In hospital Management of

Hyperglycemia
By

DR: MOKHTAR , Abdel Rahman

Consultant Internist ( NWAFH )

Barriers to better control ???

Fear of hypoglycemia
Although many hospitalized patients have
hyperglycemia , physicians traditionally
tend to look the other way , believing that
it is better to [do no harm ] rather than risk
of hypoglycemia with more aggressive
insulin therapy .This often leads to clinical
inertia.

Competing priorities :
Unless the patient admitted for
hyperglycemic emergency ( DKA ,etc ) ,
the cause for admission ( procedure ,
surgery , asthma , etc..) usually occupies
the focus of care , pushing diabetes
control to the bottom of the problem list.

High Error rate

(JCAHO Website,

Insulin is one of the top2006)

5.

Order design :
Lacking basal insulinDKA
( without basal insulin , blood glucose levels rise by about
45mg/dl/hr. )

Insulin Stacking .when SC insulin is given at

regular 4hrs or more frequent . Although it is rapid acting , it can be
active for as long as 8 hrs. Each subsequent dose has the effect of
stacking onto the previous dose , causing severe hypoglycemia
after frequent doses.

Order Implementation :
Confusing names of preparations eg , Lantus ,
lispro,,,etc.

Poor coordination of blood glucose , Insulin

injection and meal tray delivery.

Others

Workflow change
Information / reporting
Multiple teams and
hand-offs
Ongoing Education
needs

Skepticism of
benefits
Pre-existing orders
Habits
Coordination
Staff turnover

How to overcome these

barriers ??

Integrate Best Practice into protocols,

order sets, documentation

Actionable glycemic target

Constant carbohydrate / dietary plan.
A1c
Specify hyperglycemic diagnosis
Education plan
Hypoglycemia protocol
Guidance for transitions (linked protocols)
Allow variation, while encouraging
standardization

Integrate Best Practice into protocols,

order sets, documentation

Coordinated insulin / nutrition / monitoring.

Insulin preferred - DC oral agents
Basal / Nutrition / Correction terminology
Dosing adjustment guidance
Specific regimens for different situations
NPO
Eating
Tube feeds
Steroids, etc

Current Practice Best

Practice
Dependence on non-physiologic insulin prescribing (as opposed
to insulin that mimics physiologic insulin secretion)
Dependence on reactive strategies (e.g. sliding-scale insulin)
Overemphasis on simplicity (particularly simplicity from the
perspective of the ordering physician)
Overemphasis on avoidance of hypoglycemia
Lack of standardization of insulin use in the hospital

Sliding Scale Insulin

The perfect example of an insulin regimen that is NOT
considered part of the best practice of inpatient diabetes
management is the use of sliding-scale insulin alone in
hospitalized patients.

Sliding-scale insulin is not a rational insulin treatment

strategy, for all of the reasons listed on the previous slide.

The use of sliding-scale insulin alone does not mimic

physiologic insulin patterns. When using sliding scale
insulin alone, insulin is only given after metabolic control
is lost, instead of being given in an anticipatory manner.
Gregory Maynard MD, MS

Sliding Scale Alone Doesnt

Work
Sliding scale prospective cohort study
Patients treated solely with SSI were 3X
more likely to have BG>300
In 80% of patients, the orders written at
admission were never changed during
hospital stay despite poor control.

Quele et al, Arch Intern Med 1997: 157; 545-552

Sliding Scale Insulin

A common misconception is that a sliding
scale insulin regimen alone is sufficient for
diabetes management Lien, et al. Inpatients management of
Type 2 Diabetes Mellitus

This autopilot approach as the sole mode

of treatment for inpatient hyperglycemia
has been strongly condemned. Abourizk, N.
Inpatient Diabetology

 Sliding scale insulin

This is a dirty word; we dont use dirty words at
UCSD
Mindless medicine, paralysis of thought, action
without benefit, insulin insanity (Gregory
Maynard MD, MS)

Evidence does not support this technique

without basal insulin; unacceptably high rates
of
Hyperglycemia
Hypoglycemia and insulin stacking
Iatrogenic DKA in patients with type 1 DM
Umpierrez G et al. J Hosp Med. 2006; 1:141-4.

Why is sliding-scale insulin use so common if

it is such a bad practice?
SSI use has been a
reflex action passed
down from attending
physicians to
residents to medical
students for the past
several generations
despite a lack of
evidence to support
practice ( Baldwin et al .,

Sliding-scale
insulin is
ingrained in the
traditional practice
of medicine in
hospitals, as it is
easy to order.

2005 )

Namely, we kept using the tool that was easiest to

.grabeven though it didnt usually work or fit

What is the Best Practice for

Managing Diabetes and
Hyperglycemia in the Hospital?
The answer is anticipatory,
physiologic insulin dosing,
prescribed as a basal/bolus
insulin regimen
This means giving the right type
of insulin, in the right amount, at
the right time, to meet the
insulin needs of the patient

Suppresses glucose
production between
and overnight

Insulin
(U/mL)

50

Physiologic Insulin Secretion:

meals

Nutritional (prandial) insulin

25
Basal insulin

0
Breakfast

Glucose
(mg/dL)

150

Lunch

Supper

Nutritional glucose

100

The
50/50
rule

50
0

Basal glucose
7 8 9 101112 1 2 3 4 5 6 7 8 9
A.M.
P.M.

Time of Day

Basal-Bolus Concept The

normal human adult
secretes about 25-30
units of insulin a day.
As you can see, about
of this is in BASAL
insulin. You can also
see that a normal
patient would likely not
exceed PG = 150 mg/dL,
even after a meal.
These ambient glucose
levels (euglycemia) are
reflected in a normal
GHbA1c range of 4.56.5% in the USA.

 Usually, about of a
Managing a patient with
patients total daily dose of
diabetes is really an
insulin is basal insulin.
exercise in mimicking the
normal physiology of the
In certain clinical
pancreas.
situations (e.g. continuous
In order to provide
tube feeds, where there is
a risk that the patients
exogenous basal insulin,
nutrition will be abruptly
the patient should be given
stopped), it may be
a long-acting, non-peaking
prudent to give slightly
insulin to provide a
less than of the insulin
constant background level
as basal insulin.
of insulin, even when the
patient is fasting.
In other situations (e.g.
It should be sufficient to
immediately following
cardiac surgery), the basal
suppress endogenous
insulin requirement may
glucose production, but not
to as high as 60-80%
so much that hypoglycemia rise
of the total daily insulin
results.
requirement.

A Physiologic Insulin Regimen

Basal insulin
Long-acting, all Type 1 and most Type 2 DM patients
should have basal insulin whether they are eating or
not (insulin glargine, insulin detemir, or NPH)

Nutritional or pre-meal / prandial insulin

Short-acting insulin given with meals in anticipation of
carbohydrate load glycemic spike (scheduled insulin
aspart, insulin lispro, insulin glulisine, regular insulin)

Correction or supplemental insulin

Short-acting insulin given to cover high glucose; if
substantial use, it should drive adjustment of basal
and nutritional insulins

Providing Exogenous Basal

Insulin
Long-acting, non-peaking insulin is preferred as it provides
continuous insulin action, even when the patient is fasting
Required in ALL patients with type 1 diabetes
Many patients with type 2 diabetes will require basal insulin
in the hospital
Can be estimated to be about 1/2 of the total daily dose of
insulin (TDD)

Providing Exogenous Nutritional

Insulin
Usually given as rapid-acting analogue (preferred in most
cases) or regular insulin, for those patients who are eating
meals
Must be matched to the patients nutrition
Should not be given to patients who are not receiving
nutrition (e.g. NPO)
Can be estimated to be about of the total daily dose of
insulin (TDD)

Providing Exogenous Correctional

Insulin
Correctional insulin is extra insulin that is given to correct
hyperglycemia
Usually rapid-acting or regular insulin (usually the same as the
nutritional insulin)
Often written in a stepped format that is used in addition to basal
and nutritional insulin
Customized to the patient using an estimate of the patients
insulin sensitivity
If correctional insulin is required consistently, or in high doses, it
suggests a need to modify the basal and/or nutritional insulin
doses

Action Profiles of Bolus & Basal Insulins

NB: action curves are approximations for illustrative purposes. Actual patient
response will vary.

lispro/aspart 1-2 hours

Plasma Insulin levels

regular 2-4 hours

BOLUS INSULINS
BASAL INSULINS

NPH 6-12 hours

detemir ~ 6-23 hours (dose dependant)
glargine ~ 20-26 hours

Hours
Mayfield, JA.. et al, Amer. Fam. Phys.; Aug. 2004, 70(3): 491 Plank, J. et.al. Diabetes Care, May 2005; 28(5): 1107-12

Which Patients Should be Treated with a

Physiologic Insulin Regimen?
During hospitalization
Any patient with blood glucose levels consistently above the
target range

Immediately at the time of admission

All patients with type 1 diabetes
Patients with type 2 diabetes if
They are known to be insulin-requiring
They are known to be poorly controlled despite treatment with
significant doses of oral agents
They are known to require high doses of oral agents that will
be held in the hospital

A Stepwise Approach to Physiologic Insulin Dosing in the

Hospital

1.
2.
3.
4.
5.

Selecting a Non-ICU Glycemic Target For Your

Practice/Institution .
Estimate the amount of insulin the patient would need
over one day, if getting adequate nutrition = Total
Daily Dose (TDD)
Assess the patients nutritional situation
Decide which components of insulin the patient will
require, and which percentage of the TDD each
should represent
Determine the correctional factor and put a scale for
correctional insulin.

6. Assess blood glucoses at least daily, adjusting insulin

doses as appropriate

STEP 1 : Selecting a Non-ICU Glycemic

Target

Fasting 110 -140.

Pre meal 140mg / dl.
Random< 180 mg/dl

STEP 2: Estimate the Amount of Insulin the

Patient Would Need Over One Day, If Getting
Adequate Nutrition = Total Daily Dose (TDD)

Calculate from insulin infusion amount

Recent steady state hourly rate x 20, for
example

Add up insulins taken at home, adjust for

glycemic control and other factors
Calculate from weight, body habitus, other
factors

Weight based calculation

Calculate starting total daily dose (TDD)

0.3 units/kg/day (hypoglycemia risk factors, nave patient)
0.4 units/kg/day (conservative for most patients)
0.5 0.6 units/kg/day (overweight to obese)
Adjust TDD up or down based on
Past response to insulin
Presence of hyperglycemia inducing agents, stress
This Is very conservative and safe (adjust up as needed)
Basal insulin = 40-50% of TDD
Glargine q HS or q AM, detemir in 1 or 2 doses

 Malnutrition and low

body weight
Chronic renal failure
Decreased oral intake,
failure to provide
nutrition or dextrose
infusion
Advanced age
Liver disease
Beta-blockers
Iatrogenic Risk Factors:
SSI, distractions, poor
regimens: disconnect
between testing,
administration of
insulin, and nutrition

Known insulin resistance

recognized by high TDD of
insulin or obesity
Medications:
glucocorticoids,
catecholamines, tacrolimus,
cyclosporine
Significant illness: Stress
response related to the
release of counter-regulatory
hormones
Increases in nutritional intake
(e.g. restarting a diet, starting
enteral or parenteral
nutrition)

STEP 3 : Assess the Patients Nutritional

Situation
Eating meals or receiving bolus tube feeds
Eating meals but with unpredictable intake
Getting continuous tube feeds
Getting tube feeds for only part of the day
Getting parenteral nutrition
NPO

STEP 4: Decide Which Components of Insulin the Patient

Will Require, and Which Percentage of the TDD Each Should
Represent

In most cases, basal insulin should be provided

In most cases, well-designed corrective insulin regimens

should be provided
When a patient is not receiving nutrition, nutritional insulin
should not be given
Nutritional insulin needs must be matched to the actual
nutritional intake

STEP 5 Determine the correctional factor and

put a scale for correctional insulin.

How do we correct for preprandial

hyperglycemia?
We use a SLIDING SCALE!!!
Rules
Only given with meals
Do not use at bedtime or at 3am
Use the same type of short acting as your
SCHEDULED short acting
Add this to the amount of your SCHEDULED short
acting

Correctional factor :

Correctional Scale

40 Units per day

day

40-80 Units per day

<=
> 80 Units per

Pre-Meal
BG

Additional Pre-Meal
Units
BG

Additional Pre-Meal
Units
BG

Additional
Units

150-199

150-199

150-199

200-249

200-249

200-249

250-299

250-299

250-299

300-349

300-349

300-349

10

>349

>349

>349

12

STEP 6: Assess Blood Glucoses at Least Daily,

Adjusting Insulin Doses as Appropriate

There is no autopilot insulin regimen for a

hospitalized patient!

Perhaps more important than knowing

exactly how to modify an insulin program is
having the understanding that the program
must be regularly modified.
At least once a day the insulin regimen
should be scrutinized by the medical team,
considering any changes in clinical condition
or diet, as well as the glycemic control that is
being achieved.

Conclusion
In the end, optimal metabolic control in the
hospital will only be achieved by frequent (at
least daily) assessment of a patients blood
glucose, and frequent adjustment of the insulin
program.
Making adjustments to an insulin regimen, based
on the glycemic control achieved, is more art
than science. It is difficult for any educational
module to allow you to master the art of insulin
adjustment across the range of possible patients
and circumstances.

With experience, clinicians will

develop their skills in this area.

Case # 1: Initiating Subcutaneous

Insulin in an obese patient eating
regular meals
56 year old man admitted with diabetic
foot infection, eating regular meals.
Obese, weighs 100 kg
Home regimen
2 OHGs and 20 units of NPH q HS

Baseline Control:
HbA1c of 10, POC glucose in ED 240 mg/dL

What are your initial orders for insulin?

What change would you make if he had to
go to the OR the next morning?

Eating Patient
(or Bolus TF)

Case #1: Solutions for Obese,

eating patient
Accuchecks AC and HS
TDD: 100 kg x 0.6 units/kg/day = 60 units
Glargine (Lantus) Alternative
Basal: Glargine 30 units q HS
Nutritional: Lispro 10 units q ac
Correction: Lispro per scale q ac and HS

For NPO p MN and OR the next AM

Hold nutritional dose, continue adjustment dose
Give the full dose of Glargine q HS: No change.

Adjust, Adjust, Adjust

If glucoses going < 70 mg / dL, use 80%
of TDD as next days TDD
If glucose readings > 150 and no
hypoglycemic values, use 120% of
yesterdays total as new TDD (or 130%,
depending on the uniformity and degree of
poor control)

Case # 2: Patient in IMU on

Continuous TF
65 year old you are seeing for the first
time in the IMU, no outpatient history
available except on insulin. Glucose >
200 in ED, HbA1C pending.
80 kg overweight woman started on
continuous TF yesterday (HD#3), with
serum glucose in 200-250 mg/dL range
What would you order?

TPN or
Continuous
Tube Feedings

Continuous Tube Feeding Insulin

Regimen

Case #2 Solutions in a patient

on continuous TF or TPN

Accuchecks q 6 hours
TDD is 0.5 units/kg/day x 80 kg = 40 units
Basal: Glargine 16 units q hs (or q am)
Nutritional: 6 units regular insulin q 6 h
Correction: regular insulin q 6 h per scale

Patients being started on TPN do better with

separate insulin infusions initially (with y
connector) to find dose.
Conversion then can be made to insulin in TPN
(80% of TDD), or subcutaneous regimen.

Case #3: Transition from IV to

subcutaneous insulin
60 yo man with DM 2, well controlled in ICU on
insulin infusion and continuous TF at 40 ml/hour.
Insulin Infusion rate 80 units in the last 24 hours,
3 units / hour over last 6 hours.
Prior to hospitalization, baseline HbA1c was 8.7
on 40 units of 70/30 insulin per day and OHGs.
Plan: Transfer to ward, continue enteral nutrition
How do you transition this patient to a
subcutaneous insulin regimen?

Stepwise approach to moving

from IV to SC insulin
Calculate how much IV insulin the patient has
been requiring. Modify down for safety cushion.
Was this insulin supplying Basal requirements,
or Basal and Nutritional requirements? Translate
into the subcutaneous regimen.
Consider any nutritional changes that may be
implemented at the time of the transition off of
the drip
Make sure SC insulin is given before
discontinuation of the IV insulin

Case: Transition to subcutaneous

insulin
(enteral nutrition to continue)
Safe Estimate of 24 hour requirement:
3 units / hour x 20 = 60 units
60 units represents the TDD: Basal and nutritional
insulin
50:50 Rule Example
Glargine 30 units = Basal
Regular 7 units q 6 h = Nutritional

Correction dose of regular insulin also given along

with nutritional dose as needed.
Glargine / Nutritional should be given BEFORE IV
insulin stopped

What if??? Enteral to PO

Instead of continuing enteral nutrition on the
floor, you opt to stop enteral nutrition and start
patient on a mechanical soft diet?
Glargine 30 units = Basal
RAA 10 units q AC = Nutritional / Prandial
(IF you expect them to eat a full meal! )
If po intake suspect at first, use CHO counting,
or empirically reduce nutritional RAA dose and
give the dose just AFTER the meal instead of
just BEFORE the meal.
CORRECTION dose RAA insulin also needed.

Have a Discharge Plan

Tailored to Patient!
Diabetes and insulin education, survival skills:
START EARLY and repeat
Follow up and community resources
Covered by insurance
Patient and family can understand
Reconcile medications
Language, health literacy, and cultural barriers
Use HbA1c
Insulin requirement may decrease post discharge