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Inpatient Management of Diabetes Mellitus. William Harper, MD, FRCPC Endocrinology & Metabolism Assistant Professor of Medicine, McMaster University. BS > 11.1 mmol/L. Renal threshold for glycosuria (normal GFR). Decreased WBC function Chemotaxsis Phagocytosis. Decreased Wound Healing.

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Inpatient Management of Diabetes Mellitus

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Inpatient management of diabetes mellitus l.jpg

Inpatient Management of Diabetes Mellitus

William Harper, MD, FRCPC

Endocrinology & Metabolism

Assistant Professor of Medicine, McMaster University


Bs 11 1 mmol l l.jpg

BS > 11.1 mmol/L

Renal threshold for glycosuria (normal GFR)

Decreased WBC function

Chemotaxsis

Phagocytosis

Decreased Wound Healing


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Evidence to support Inpatient BS control?

DIGAMI

  • 620 patients AMI, prior dx DM or BS > 11 mM

  • IV insulin gtt started @ 5 U/h

  • Titrated to keep BS 7-10.9 mM

  • Insulin IV > 24h  MDI > 3 months

  • No in-hospital mortality benefit.

  • Rx Increased hospitalization by 1.8d

  • 0.5% reduction HbA1c @ 3 months

  • @ 1 year % on Insulin: 72% Rx Group 49% Cntrl Group

  • 1 year mort: ARR 7.5% NNT 13

  • 3.4 y mort: ARR 11% NNT 9


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Evidence to support Inpatient BS control?

Leuven, Belgium Study

  • 1548 ICU patients (63% CV Sx)

  • If BS > 6.1 mM: Rx with IV insulin gtt & TPN +/- tube feeds

  • Start IV insulin @ 2-4 U/h, titrated to BS 4.4-6.1 mM

  • Ave insulin dose: Rx group 3.0 U/h Cntrl group 1.4 U/h

  • Once out of ICU relaxed treatment goal to < 11.1 mM

  • Mortality in ICU: ARR 3.4% NNT 29

  • Mortality in-hospital: ARR 3.7% NNT 27

  • Greatest reduction in mortality was sepsis-related.

  • Insulin Rx reduced: bacteremia, ARF needing HD, need for PRBC, critical illness polyneuropathy, duration of ventilation and length of stay in ICU

  • To what extent were benefits nutrition related as opposed to insulin related?


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Goals of Inpatient DM Management

  • “Avoid hypoglycemia and marked hyperglycemia”

  • Target BS: 7.0 - 11.0 mM (5.0 – 10.0 mM)

  • Avoid Hypoglycemia

    • Precipitating arrhythmia or other cardiac events

    • Inducing seizure, focal or cognitive defects periop

  • Avoid Marked Hyperglycemia (BS > 11.1 mM)

  • Treat (and avoid) DKA, HONC


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    DM Inpatient Management

    • Eating

    • NPO: temporary (for a test or surgery)

    • NPO: prolonged


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    DM Inpatient Management

    • Eating

      Diet (T2DM)

      OHA (T2DM)

      Insulin (T2DM and T1DM)

    • NPO: temporary (for a test or surgery)

    • NPO: prolonged


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    Pathophysiology of T2DM

    _

    Hepatic glucose output

    INSULIN

    +

    Blood glucose

    Peripheral

    Tissue

    Uptake

    diet


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    Sites of Action of Currently Available Therapeutic Options

    MUSCLE

    ADIPOSE TISSUE

    LIVER

    PANCREAS

    GLUCOSE PRODUCTION

    Metformin

    Thiazolidinediones

    PERIPHERAL

    GLUCOSE UPTAKE

    Thiazolidinediones

    Metformin

    INSULIN SECRETION

    Sulfonylureas: Glyburide, Gliclazide, Glimepiride

    Non-SU Secretagogues: Repaglinide, Nateglinide

    INTESTINE

    GLUCOSE ABSORPTION

    Alpha-glucosidase inhibitors


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    OHAs:


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    TZD adverse effects

    • Edema

      • 4-5% of patients get mild-moderate edema

      • 15% if TZD used in combo with insulin

  • Mild anemia (dilutional)

  • Weight gain

    • Increase in subcutaneous not visceral fat

  • Myalgia (pioglitazone only)

    • Myalgia 5.4% pioglitaz. versus 2.7% placebo

    • Few patients with unexplained CK > 10x ULN

  • Contraindicated in class II, III and IV CHF

  • Contraindicated if ALT > 2.5x ULN or active liver disease


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    Metformin

    • Contraindications:

      • Creatinine >133 uM (men), >124 uM (women), CrCl < 1.17 mL/s

      • CHF symptomatic (> NYHA class III, E.F. < 35-40%)

      • Liver failure

      • Alcoholism

      • Hypoxic respiratory condition

      • Active moderate to severe infection

      • Radiocontrast or Surgery with GA:

        • Hold metformin for 24-48h

        • Restart after documented preservation of renal function


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    Metformin

    • Side effects:

      • Lactic acidosis (metformin 0.03 cases/1000 patient years)

        • Phenformin 10-20X higher rates of lactic acidosis

      • GI: diarrhea, flatulence, abdominal discomfort

        • Usually disappear within 2 weeks

        • Dose dependent: avoided by slow titration & in some cases dose reduction

        • 5% of patients can’t tolerate metformin due to GI S/E’s

  • Starting dose: 500 mg with largest meal (prevent GI S/E’s)

  • Increase by 500 mg increments q1-2 wk

  • Maximal hypoglycemic affect: 1000 mg bid


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    Insulin


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    BIDS Therapy

    • T2DM: “Introduction to insulin”

    • Keep on OHAs

    • Start NPH 0.2 U/kg SC qhs

    • Increase by 2-4 U q4d until FBS 4-7

    • If dose > 30-40U or if BS high late in day despite OK FBS than split into 2 injections with 2/3 acB and 1/3 qhs


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    Starting Insulin Regimen

    • TDD = 0.5-0.7 U/kg

    • “2/3, 1/3” Regimens

      • 2/3 of TDD acB, 1/3 acD

      • 2/3 of TDD as Long-acting, 1/3 as short acting

      • Pre-mix: acB 30/70 acD 30/70

  • MDI Regimens

    • 2/3, 1/3 Regimen: move acD long acting to qhs

    • i.e. acB N, H acD H qhs N

    • ac meals H qhs N (bolus 60%, basal 40%)

    • ac meals H UL q12h (bolus 50%, basal 50%)


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    Insulin Regimens

    acB acL acD qhs

    Bedtime NPH (+/-bids) N

    NPH bid N N

    30/70 bid 30/70 30/70

    MDI (3 injections) H + N H N

    MDI (>4 injections) H (+/-N) H H N

    MDI (>4 injections) H + UL H H UL

    CSII (Insulin Pump)


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    NEJM 347:1342-9


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    Surgeon:?

    Internal Medicine:?

    Endocrinologist:?


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    Surgeon:Give 5 U Regular SC now

    Internist:?

    Endocrine:?


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    Surgeon:Give 5 U Regular SC now

    Internist:Increase qhs N to 12 tonight and acB R to 12 tomorrow

    Endocrine:?


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    Surgeon:Give 5 U Regular SC now

    Internist:Increase qhs N to 12 tonight and acB R to 12 tomorrow

    Endocrine:Increase qhs N to 12 start tonight

    Decrease acB N15 R7 starting tomorrow AM

    Check 3AM BS tonight


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    Guideline for Insulin Adjustments

    • Adjust the insulin that accounts for the high or low reading.

    • Always compare an abnormal BS reading with the one previous.

    • If insulin dose is:

      • Less than 8U, adjust by 1U

      • 8-20U, adjust by 2U

      • > 20 U, adjust by 10% (increase), 20% (decrease)

    • Don’t forget to compensate for a successful adjustment


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    SC Insulin Supplemental Scale


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    DM Inpatient Management

    • Eating

    • NPO: temporary (for a test)

    • NPO: prolonged


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    NPO for a test: T2DM on Diet Rx or OHA

    • Schedule test for the AM

    • Hold OHAs on AM of test

    • CBG @ 7AM:

      < 3.0Consider postpone test

      3.1-4.0IV D5W gtt @ 75-100 cc/h

      4.1-11.0Proceed with test, no Rx necessary

      > 11.1Insulin R or analogue SC supplemental

      or

      IV insulin gtt & IV D5W gtt @ 75-100 cc/h

      > 20.0Check urine ketones, consider postpone test


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    Insulin IV gtt

    • Add 50 U of Human regular insulin (Humulin R or Novolin Toronto) to 500cc D5W (1U/10cc).

    • Flush & discard first 50cc.

    • Infuse insulin solution by IVAC (intravenous infusion pump), piggybacked into D5W running at 100cc/h.

    • Start insulin @ 0.9 U/h (9cc/h) or start at a rate dependent on patient’s insulin dose:

      IV insulin gtt rate = ( ½ TDD ) / 24


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    Insulin IV gtt

    CPG q1h x 2, then q2h:

    Adjust Insulin IV infusion rate as per scale below:

    < 4.0 Call MD

    4.1-6.0 0.5 U/h (5cc/h)

    6.1-8.0 1.0 U/h (10cc/h)

    8.1-10.0 1.5 U/h (15cc/h)

    10.1-12.0 2.0 U/h (20cc/h)

    12.1-15.0 2.5 U/h (25cc/h)

    15.1-18.1 3.0 U/h (30cc/h)

    18.1-22.0 3.5 U/h (35cc/h)

    > 22.1 Call MD


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    NPO for a test: T1/T2DM on Insulin

    • Schedule the test for the AM

    • Hold AM Insulin on day of test

    • CBG @ 7AM:

      < 3.0Consider postpone test

      3.1-11.0Give ½ of total AM insulin dose as NPH SC

      IV D5W gtt @ 75-100 cc/h

      > 11.1IV insulin gtt & IV D5W gtt @ 75-100 cc/h

      > 20.0Check urine ketones, consider postpone test


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    DM Inpatient Management

    • Eating

    • NPO: temporary (for a test)

    • NPO: prolonged

      • Patient put on D5W if not on feeds or TPN

      • IV insulin gtt

      • SC NPH or UL q12h (+/- supplemental scale)

        • Starting dose 0.2 U/Kg q12h


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