In Hospital DM Lecture Part 1
-
Upload
abdo-ibraheem -
Category
Documents
-
view
221 -
download
0
Transcript of In Hospital DM Lecture Part 1
-
7/30/2019 In Hospital DM Lecture Part 1
1/47
By
DR: MOKHTAR , Abdel Rahman
Consultant Internist ( NWAFH )
In hospital Management of
Hyperglycemia
-
7/30/2019 In Hospital DM Lecture Part 1
2/47
Why ?
Huge Implementation Gap
Regulatory guidelines etc.
Can be cost effective
Inpatient hyperglycemia is very strongly
associated with poor outcomes
Improved glycemic control is associatedwith improved outcomes
Society of Hospital Medicine. http://www.hospitalmedicine.org/ResourceRoomRedesign/
pdf/GC_Workbook.pdf.
-
7/30/2019 In Hospital DM Lecture Part 1
3/47
Hyperglycemia*: A Common Comorbidityin Medical-Surgical Patients in Hospitals
64%(1.7% mortality)
12%(16% mortality)
26%3% mortality
Normoglycemia
Known Diabetes
New Hyperglycemia
Umpierrez G et al, J Clin Endocrinol Metabol 87:978, 2002
n = 2,020
* Hyperglycemia: Fasting BG 126 mg/dlor Random BG 200 mg/dl X 2
-
7/30/2019 In Hospital DM Lecture Part 1
4/47
Landmark trials favoring tight glycemiccontrol for inpatients and outpatients
Inpatient
DIGAMI (1997)
van den Berghe (2001):IV insulin in SICU
Outpatient
DCCT
UKPDS
-
7/30/2019 In Hospital DM Lecture Part 1
5/47
van den Berghe (2001) ,Leuven Belgium
IV insulin in SICU
-
7/30/2019 In Hospital DM Lecture Part 1
6/47
Intensive Insulin Therapy in Critically Ill SurgicalPatients: Morbidity and Mortality Benefits
van den Berghe G, et al. N Engl J Med. 2001;345:13591367.
-60
-50
-40
-30
-20
-10
0
Reduction
(%)
Mortality Sepsis Dialysis PolyneuropathyBlood
Transfusion
34%
46%41%
44%
50%
N = 1,548
-
7/30/2019 In Hospital DM Lecture Part 1
7/47
Van den Berghe, Crit Care Med 2003
Filled bars
< 110
Shaded bars110-150
Open bars
> 150 mg/dL
Complications
correlated
withaverage
blood glucose
-
7/30/2019 In Hospital DM Lecture Part 1
8/47
Van den Berghe, Crit Care Med 2003
Although the
Van den Berghe study
was not designed
to determine
the threshold
above which
mortality increases,
mortality was higherat glucose 110-150,
compared to
glucose < 110 mg/dL. < 110
110-150
> 150 mg/dL
-
7/30/2019 In Hospital DM Lecture Part 1
9/47
Baird. Persistent post stroke hyperglycemia is independentlyassociated with infarct expansion and worse clinical outcome.
Stroke 2003; 34: 2208.
-
7/30/2019 In Hospital DM Lecture Part 1
10/47
The results of the Leuven studies have led
to a worldwide increase in the
implementation of strict glycemic control in
the intensive care units (ICU). Themortality reduction in these landmark trials
was attributed to the strict lowering of
mean glucose (target 80110 mg/dL)during admission in the intervention group.
-
7/30/2019 In Hospital DM Lecture Part 1
11/47
ACE / ADA Position Statement onDiabetes and Metabolic Control 2004
ICU Non-ICUPreprandial
Non-ICUMaximal
AACE/ACE
ADA
110 mg/dL
100 mg/dL
110 mg/dL
90-130 mg/dL
180 mg/dL
180 mg/dL
-
7/30/2019 In Hospital DM Lecture Part 1
12/47
Limitations of the van denBerghe studies
1- It was not blinded.
2- Most cases were recruited after cardiac surgery !!.
3- Patients received IV glucose on arrival to ICU of 200300 g/day ( 2-3 L of D10% ).
4- Parentral N , enteral feeding , or combined feeding wasprovided to all patients within 24 h of ICU admission !!.
5- The mortality of patients in the control group was twicethe national average of Australia for ex !!!.
6- Intrinsic limitations of single center studies make themunsuitable for level I evidence.
( Bellomo and Egi ,Mayo Clinic Proc. May , 2009 ; 84 ( 5 ): 400 402 )
-
7/30/2019 In Hospital DM Lecture Part 1
13/47
The tight glucose control expressseemed unstoppable ...till 2009
-
7/30/2019 In Hospital DM Lecture Part 1
14/47
Normoglycemiain Intensive CareEvaluationSurvival Using Glucose
Algorithm Regulation
(NICE-SUGAR) trial 2009 -This is the second largest randomized study sample in
the history of critical care medicine :
- 6100 patients included.
- One million glucose and insulin dose
measurement included.
-
7/30/2019 In Hospital DM Lecture Part 1
15/47
Methodology:Within 24 hours after admissionto an intensive care unit (ICU), Patients were
randomly assigned to undergo either :
Intensive glucose control, with a target blood
glucose range of 81 to 108 mg per deciliter (4.5to 6.0 mmol per liter), or
Conventional glucose control, with a target of
180 mg or less per deciliter (10.0 mmol or lessper liter).
The primary end point was death from any
cause within 90 days after randomization.
-
7/30/2019 In Hospital DM Lecture Part 1
16/47
-
7/30/2019 In Hospital DM Lecture Part 1
17/47
-
7/30/2019 In Hospital DM Lecture Part 1
18/47
Investigators found that, compared with conventional therapy . IIT wasassociated with an increased mortality 90 days after randomization.This detrimental IIT mortality effect in the NICE-SUGAR trial occurredin all subgroups, including surgical patients.
Severe hypoglycemia (blood glucose
below 40 mg/dl) occurred in
approximately 6.8 percent of
intensively treated patients compared
to 0.5 percent of conventionally treated
patients.
-
7/30/2019 In Hospital DM Lecture Part 1
19/47
American Association of Clinical EndocrinologistsAnd American Diabetes AssociationCONSENSUS STATEMENT ON INPATIENTGLYCEMIC CONTROL
-
7/30/2019 In Hospital DM Lecture Part 1
20/47
h b ( ) d
-
7/30/2019 In Hospital DM Lecture Part 1
21/47
The American Diabetes Association (ADA) andthe American Association of Clinical
Endocrinologists (AACE Until more information is available, it
seems reasonable for clinicians to treat
critical care patients with the less intensive
" yet good - glucose control strategiesused in the conventional arm of the NICE-
SUGAR trial.
(insulin infusion begun if blood glucose was over 180 mg/dl,
and discontinued if blood glucose dropped below 144 mg/dl).
-
7/30/2019 In Hospital DM Lecture Part 1
22/47
Hermanides et al., 2010
-
7/30/2019 In Hospital DM Lecture Part 1
23/47
Glucose variability :
Hermanides and associates 2010 , Publishedthe results of another large study in
Amsterdam that included 5728 patients
aiming at : Measuring GV over time in a largestrict glucose control-treated ICU populationacross several ranges of mean glucose andto investigate the association of GV and
mean glucose values with ICU and in-hospital mortality.
Variability was measured by , MAG ( Mean
absolute Glucose change per hour ) & SD.
-
7/30/2019 In Hospital DM Lecture Part 1
24/47
Figure 1. Two fictitious patients with identical mean glucose and sdbut different patterns of variability expressed by mean absolute glucose
change (MAG).
-
7/30/2019 In Hospital DM Lecture Part 1
25/47
RESULT :
In this retrospective cohort study, it has been shownthat GV, expressed as MAG, is highly associated withICU death in both high and low ranges of mean
glucose. In combination with a high mean glucose, GVseems most detrimental.
There appears to be a synergistic negative effect ofhigh mean glucose in combination with high GV.
For those with persistently high mean glucose valuesduring admission, low GV seems protective.
DISCUSSION
-
7/30/2019 In Hospital DM Lecture Part 1
26/47
DISCUSSION : From a pathophysiological viewpoint, acausal relationship can be substantiated; in vitro, varyingglucose levels have been shown to enhance cellapoptosis.[24] In rats,
Glycemic reperfusion after hypoglycemia caused neuronaldeath,[25] and altering glucose levels were impairingendothelial function in healthy volunteers.[26]
Even more, tubulointerstitial cells exposed to intermittenthigh glucose concentrations showed enhanced cell growthand collagen syntheses compared with stable high glucoseconcentrations.[27]
Possibly, the adaptive cell mechanisms that are initiated incase of constant hyperglycemia are ineffective when thehyperglycemia is not constant but varying, explaining thetoxicity of GV.[28]
Managing Diabetes in the Hospital Presents
-
7/30/2019 In Hospital DM Lecture Part 1
27/47
Managing Diabetes in the Hospital PresentsDifferent Challenges than Managing
Diabetes in the Outpatient Arena!
-
7/30/2019 In Hospital DM Lecture Part 1
28/47
- Much of the management of diabetes inoutpatients is predicated on stability in the
lifestyle regimen.
- Diabetes patients are generally instructed to
eat consistent amounts of carbohydrate, takethe prescribed doses of insulin, and doregular exercise, each day.
- The hospital, however, results in a high levelof instability in these and other variables thatimpact blood glucose.
The hospital is also associated with:
-
7/30/2019 In Hospital DM Lecture Part 1
29/47
The hospital is also associated with:
- Acute illness, stress-related hyperglycemia
- Use of medications that impact glycemic control
COMMONLYASSOCIATED
Steroids
Catecholamines
Tacrolimus
Cyclosporine
Gatifloxacin
TPN
SIGNIFICANT butLESS PROMINENT
Oral contraceptivepills
Thiazides
Atypical
antipsychotics
Calcium-channel
blocking agents
Protease inhibitors
Managing diabetes &
-
7/30/2019 In Hospital DM Lecture Part 1
30/47
Managing diabetes &hyperglycemia in thislabile environment
requires a flexiblemanagementstrategy.
-
7/30/2019 In Hospital DM Lecture Part 1
31/47
Oral agents can be continued instable patients with normal
nutritional intake, normal blood
glucose levels, and stable renal and
cardiac function. However, there
are several potential disadvantages
to using these medications in
hospital patients:
Oral Anti diabetes Agents in the Hospital
http://www.google.com.sa/imgres?imgurl=http://living.oneindia.in/img/2010/08/19-diabetes-tablets-190810.jpg&imgrefurl=http://living.oneindia.in/health/disorders-and-ailments/2010/diabetes-tablet-treatment-190810.html&usg=__NfPbeEhurAhi0yZiXzK6mCwLZ5k=&h=150&w=200&sz=7&hl=ar&start=21&zoom=1&itbs=1&tbnid=R3FB-9-ueZyhuM:&tbnh=78&tbnw=104&prev=/images%3Fq%3DDiabetes%2Boral%2Btablets%26start%3D20%26hl%3Dar%26safe%3Dactive%26sa%3DN%26gbv%3D2%26ndsp%3D20%26tbs%3Disch:1http://www.google.com.sa/imgres?imgurl=http://living.oneindia.in/img/2010/08/19-diabetes-tablets-190810.jpg&imgrefurl=http://living.oneindia.in/health/disorders-and-ailments/2010/diabetes-tablet-treatment-190810.html&usg=__NfPbeEhurAhi0yZiXzK6mCwLZ5k=&h=150&w=200&sz=7&hl=ar&start=21&zoom=1&itbs=1&tbnid=R3FB-9-ueZyhuM:&tbnh=78&tbnw=104&prev=/images%3Fq%3DDiabetes%2Boral%2Btablets%26start%3D20%26hl%3Dar%26safe%3Dactive%26sa%3DN%26gbv%3D2%26ndsp%3D20%26tbs%3Disch:1http://www.google.com.sa/imgres?imgurl=http://living.oneindia.in/img/2010/08/19-diabetes-tablets-190810.jpg&imgrefurl=http://living.oneindia.in/health/disorders-and-ailments/2010/diabetes-tablet-treatment-190810.html&usg=__NfPbeEhurAhi0yZiXzK6mCwLZ5k=&h=150&w=200&sz=7&hl=ar&start=21&zoom=1&itbs=1&tbnid=R3FB-9-ueZyhuM:&tbnh=78&tbnw=104&prev=/images%3Fq%3DDiabetes%2Boral%2Btablets%26start%3D20%26hl%3Dar%26safe%3Dactive%26sa%3DN%26gbv%3D2%26ndsp%3D20%26tbs%3Disch:1 -
7/30/2019 In Hospital DM Lecture Part 1
32/47
Disadvantages of most oral agents:
Slow-acting/difficult to titrate
Disadvantages of insulin secretagogues (e.g.sulfonylureas and meglitinides such as glyburide,glypizide, repaglinide, etc.):
Hypoglycemia if caloric intake is reduced
Some are long-acting (hypoglycemia may beprolonged)
Disadvantages of metformin:
Lactic acidosis can occur when used in the setting ofrenal dysfunction, circulatory compromise, orhypoxemia
Slow onset of action
GI complications: Nausea, diarrhea
Disadvantages of thiazoladinediones :
-
7/30/2019 In Hospital DM Lecture Part 1
33/47
_ Disadvantages of thiazoladinediones :
Slow onset of action (2-3 weeks)
Can cause fluid retention (particularly when used with
insulin), and increase risk for CHF
Disadvantages of alpha-glucosidase inhibitors (e.g.acarbose, miglitol)
Abdominal bloating and flatus Need pure glucose to treat hypoglycemia
Disadvantages of GLP-1 mimetics (e.g. exenatide)
Newer agents without data to support use in thehospital
Abdominal bloating and nausea secondary to delayed
gastric emptying
-
7/30/2019 In Hospital DM Lecture Part 1
34/47
Managing diabetes &
-
7/30/2019 In Hospital DM Lecture Part 1
35/47
Managing diabetes &hyperglycemia in thislabile environment
requires a flexiblemanagementstrategy.
-
7/30/2019 In Hospital DM Lecture Part 1
36/47
The winning card
-
7/30/2019 In Hospital DM Lecture Part 1
37/47
The story of Tom and Harry
65 year old twins
Diabetes: on NPH 20 units and OHGs with
poor control, neither sees MD regularly Smokers
At a Gentlemans Club when both
developed chest pain. After 6 hours.. Tom: goes to Hospital A
Harry: Hospital A full, so Harry goescross town to Hospital B
-
7/30/2019 In Hospital DM Lecture Part 1
38/47
Tom at Hospital A
Admitted to CCU, MI confirmed
Glucose 230 mg/dL
No infusion started for 18 hours Infusion control poor, glycemic excursions
when Tom eats.
Recurrent hypoglycemia, treatedinconsistently, especially with trips to
Radiology
Finally controlled on infusion day 4.
-
7/30/2019 In Hospital DM Lecture Part 1
39/47
Tom at Hospital A contd
Transition to ward: Tom on sliding scale Recurrent hyperglycemia to 300
Brief return to unit .
Confusion with various insulin regimens asTom goes from eating to NPO severaltimes.
No mention of hyperglycemia in dischargesummary
Tom discharged on same meds as admit
LOS 6 days, EF 35% at 1 month
-
7/30/2019 In Hospital DM Lecture Part 1
40/47
Tom: 3 years later
Follows up with Cardiology only .
Glycemic control remains poor
Recurrent CV events Recurrent hospitalizations
-
7/30/2019 In Hospital DM Lecture Part 1
41/47
Harry at Hospital B
Admit CCU, MI confirmed, glu 230 mg / dL
Infusion started by protocol when glucose >140 mg/dL x 2.
Glycemic excursions with meals covered w/subcutaneous RAA-I per protocol.
Minor hypoglycemia covered routinely
Transitioned to ward on basal / bolusregimen, TDD of 80 units.
A1C obtained: 10
-
7/30/2019 In Hospital DM Lecture Part 1
42/47
Harry at Hospital B contd
When Harry goes NPO for test, nursescontinue basal insulin, hold nutritionalinsulin (as per protocol )
Education on smoking cessation and DM Information about DM / glucose control
included in DC summary.
Hospitalist arranges for PMC, dischargeregimen of Glargine 35 units, 10 unitsRAA-I w/ meals prescribed.
LOS 5 days, EF at 1 month 45%
-
7/30/2019 In Hospital DM Lecture Part 1
43/47
Harry: 3 years later
Quits smoking
A1c = 6.2
Not re-hospitalized
What can you do to make sure all patientswith hyperglycemia are treated likeHarryevery time?
d d f l
-
7/30/2019 In Hospital DM Lecture Part 1
44/47
Despite wide spread use of InsulinImplementation gap is their
One-third with mean glucose > 200 mg/dL
60%-70% of insulin regimens sliding scale only
(even if horrible control)
>10% with hypoglycemic episodes. Uneven training amongst staff
Poor coordination of tray delivery, monitoring,
and insulin Inconsistent transitions
Patients often confused or angry
l h l b h
-
7/30/2019 In Hospital DM Lecture Part 1
45/47
Not only the tool but the wayusing the tool
How Do We Close the Gap?
-
7/30/2019 In Hospital DM Lecture Part 1
46/47
How Do We Close the Gap?Essential Elements
Institutional support and multidisciplinary teams Standardized order sets Infusion
Subcutaneous which promote basal / bolus regimens
Algorithms / protocols / policies Address dosing Nutritional intake
Special situations: TPN, enteral tube feedings,perioperative insulin, steroids
Safety issues Transitions in care and discharge planning
Metrics:How will you know youve made adifference?
Comprehensive educational program
-
7/30/2019 In Hospital DM Lecture Part 1
47/47