Management in
Hospital Based -
Insulin Therapy
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Diabetes in Hospitalized Patients
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Higher Costs: Diabetes in
Hospitalized Patients
Higher rate of hospitalization
Longer stays
More procedures, meds.
Chronic complications
More arteriosclerotic disease-
More infection
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Hyperglycemia in Patients with
Undiagnosed Diabetes
Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-
hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978-82.
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The Increasing Rate of Diabetes Among
Hospitalized Patients
48%
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Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:978-982. Bolk J et al. Int J Cardiol. 2001;79:207-214.
Williams LS et al. Neurology. 2002;59:67-71. Malmberg K, et al. BMJ. 1997;314:1512. Van den Berghe G et al. N
Engl J Med. 2001;345:1359-1367. Capes SE et al. Stroke. 2001;32:2426-2432.
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Proposed Pathophysiology of Glucose Damage
Hyperglycemia and Poor Hospital Outcome
Metabolic stress response
Glucose
Insulin
Reactive O2 species
Immune dysfunction
FFA
Ketones Transcription
Lactate factors
Infection dissemination
Secondary
Cellular injury/apoptosis mediators
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Inflammation
Tissue damage
Altered tissue wound repair
General wards - newly identified diabetes with FBG >126 mg/dl or random
>200 mg/dl 10-fold increase in mortality and longer hospital stays.
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Post-surgery - BS > 220 day post-op day 1 near 6-fold increase in serious
infections.
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Potential Benefits Of Improved Glucose
Control In The Hospital
Reduced Mortality
Reduced Morbidity
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Intensive Insulin Therapy in Critically Ill
PatientsMorbidity and Mortality Benefits
Blood
Mortality Sepsis Dialysis Transfusion Polyneuropathy
Percent
Reduction
34%
41%
44%
46%
50%
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Insulin: The Most Effective Treatment
for Inpatient Glycemic Control
Adaptable to increased insulin requirement
during acute illness
Basal insulin administration can prevent
excess gluconeogenesis and ketogenesis
Dose can be adapted to various categories
of patient nutrition status
IV dextrose
Total parenteral nutrition
Enteral feeding
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Nutritional supplements
130 mg/dl
AACE- Endocrine Practice 10 (1): 77-82, 2004
ADA- Diabetes Care 27: 553-591, 2004
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AACE-ADA Consensus Statement
on Inpatient Glycemic Control: ICU
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Inpatient Management Principles
protocols.
Aggressive BS management.
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Control highs, minimize lows.
Potential Effects Of Insulin Therapy
Reduction of hyperglycemia
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Reported Benefits of Insulin Therapy Acute and
Chronic
Anti-inflammatory effect
Reduced CRP
Reduced ROS generation in monocytes
Reduced monocyte chemoattractant protein-1
(MCP-1)
Reduced NFB activation
Induction of eNOS and increased NO
Inhibition of growth response gene-1 (Egr-1)
Anti-fibrinolytic effect
Reduced PAI-1 levels
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Reduced fibrinogen
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Methods For Managing Hospitalized Persons
with Diabetes
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NO to Sliding Scales!!
WHY?
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Physiologic Insulin needs
ILLNESS-
RELATED
SUPPLEMENTAL/Correction
NUTRITIONAL
BASAL
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Insulin Terminology
There are three components to subcutaneous
insulin therapy:
immediately postmeal
Aspart Prandial 34 15 min premeal to
olus
immediately postmeal
Glulisine Prandial 34 15 min premeal to
20 min postmeal
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0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Hours
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Burge MR, Schade DS. Endocrinol Metab Clin North Am. 1997;26:575-598; Barlocco D. Curr Opin Invest
Drugs. 2003;4:1240-1244; Danne T et al. Diabetes Care. 2003;26:3087-3092
Ideal Basal Insulin
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Basal/Bolus Treatment with Rapid-acting & Long-
acting Insulin Analogs
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Starting Basal-Bolus
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
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* *All patients with type 1 diabetes and most patients with insulin-
dependent type 2 diabetes require basal insulin, even when NPO.
dose
o short-acting insulin: hold rapid-acting (lispro, aspart,
glulisine)
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Initiating SQ insulin therapy
NPH insulin - about 44% of total daily dose before breakfast meal, and
about 17% of total daily dose at hs
Regular insulin - about 22% of total daily dose before breakfast
meal, and about 17% of total daily dose before supper meal
Example: For an 80 kg patient who is new to insulin -
- NPH insulin 11 units SQ before breakfast
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and 4 units SQ at hs
- Regular insulin 5 units SQ before breakfast
and 4 units SQ before supper meal
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nitiating SQ insulin therapy
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Insulin Administration Guidelines
Test capillary blood glucose before meals,
bedtime and when appropriate at 3 AM.
If BG is in target range at meal time give the
meal bolus within 15 minutes of the start of
the meal
If the BG is above target range at meal time
give the meal bolus plus the correction bolus
The basal insulin is administered whether the patient is eating or
not.
Corrections are given whether the patient is eating or not.
The meal bolus is held if the patient is not eating or is adjusted
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If the Patient is NPO or unable to eat
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Correction Factor Insulinthe new, improved
sliding scale
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Correction Factor Insulin
Premeal Prandial Premeal Prandial
Premeal Prandial
BG Insulin BG Insulin
BG Insulin
130-170 1 unit 130-170 3 unit
130-170 1 unit
171-220 2 units 171-220 3 units 171-220 5 units
>320 5 units
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Adjusting Basal Insulin
Fasting BG Change
Make daily Basal
adjustments of basal Insulin
insulin based on <70 20%
fasting (AM) BG
71-90 10%
90-130 no change
131-180 by 10%
181-230 20%
231-280 30%
>281 40%
Correction Bolus (Supplement)
= ~30
meaning 1 unit will lower the BG ~30
mg/dl ]
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Formula
Current BG - Ideal BG
Glucose Correction factor
Example:
Current BG: 250 mg/dl
Ideal BG: 100 mg/dl
Glucose Correction Factor: 30 mg/dl
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250 - 100
30 = 5.0 u
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Initiating SC Basal Bolus
Advantages Disadvantages
Frequent monitoring
Tightest control (ICU needed?)
Good absorption Nursing time!
Rapid adjustments Catheter
Easy standardized complications
Problems when
switching to SQ
regimen
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Indications for IV Insulin Drip - Think
broad.
Diabetic Labor and delivery
ketoacidosis High-dose
glucocorticoid
Nonketotic therapy
hyperosmolar state Perioperative period
Critical care illness After organ
(surgical, medical) transplant
Postcardiac surgery Total parenteral
nutrition therapy
Myocardial
infarction or
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cardiogenic shock
American Association of Clinical Endocrinologists. Available at:
http://www.aace.com/pub/ICC/inpatientStatement.php. Accessed March 17, 2004.
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Threshold blood glucose in mg/dL for
starting IV insulin infusion
Peri-operative care: > 140
ICU care: > 110 - 140 *
Non-surgical illness: > 140 - 180 * *
Pregnancy > 100
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Optimal Glucose Targets in Hospital Patients:
The ADA-ACE Consensus Statement
based on the results of NICE-SUGAR
Diabetes Care, May 2009
Critically ill patients
Use IV insulin in the majority of patients in the ICU
setting
Maintain glucose levels between 140 and 180 mg/dL
Targets less than 110 mg/dL are NOT recommended
Noncritically ill (floor) patients
Recommendations are based on clinical experience
and judgment
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Various Protocols Exist
Author
Target glucose Bolus Initial Insulin infused Highest hourly
(mg/dL) (U) infusion rate BG >200mg/dL dose
(U/hr) (U) (U)
Bode 100150 0 8 41 11
Boord 120180 0 1 14.3 4.3
Chant 90144 0 6 42 15
Marks 120180 0 1 54 18
Van den Berghe 80110 0 4 40 15
Zimmerman 101150 10 4 88 21
Wilson M et al. Diabetes Care.
2007;30:1005-11.| 54
No Ideal Insulin Infusion
Protocol
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Converting from IV to SC insulin
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Stepwise approach to moving from IV to SC insulin
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Protocol for Treatment of Hypoglycemia
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Discharge
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Patients without History of
Diabetes
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Take-home Points
All hospital patients should
have normal glucose
Be aware of glucose targets
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