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)
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