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Robert J. Rushakoff, MD Professor of Medicine University of California, San Francisco robert.rushakoff@ucsf.edu. Hyperglycemia in Hospitalized Patients. Strategies For Implementing Change Nuts and bolts of management. Strategies For Implementing Inpatient Glycemic Control.

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slide1
Robert J. Rushakoff, MD

Professor of Medicine

University of California, San Francisco

robert.rushakoff@ucsf.edu

Hyperglycemia in Hospitalized Patients
  • Strategies For Implementing Change
  • Nuts and bolts of management
strategies for implementing inpatient glycemic control
Strategies For Implementing Inpatient Glycemic Control

www.rushakoff.com

www.endotext.com

ucsfinpatientdiabetes.pbworks.com

slide4

Inpatient Diabetes Goals

Appropriate Glucose Control Based on physiology and outcome studies

Inpatient Diabetes Goals

Normal glucoses for everyone

A high glucose means failure

Sliding Scales are banned

Some hypoglycemia is acceptable

Inpatient Diabetes Goals

Who Cares

Just get patient home

Sliding Scales are fine

Avoid that scary hypoglycemia

care of the hospitalized diabetic patient
Goals for Inpatient management

Evidence, if any, for stated goals

Methods to Achieve Glucose Goals

Insulin order forms

NPO patients

Patients eating

TPN and hyperalimentation

Special Situations

Glucocorticoids

Implementation

Cases

Care of the Hospitalized Diabetic Patient
target glucose levels7
Target Glucose Levels

No DKA or Hyperosmolar Coma

slide8

Quantifying the Impact of a Short-Interval

Interruption of Insulin-Pump Infusion Sets

on Glycemic Excursions

Diabetes Care 31:238–239, 2008

target glucose levels9
Target Glucose Levels

Occasional hypo- and hyperglycemia

target glucose levels10
Target Glucose Levels

No hypo- or hyperglycemia

  • Prevent fluid and electrolyte abnormalities secondary to osmotic diuresis
  • Improve WBC function
  • Improve gastric emptying
  • Decrease surgical complications
  • Earlier hospital dischange
  • Decreased post-MI mortality
  • Decreased post-CABG morbidity and mortality
target glucose levels11
Target Glucose Levels

Normal Glucoses

Decreased Morbidity and Mortality

slide13

Increased Infections

Early postoperative glucose control predicts nosocomial infections rate in diabetic patients

Pomposelli et al: J Parenteral Ent Nut. 1998; 22:77-81

  • Relative risk for “serious” postop infections increased to 5.7 when glucose >220 mg/dl
slide14

Increased Infections

Relative Odds of Wound Infections

121-206 -------207-229 1.17230-252 1.86 253-3531.78

(p<0.05 for upward trend)

Perioperative Glycemic Control and the Risk of Infectious Complications in a Cohort of Adults with Diabetes

Golden et al: Diabetes Care, 22:1408, 1999

411 diabetics who underwent CABGLeg and chest wounds, pneumonia and UTI

slide15

Glucose and post-CABG morbidity and mortality

Diabetes and Coronary Artery Bypass Surgery. An examination of perioperative glycemic control and outcomes

Diabetes Care 2003; 26:1518-1524

  • Retrospective Review of 291 patients surviving 24 h post op
  • 40% with retinopathy, nephropathy or neuropathy

Inpatient Complications

For each 1 mmol/l (18 mg/dl) increase in postop day 1 over 6.1 mmol/l (110 mg/dl), a 17% increase risk of complications

slide16

HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH INCREASED MORTALITY IN ICU

  • Retrospective Review of 216,000 critically ill patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati
  • Hyperglycemia was an independent predictor of mortality starting at 111 mg/dl.
  • Effect was greatest with acute myocardial infarction, unstable angina, and stroke
    • heart attack - 1.6-5 time
    • a stroke it raised risk from 3.4 to 15.1 times
    • unstable angina it raised risk from 1.7 to 6.2 times

Falciglia et al: ADA Scientific Meetings, 2006, late breaking abstracts

slide17

HIGH BLOOD GLUCOSE LEVELS ASSOCIATED WITH INCREASED MORTALITY IN ICU

  • Retrospective Review of 216,000 critically ill patients conducted by the Veterans Affairs Inpatient Evaluation Center based in Cincinnati
  • A significant but weaker effect was seen in patients with sepsis, pneumonia, and pulmonary embolism. Hyperglycemia was not found to be associated with mortality in diseases such as COPD and hepatic failure.
  • In diabetes patients, the increase in mortality risk was not seen until mean glucose was >146 mg/dl

Falciglia et al: ADA Scientific Meetings, 2006, late breaking abstracts

hyperglycemia an independent marker of in hospital mortality in patients with undiagnosed diabetes
Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes
  • Retrospective Review
  • Hyperglycemia in 38%
    • 26% known diabetes
    • 12% no known diabetes
  • Mortality

New hyperglycemia 16%

Known Diabetes 3%

Nondiabetics 1.7%

J. Clin Endocrinol. 2002;87:978-982.

slide19

TPN: Adverse Outcomes

Hyperglycemia Is Associated With Adverse Outcomes in Patients Receiving Total Parenteral Nutrition

Cheung et al: Diabetes Care, 28:2367-2371, 2005

Risk of complications in relation to mean daily blood glucose level

slide20

Risk of Complications by glucose level quartile after adjusting for age, sex and presence of preexisting diabetes

Cheung et al: Diabetes Care, 28:2367-2371, 2005

slide22

Decreased post-CABG morbidity and mortality

Intensive Intervention by a Diabetes Team Diminishes Excess Hospital Mortality in Patients with diabetes who undergo CABG

Kalin et al. Diabetes Suppl. 47:A87 1998

Diabetes team followed patientPerioperative IV insulin infusionAlgorithm based SQ premeal insulin

Mortality during CABG 1993-96

Relative risk

National 1.46Beth Israel 1.02

slide23

Decreased post-MI mortality

Effects of insulin treatment on cause-specific one year mortality and morbidity in diabetic patients with acute myocardial infarction. DIGAMI Study Group.

Malmberg et al. Eur Heart J 1996

PeriMI IV insulin infusionAlgorithm based SQ premeal insulin for 1 year

Mortality (%)

1 year3.4 years

Control 26 44

Insulin 19 33

digami design
DIGAMI Design
  • 620 patients
    • MI within 24 hours
    • Previous known DM with glucose > 11 mmol/l (198 mg/dl) or glucose > 11 mmol/l without known DM
    • Exclusion: (50% of 1240 were excluded)
      • To sick for consent
      • Unable to manage multidose insulin
    • Usual acute CCU MI care
    • Treatment group
      • Infusion for >24 hours (until stable) , then 3 months multiple shots insulin

J Am Coll Cardiol 1995;26:57-65

digami2 european heart j prepublication feb 2005
DIGAMI2 (European Heart J. Prepublication Feb 2005)
  • Group 1 – IV insulin then long term SQ insulin
  • Group 2 – IV insulin then standard treatment
  • Group 3 – Standard treatment

Mortality

slide26

Decreased Infections

Insulin infusion improves neutrophil function in diabetic cardiac surgery patients.

Rassias AJ, Marrin CA, Arruda J, Whalen PK, Beach M, Yeager MP. Anesth Analg 1999; 88:1011-6.

Perioperative IV insulin infusion

Neutrophil phagocytic activity

% baseline Control 47

Insulin 75

slide27

Decreased Infections

Glucose control lowers the risk of wound infection in diabetics after open heart operations

Zerr et al: Ann Thoracic Surgery, 1997, 63:356-61Furnary et al. Annals of Thoracic Surgery 1999, 67:352-60Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021

Perioperative IV insulin infusionProtocol to maintain glucoses <200

Incidence of Deep Wound Infections (%)

19971999 Routine Control 2.4 2.0“Tight” Control 1.5 0.8

slide28

Decreased Infections

Glucose control decreases mortality in diabetics after open heart operations

Furnary et al. J Thoracic Cardiovascular Surgery 2003, 125: 1007-1021

14.5%

6.0%

4.1%

2.3%

1.3%

0.9%

slide29

Decreased Morbidity and Mortality

Intensive Insulin Therapy in Critically Ill Patients.

Van den Berghe G, Wouters P, Weekers F, et al. N Engl J Med 2001; 345:1359-1367.

Patients (all) on mechanical Ventilation in ICU

Randomly assigned to IV insulin maintaining glucoses between 80-110 mg/dl or conventional treatment (iv insulin if glucose >215 mg/dl then maintain glucose between 180-200.)

% given Insulin24 hour doseAM glucose

Intensive 99 71U 103

Conventional 39 33U 153

slide30

Decreased Morbidity and Mortality

12 month mortality

Intensive 4.6%

Conventional 8.6%

Main effect on patients in ICU >5 days

Intensive Insulin Therapy in Critically Ill Patients.

Van den Berghe G, Wouters P, Weekers F, et al. N Engl J Med 2001; 345:1359-1367.

Patients (all) on mechanical Ventilation in ICU

Randomly assigned to IV insulin maintaining glucoses between 80-110 mg/dl or conventional treatment (iv insulin if glucose >215 mg/dl then maintain glucose between 180-200.)

slide31

Decreased Morbidity and Mortality

Intensive Insulin Therapy in Critically Ill Patients.

Van den Berghe G, Wouters P, Weekers F, et al. N Engl J Med 2001; 345:1359-1367.

Patients (all) on mechanical Ventilation in ICU

Randomly assigned to IV insulin maintaining glucoses between 80-110 mg/dl or conventional treatment (iv insulin if glucose >215 mg/dl then maintain glucose between 180-200.)

  • Intensive Treatment reduced:
          • In hospital mortality 34%
          • Sepsis 46%
          • Need for dialysis 41%
          • Number of transfusions 44%
decreased morbidity and mortality
Decreased Morbidity and Mortality
  • Post-op received high dose glucose - 200-300 g in 24 hours
  • All adults receiving mechanical ventilation who were admitted to intensive care unit
  • 63% had cardiac surgery
    • 59 percent had undergone coronary bypass surgery, 27 percent valve replacement, and 14 percent a combined procedure
  • Randomly assigned to IV insulin maintaining glucoses between 80-110 mg/dl or conventional treatment (iv insulin if glucose >215 mg/dl then maintain glucose between 180-200.)
  • Whole glucose, so Plasma range would be: 90-123 mg/dl
slide33
Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery
  • Patients: Adults with and without diabetes who were undergoing on-pump cardiac surgery.
  • Primary outcome: composite of death, sternal infections, prolonged ventilation, cardiac arrhythmias, stroke, and renal failure within 30 days after surgery. Secondary outcome measures were length of stay in the intensive care unit and hospital.
  • Intervention:
    • continuous insulin infusion to maintain intraoperative glucose levels between 4.4 (80 mg/dL) and 5.6 mmol/L (100 mg/dL) (n = 199)
    • not given insulin during surgery unless glucose levels were greater than 11.1 mmol/L (>200 mg/dL).
    • Both groups were treated with insulin infusion to maintain normoglycemia after surgery.

Ann Int Med. 2007 146: 233-243

slide34
Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery
  • The groups had the same risk for perioperative adverse events (risk ratio, 1.0 [95% CI, 0.8 to 1.2]).
  • The intensive treatment group had more strokes (8 vs. 1) and more deaths (4 vs. 0) than the conventional treatment group.

Ann Int Med. 2007 146: 233-243

slide35

Kaplan-Meier Curves for In-Hospital Survival

Van den Berghe, G. et al. N Engl J Med 2006;354:449-461

intensive insulin therapy and pentastarch resuscitation in severe sepsis visep trial
Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis: VISEP trial
  • Multicenter, two-by-two factorial trial
    • 537 patients
    • 18 academic tertiary hospitalsin Germany
  • Patients with severe sepsis receive either intensiveinsulin therapy to maintain euglycemia or conventional insulintherapy and either 10% pentastarch, a low-molecular-weight hydroxyethylstarch (HES 200/0.5), or modified Ringer's lactate for fluidresuscitation.
  • The rate of death at 28 days and the mean scorefor organ failure were coprimary end points.
  • The trial was stopped early for safety reasons

Brunkhorst F et al. N Engl J Med 2008;358:125-139

intensive insulin therapy and pentastarch resuscitation in severe sepsis
Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis

Blood Glucose According to the Type of Insulin Therapy

Kaplan-Meier Curves for Overall Survival

Brunkhorst F et al. N Engl J Med 2008;358:125-139

intensive insulin therapy and pentastarch resuscitation in severe sepsis38
Intensive Insulin Therapy and Pentastarch Resuscitation in Severe Sepsis
  • Findings similar to second study by Vanden Berghe et al
    • Nonsignificant differencesin the rates of death at 28 days and at 90 days in the intensive-therapygroup and the conventional-therapy group
    • Increase in hypoglycemic episodes the same:
      • VB: 18.7% vs. 3.1%
      • VSEP: 17.0% vs. 4.1%
    • Hypoglycemia the same:
      • VB: (32 mg and 31 mg per deciliter, respectively; P=0.50
      • VISEP: 31 mg and 28 mg per deciliter, respectively; P=0.30
    • Glucose levels the same:
      • VB: 111±29 mg and 153±31mg per deciliter, respectively
      • VISEP: 112±18 mg and 151±33 mg per deciliter,respectively
  • Taken together, these studies establish that intensive insulin therapy has nomeasurable, consistent benefit in critically ill patients ina medical ICU, regardless of whether the patients have severesepsis, and that such therapy increases the risk of hypoglycemicepisodes.

Brunkhorst F et al. N Engl J Med 2008;358:125-139

glucontrol study
GluControl Study
  • Anticipated 3500 subjects to be randomized
    • 80-110 vs 140-180 mg/dl
    • Stopped because of safety concerns
    • 1082 subjects recruited.
slide40

Intensive versus Conventional Glucose Control in Critically Ill Patients

The NICE-SUGAR Study Investigators

N Engl J Med

Volume 360(13):1283-1297

March 26, 2009

slide41

Study Overview

  • In this study, adults who were expected to require treatment in the intensive care unit on 3 or more consecutive days were randomly assigned to undergo intensive blood glucose control (target range, 81 to 108 mg per deciliter [4.5 to 6.0 mmol per liter]) or conventional blood glucose control (180 mg per deciliter [10.0 mmol per liter])
  • The primary end point was death from any cause within 90 days after randomization
  • Intensive glucose control increased mortality among the patients
slide42

NICE- SUGAR: Data on Blood Glucose Level, According to Treatment Group

The NICE-SUGAR Study Investigators. N Engl J Med 2009;360:1283-1297

slide43

NICE-SUGAR: Probability of Survival and Odds Ratios for Death, According to Treatment Group

The NICE-SUGAR Study Investigators. N Engl J Med 2009;360:1283-1297

slide44

NICE-SUGAR: Probability of Survival and Odds Ratios for Death, According to Treatment Group

The NICE-SUGAR Study Investigators. N Engl J Med 2009;360:1283-1297

aace position statement hospital glycemic goals
AACE Position Statement: Hospital Glycemic Goals

Intensive Care Units: 110 mg/dL

Non-Critical Care Units:

Pre-Prandial 110 mg/dL

Max. Glucose 180 mg/dL

how to obtain tight control
How to Obtain “Tight” Control
  • Bedside glucose monitoring
  • IV insulin drips
  • Diabetic Flow sheets
  • Discourage the use of traditional Sliding Scale insulin
slide48

INSULIN

SLIDING

SCALE

slide49

INSULIN

SLIDING

SCALE

slide51

Mr. And Mrs. XXXXX are admitted for spring fever.

Mr. XXXXX has Type 2 diabetes and takes a total of 75 Units insulin per day (2 shots). Glucoses at home are “poorly controlled.”

Mrs. XXXXX also has Type 2 diabetes but she has good control taking about 25 units of Lispro premeal and 40 Units glargine at night.

slide52

Fingerstick qid with regular insulin SQ coverage:

FSBG Action

< 50 1 amp D50 iv and call HO

51-80 give juice and repeat in 0.5-1 hr

81-200 no coverage

201-250 3U regular insulin SQ

251-300 6U regular insulin SQ

301-350 8U regular insulin SQ

351-400 10U regular insulin SQ

>400 12U regular insulin SQ, call HO

slide53

INSULIN

SLIDING

SCALE

insulins available in the us

Action profile (h)

Types andPreparations

Onset Peak Duration

Insulins Available in the US

Rapid-acting Lispro/aspart/ glulisine 0.25 0.5-1.5 3-5 Regular 0.5 2-5 6-8

Intermediate-acting NPH 1-2 4-12 18-26 U-500 1-3 6-12 12-18

Long-acting Glargine 1.5 ---- 24 Detemir 1 ---- 23

insulin use and adjustments

Timing

Types andPreparations

Injection Glucose check

Insulin: Use and Adjustments

Rapid-acting Lispro/aspart/ 10 min premeal 2 hour post meal glulisine and before next meal Regular 30 min premeal before next meal

Intermediate-acting NPH Morning Pre-dinner Night Fasting

Long-acting Glargine/detemir PM Fasting

insulin and glucose patterns
Insulin and Glucose Patterns

Normal

Glucose

Insulin

400

120

100

300

80

mg/dL

U/mL

200

60

40

100

20

0600

1000

1400

1800

2200

0200

0600

0600

1000

1400

1800

2200

0200

0600

B

L

S

B

L

S

Time of Day

Time of Day

Polonsky, et al. N Engl J Med. 1988;318:1231-1239.

slide57

Insulin Regimens

Relative Insulin Level

12pm

Breakfast

Lunch

Dinner

Time

slide58

Insulin Regimens

AM NPH

Relative Insulin Level

12pm

Breakfast

Lunch

Dinner

Time

slide59

Insulin Regimens

BID lispro/aspart

Lispro/aspart

Relative Insulin Level

Long analogue

12pm

Breakfast

Lunch

Dinner

Time

slide60

Insulin Regimens

TID lispro/aspart and hs NPH

Relative Insulin Level

Lispro/aspart

NPH

12pm

Breakfast

Lunch

Dinner

Time

slide61

Insulin Regimens

TID lispro/aspart and ultralente

Relative Insulin Level

Lispro/aspart

ultralente

12pm

Breakfast

Lunch

Dinner

Time

slide62

Insulin Regimens

PM glargine

Relative Insulin Level

glargine

12pm

Breakfast

Lunch

Dinner

Time

slide63

Insulin Regimens

TID lispro/aspart/glulisine and hs glargine

Relative Insulin Level

Lispro/aspart/glulisine

glargine

12pm

Breakfast

Lunch

Dinner

Time

slide64

Insulin Regimens

Insulin pump

Relative Insulin Level

Lispro/aspart

12pm

Breakfast

Lunch

Dinner

Time

slide65
Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT 2 Trial)
  • Prospective,multicenter, randomized trial to compare the efficacy and safetyof a basal-bolus insulin regimen with that of sliding-scaleregular insulin (SSI)
  • Type 2 diabetes. 130 insulin-naive patients were randomized to receive glargineand glulisine (n = 65) or a standard SSI protocol (n = 65).
  • Glargine was given once daily and glulisine before meals ata starting dose of 0.4 units · kg–1 · day–1 for blood glucose 140–200 mg/dl or 0.5 units ·kg–1 · day–1 for blood glucose 201–400mg/dl. SSI was given four times per day for blood glucose >140mg/dl.

Diabetes Care 30:2181-2186, 2007

slide66
Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT 2 Trial)

Changes in blood glucose concentrations in patients treated with glargine plus glulisine (•) and with SSI (○). *P < 0.01; ¶P < 0.05.

Diabetes Care 30:2181-2186, 2007

current insulin order forms
Adult

DKA

Adult SQ Insulin – Patient eating

Adult SQ Insulin – NPO, TPN, Tube Feeding

IV insulin – ICU protocol

IV insulin – Med-Surgical Unit protocol

Adult Insulin pump

Patient waver form to use pump

Adult SQ insulin algorithm for NPO patients**

OB-GYN

SQ Insulin – Patient eating

Pump Form**

Pediatrics

SQ Insulin – Patient eating

Pump Form**

DKA**

IV insulin**

Current Insulin Order Forms

** major update or under development

subcutaneous insulin order sheet bedtime and 2am insulin adjustments
Subcutaneous Insulin Order Sheet : Bedtime and 2am insulin adjustments

Shown below is the section C the page for “patients eating”. The area indicates the orders for supplemental insulin that should be given at bedtime and/or 2am. Aspart insulin is to be used at these times. These testing times are important not just for checking for high glucoses but also to monitor and treat low glucoses. These checks are also important in helping to adjust the overall insulin doses.

subcutaneous insulin order sheet q4hour correctional dosing for npo tube feeds or tpn
Subcutaneous Insulin Order Sheet : q4hour correctional dosing for NPO, Tube Feeds or TPN

q4hour correctional insulin options are shown. Here correctional insulin is generally used to add or subtract insulin from the q4hour nutritional insulin ordered in section A. There are times it can be used even if no standing q4hour dose is written.

low glucose reading
Low Glucose Reading

The final section of the both forms of the order sheets describes the treatment for hypoglycemia. The key item is that when a person can eat, the hypoglycemia is treated by oral glucose.

  • For BG <70 mg/dl, use Hypoglycemia Protocol below:For patient taking PO, give 20 g of oral fast-acting carbohydrate: 4 glucose tablets (5 grams glucose/tablet)-OR- Give 6 oz. fruit juice Give 25 ml of D50 IV pushIf patient cannot take POCheck fingerstick glucose every15 minutes and repeat above treatment until BG is ≥100 mg/dl.
transition from iv to sq insulin
Transition from IV to SQ Insulin

Take 80% of last 24 h insulin infusion

Basal: ½ of the value

premeal: ½ of the value divided for the meals

Example: 1.5 units per hour = 36U

36 x .8= 29

Basal: 30x.5=15

premeal: 30x.5=15 5 per meal

transition from iv to sq insulin77
Transition from IV to SQ Insulin
  • What to do if unclear how much the patient will eat? What if transition to clear liquids?
  • Basal calculation remains unchanged
  • Premeal 0-50% of calculated dose
slide79

Transition from IV to SQ Insulin

Glucose 140 255 180 150

Insulin 5 A(5+0) 8 A(5+3) 6 A(5+1)

15 glargine

Change for next day would be increase in Breakfast and lunch Aspart

patient on insulin who is eating
Patient on Insulin who is Eating

Easy method:

Choose the U/kg (.3 to .5 U/kg)

Basal: ½ of the value

premeal: ½ of the value divided for the meals

If on premixed insulin changing to MDI:

Basal: ½ of the total dose

premeal: ½ of the total dose divided for the meals

Patient on 40Uam,30Upm of 70/30

Poorly controlled, 80kg

30 U glargine

10U aspart/humalog premeal

patient on diet or oral agents who is eating
Patient on Diet or Oral Agents who is Eating

Depending on which oral agents – may or may not be continuing- - - -

pharmacologic classes of agents to control hyperglycemia in type 2 diabetes
Pharmacologic Classes of Agents to Control Hyperglycemia in Type 2 Diabetes

Action

Class

Thiazolidinediones—e.g., rosiglitazone, pioglitazone

Bind to peroxisome proliferator activated receptor-gamma (PPAR) in muscle, fat and liver to decrease insulin resistance

Insulin secretagogues—e.g., sulfonylureas (glyburide, glipizide); repaglinide

Stimulate pancreatic -cells to increase insulin output

Biguanides—e.g., metformin

Target liver to decrease glucose production

Alpha-glucosidaseinhibitors—e.g.,acarbose & miglitol

Inhibit intestinal enzymes that break down carbohydrates, which delays carbohydrate absorption

Insulin

Target insulin-sensitive tissue to increase glucose uptake

pharmacologic classes of agents to control hyperglycemia in type 2 diabetes83
Pharmacologic Classes of Agents to Control Hyperglycemia in Type 2 Diabetes

Special Considerations

Class

Thiazolidinediones—e.g., rosiglitazone, pioglitazone

Takes 2-3 weeks to see initial effect. Effects continue for weeks or months after discontinuation of medication. Issues with fluid retention, CHF

Insulin secretagogues—e.g., sulfonylureas (glyburide, glipizide); repaglinide

Keep in mind the metabolic t1/2 of each drug

Biguanides—e.g., metformin

Withholdin conditions predisposing to renal insufficiency and/or hypoxia

CV collapse

Acute MI or acute CHF

Severe infection

Use of iodinated contrast material

Major surgical procedures

Alpha-glucosidaseinhibitors—e.g.,acarbose & miglitol

In case of hypoglycemia(due to sulfonylurea or insulin treatment)

Glucose (dextrose) must be administered

Sucrose and complex carbohydrates should not be administered

Insulin

patient on diet alone or oral agents who is eating
Patient on Diet alone or Oral Agents who is Eating

Day 1 – Use Correctional dosing only

Base on BMI, anticipated sensitivity

slide85

Patient on Diet alone or Oral Agents who is Eating

Glucose 140 255 180 190

Insulin 1 A(0+1) 6 A(0+6) 2 A(+2)

0 glargine

  • Change for next day:
  • FBS >130 so start basal insulin at .1 to .3 U/kg
  • Preprandial >130 so start premeal insulin
patient scheduled for npo procedure
Patient Scheduled for NPO Procedure

Patient is scheduled for a CT scan and is NPO tomorrow morning. Glucoses at what would be breakfast time is 240. Orders are as follows. What should be done with the insulin?

slide87

Patient on Insulin who is Eating

Glucose 240

Insulin 6 A(0+6)

65 glargine

tube feeds
Tube Feeds

Method 1:

Take the last 24 hour insulin infusion

Basal: 24 hour total/2

Aspart: 24 hour total/10 given q4h

Example: 2 units per hour – 48U

Basal: 48/2=24U glargine

aspart: 48/10=4.8 (5 U aspart q4h)

Method 2:

Similar to Method 1 – just using a higher proportion of basal insulin

Method 3:

If no IV – just use 1 unit per 6-10g CHO to start and calculate as per #1

slide90

Tube Feeds

Glucose 140 255 180 260

Insulin 6 A(5+1) 11 A(5+6) 7 A(5+2) 11 A(5+6)

24 glargine

Change for next day would be increase in glargine

glucocorticoids and diabetes
Glucocorticoids and Diabetes

Peripheral Tissues

(Muscle)

postreceptor defect

Insulin

resistance

Glucose

Liver

Increased glucose production

Pancreas

Impaired insulin secretion

glucocorticoids and diabetes92
Glucocorticoids and Diabetes:

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes93
Glucocorticoids and Diabetes:

Typical sliding

scale insulin

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes94
Glucocorticoids and Diabetes:

Typical sliding

scale insulin

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes95
Glucocorticoids and Diabetes:

Revved Up sliding

scale insulin

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes96
Glucocorticoids and Diabetes:

Revved Up sliding

scale insulin

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes97
Glucocorticoids and Diabetes:

NPH andRegular

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes98
Glucocorticoids and Diabetes:

NPH andRegular

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

glucocorticoids and diabetes99
Glucocorticoids and Diabetes:

Increase NPH andRegular

Glucose

Lunch

Bedtime

Breakfast

Dinner

Breakfast

slide100

Glucocorticoids and Diabetes

Glucose 151 220 340 350

Insulin 12 A(10+2) 14 A(10+4) 18 A(10+8) 3A(+3)

15 glargine

Change for next day would be increase Aspart

Breakfast: 16units; Lunch 18 units; Dinner 18 units

committee members
Committee Members
  • Physicians: Endocrinologist, Hospitalist
  • Clinical Nurse Specialists: Diabetes, education
  • Nurses: ICU Manager, at least one manager from medical floor (or their representative)
  • Clinical Pharmacist
  • Administration presence – from level of quality assurance or similar title
  • Discharge Coordinator – not required for initial discussions and implementation, but needed later
  • Nutritional services – not required for initial design and implementation of forms.
tasks
TASKS
  • Formulary
    • Clean up insulin
    • Clean up oral agents
  • Nursing Issues
    • Policy on IV insulin use
    • Policy on frequency of glucose monitoring
  • Forms
    • Design forms
      • IV insulin forms
      • SQ insulin forms
      • ?DKA treatment forms
other committees to be conquered
Other Committees To be Conquered
  • Pharmacy and Therapeutics
    • Formulary issues
    • Oral agents
    • Insulins
    • Insulin Forms – iv, sq
  • Forms
    • Insulin forms – iv, sq
  • Quality Improvement
    • Need buy in at this level to achieve administrative support
other people to be conquered
Other People To be Conquered
  • Smaller Hospitals
    • CEO
    • Chief of Staff
  • Larger Institutions
    • Chairs of Medicine, Surgery
    • Heads of training programs from Medicine, Surgery
    • Chief of Staff, Chief Medical Officer, CEO
    • Chairs of other Departments
    • Chief Residents
    • Dean for Education
implementation
Implementation
  • Smaller Hospitals
    • Entire Institution
  • Larger Institutions
    • ? One unit at a time
    • ? One service at a time
  • Make certain forms are available
    • Unit clerks must be aware!!!!
    • If orders written in ER, forms must be in ER
    • If forms not available, this will fail.
ucsf implementation
UCSF Implementation
  • Nursing Education
    • Diabetes Nurse Specialist
    • Intranet Training
  • Physician Training
    • Small group sessions
    • Internet training
question 1 transition from iv to sq insulin
Question 1: Transition from IV to SQ Insulin
  • The IV rate has been changing, what do you use to base the conversion rate on?
    • The idea is to take the most recent steady rate and use that as the rate for the previous 24 hours. Thus for this patient, for 6 hours it has been at 1.8 units per hours, so that will be the rate used to calculate a 24 hour dose.
question 1 transition from iv to sq insulin108
Question 1: Transition from IV to SQ Insulin

Take 80% of last 24 h insulin infusion

Basal: ½ of the value

premeal: ½ of the value divided for the meals

Example: 1.8 units per hour = 43.2U

43 x .8= 34

Basal: 34x.5=17

premeal: 34x.5=17 6 per meal

case 2 sq insulin adjustments
Case 2: SQ Insulin Adjustments

Breakfast: 179; Lunch 202, Dinner 105 bedtime 143

Change for next day

Breakfast: 12A, 46 G; Lunch 12A; Dinner 15A

Insulin 11 A(9+2) 16 A(12+4) 15 A(15+0)

42 glargine

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Case 3: Patient Starting Insulin

5’7”, 270 lb, glucose 279, HgA1c 8.9

case 3 patient starting insulin
Case 3: Patient Starting Insulin

There is no perfect formula, the idea is to start with a reasonable choice and make quick adjustments

This patient is sick, obese, insulin resistant to begin with. Would be reasonable to use .5 U/kg and give ½ as basal and ½ split for premeal. Thus:

279/2.2= 122.7 kg 122x .5= 61

So about 30units basal and 10 units premeal.

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Case 4: Patient NPO for short time

Glucose 240

Insulin 6 A(0+6)

55 glargine

slide116

Glucocorticoids and Diabetes

Glucose 151 220 340 360

Insulin 6 A(5+1) 7 A(5+2) 9 A(5+4) 3A(+3)

20 glargine

Change for next day would be increase Aspart

Breakfast: 10units; Lunch 10 units; Dinner 9 units

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Case 6: Tube Feeds

Patient is being started on Tube feeding. It would be easiest to titrate insulin using in IV drip, but you decide to just use SQ insulin. You are starting continuous feedings of ensure at 60 ml/hour. Ensure has .175 g CHO/ml (hint – 10.5 g/hour, 252g/24 hours). Write some orders

tube feeds118
Tube Feeds

If no IV – just use 1 unit per 6-10g CHO to start

1U/10g= X U/256 g (basically 256/10 for those of you sleeping by now)- for 26 units of insulin in 24 hours.

Use 26 units for 24 hours

Basal: 24 hour total/2

Aspart: 24 hour total/10 given q4h

Example:

Basal: 26/2=13U glargine

aspart: 26/10=2.6 (3 U aspart q4h)