continuing accuchecks qid despite being in target range

Forgetting about IVs that continue unnecessarily

Not reassessing sliding scales if NPO, vomiting etc

Using metformin with IV contrast, especially cardiac caths

Complications associated with Acute Kidney Injury

Giving extra doses of short-acting insulin in between sliding scale

Discharge Planning

In most situations, resume medications as prescribed at

home

Dietary counselling/Pt education

Consider modifying treatment if clear evidence of sub-

optimal baseline control (ideally in consultation with pt’s

primary care provider)

May need to modify based on sequelae of hospitalization

(e.g., new renal failure, new medications)

Ensure safe and effective transition to pt’s health care

provider(s)

Key Messages

Determine goals of therapy

Be aware of co-morbities

Safe and effective use of

sliding scales

References

Clinical Practice Guidelines from the

Canadian Diabetes Association

http://guidelines.diabetes.ca

American Diabetes Association: Standards

of Medical care in Diabetes 2016

http://care.diabetesjournals.org/content/s

uppl/2015/12/21/39.Supplement_1.DC2/20

16-Standards-of-Care.pdf

QUESTIONS?

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