Management of Diabetes Mellitus in the Hospital

Kathleen Dungan, MDAssistant Professor,Division of Endocrinology, Diabetes and Metabolism

Part 2

Objectives

Describe the pathophysiology and clinical significance of “stress hyperglycemia”.

Identify patients that require IV insulin.Explain the difference between DKA and

HNK.Describe the initial therapy for DKA.Understand how and when to

discontinue IV insulin.Be able to calculate daily adjustments in

insulin dose.

Case 3: Post-Op Hyperglycemia

68 YOM with 20 year h/o T2DM is scheduled for elective cardiac catheterization due to abnormal stress test.

Home medications: Glargine 54 units QHS, Metformin 1000 mg BID, Glipizide 10 mg BID

Last A1c 7.5%

Post-op Quiz

Patient getting a procedure

In general, DO NOT hold basal insulin May reduce 20-50% so that it accounts for

50% or less of the total daily dose Premix insulin : reduce 50%

But, do hold meal insulin

*Under no circumstances should you completely withhold basal insulin from a patient with type 1 diabetes!

Case 3: Post-op HyperglycemiaThe patient is sent for CABG. Intra-

operatively, an insulin drip is started. Post-op Day 1

Extubated, pressors still running Insulin drip running at 1-6 unit/hour , BG

100s-200s Taking sips of fluids, ADA diet ordered

Transition to SQ Quiz

Predictors of Successful Cessation of Insulin Drip

Our patient

On drip at least 24 hours Yes

DKA is resolved NA

Hemodynamically stable No

Extubated Yes

Minimal rate (<4 unit/hr) and minimal changes for at least 6 hrs No

BG controlled <150 mg/dl Yes

Tolerating PO intake Yes

Am J Cardiol. 2006;98(4):557-64.

Case 3: Converting off the drip

Day 3: Patient is off pressors, afebrile Insulin drip running at 2 units/hr and

stable. BG 100-130s Receiving Lispro SQ 1 unit/10 gm CHO

Convert to SQ Quiz

Does the patient need basal insulin?

Yes DKA or type 1 diabetes Requiring >1 unit/hour

If not… Check BG frequently once drip is stopped Patient may need meal coverage or oral

med

Conversion to SQ insulin

Basal insulin dose = 70% of total infusion requirements Assumes that the drip is not being used for

meal coverage Compare to home dose of insulin Continue IV insulin/IVF for 4-6 hours after

the dose

Insulin(µU/mL)

Glucose(mg/dL)

Physiologic Insulin Regimen

150

100

50

07 8 9 10 11 12 1 2 3 4 5 6 7 8 9

A.M. P.M.

Basal Glucose

Time of Day

50

25

0 Basal Insulin

Breakfast Lunch Dinner

Bolus Insulin = prandial + correction dose

Prandial Glucose

Physiologic Insulin Regimen3 components

Examples

Basal Long-acting insulin analogueNPH

Continuous SQ rapid acting insulin analogue (pump)

IV insulin drip

Prandial Rapid-acting insulin analogueRegular insulin (tube feeds)

Correction (supplemental)

Prandial insulin aboveIV insulin drip

Rapid acting insulin analogues: Aspart (Novolog), Lispro (Humalog), Glulisine (Apidra); Long acting insulin analogues: glargine (Lantus), detemir (levemir)

BO

LU

S

Insulin Preparations

Onset of Action Peak Action Duration of Action

BOLUS INSULIN

Regular 30 minutes 2-4 hours 6-10 hours

Lispro (Humalog)

Aspart (Novolog)

Glulisine (Apidra)

5-15 minutes 1-2 hours 4-6 hours

BASAL INSULIN

NPH 1-2 hours 4-8 hours 10-20 hours

Glargine (Lantus) 1-2 hours Flat ~ 24 hours

Detemir (Levemir)

? Flat ~ 24 hours*

Mooradian, A. D. et. al. Ann Intern Med 2006;145:125-134

*Detemir lasts 24 hours in most patients but is slightly shorter in duration than glargine.

Insulin: The most effective therapy for hyperglycemia.

Steps to initiating SQ insulin

1. Calculate total daily insulin dose= 0.4-0.5 unit/kg or based on insulin drip requirement

2. Basal = 50% of total daily dose

3. Prandial dose:a) 50% of total daily dose divided over mealsb) I:CHOHigh=1u/5gm, Standard =1 u/10gm, Low=1 u/15 gm

4. Add correction dose (drop in BG/unit): High=1 unit/25 mg/dl above target, Standard=1unit/50 mg/dl, Low=1 unit/100 mg/dl

Target (when you start giving it)=default is 150 mg/dl

“Sliding Scale” Monotherapy

Without basal insulin, results in Hyperglycemia Hypoglycemia (possibly) Iatrogenic DKA with Type 1 diabetes

American Association of Clinical Endocrinologists. Available at:http://www.aace.com/pub/ICC/inpatientStatement.php. Accessed March 17, 2004.

Plus, “Sliding Scale” is anti-intellectual:

Reactionary rather than anticipatory

What is a sliding scale?Measure FSG give insulin

(usually qac+hs)

Premeal BG

Additional Insulin

Premeal

BG Additional

Insulin

150-199 1 unit 150-199 ___ units

200-249 2 units 200-249 __ units

250-299 3 units 250-299 ___ units

300-349 4 units 300-349 ___ units

>349 5 units > 349 ___ units

Standard Dose Algorithm Individualized Dose Algorithm

Why not sliding scale?

Blood sugar before lunch 280

“Typical sliding scale”

Patient receives 6 U insulin sliding scale, but

then eats 75 g carb lunch!

Blood sugar before dinner 245!!

Blood sugar before lunch 280

“The better way”

Patient receives 6 U insulin sliding scale

(correction factor), PLUS 5 U insulin for 75 g carb

lunch

Blood sugar before dinner 124!!

Dose-finding strategy

1. Determine yesterday’s total insulin dose actually administered

2. Address hypoglycemia first3. Adjust at least 10-20% based on the

glucose

Oral Agents in the Hospital

Often contraindicated Slower onset of action In some circumstances, patients can continue

orals, with the following important caveats Short hospital stay Acceptable glycemic control Meformin probably contraindicated (risk of lactic

acidosis) Creatinine >1.4-1.5 IV contrast Symptomatic heart failure Respiratory failure Hepatic failure

TZDs (Glitazones) contraindicated in CHF, very slow onset

Sulfonylureas Risk of hypoglycemia

Treatment of Hypoglycemia

Do not overtreat!PO route preferred

10-20 gms IV dextrose

12.5 gms (1/2 amp D50)-full 25 gm Double current dextrose infusion

Glucagon if no IV

Decreased intake of calories

Adjustment of insulin dosage

Incorrect dose of insulin given

No cause identified

Iatrogenic hypoglycemia is usually predictable and preventable. (Fischer)

Reduce insulin, increase monitoring if • Any form of carbohydrate is interrupted• Declining renal or hepatic function

In summary

Management of diabetes in the hospital is aimed at achieving a nearly normal blood sugar

Think!! Good BS management is possible in most

patients with some careful considerationDiabetes consult team is available for

help (at least at OSU)

Please direct questions to: [kathleen.dungan@osumc.edu]

QUESTIONS?

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