Glycemic Control in the Hospitalized Patient

How do you do it?

Hospitalization of the Patient With Diabetes

Acute metabolic complications Chronically poor metabolic control Acute or chronic complications of diabetes Newly diagnosed diabetes (children) Uncontrolled diabetes during pregnancy Acute or chronic problems unrelated to diabetes

Barriers to Inpatient Diabetes Management

Increased insulin requirement due to illness Exaggerated variability in subcutaneous insulin absorption NPO status; inconsistent oral intake; interruption of meals by procedures Unpredictable arrival of meals Inability of patient to participate in management decisions Medication errors

Why be concerned about short-term glycemic control in hospital?

Critical illness Acute myocardial infarction Post-operative infection/wound healing In-hospital mortality Stroke

NEJM 2001;345:1359

BMJ 1997;314:1512

Mortality in DIGAMI 2

European Heart Journal 2005;26:650

Fasting Blood Glucose in DIGAMI 2

European Heart Journal 2005;26:650

HbA1c in DIGAMI 2

European Heart Journal 2005;26:650

Ann Thorac Surg 1999;67:352-62

J Clin Endocrinol Metab 2002;87:978

Stroke 2001;32:2426

Glucose: the 6th vital sign

Measure blood glucose in all patients admitted with acute illness

All patients with type 1 diabetes will require at least basal insulin replacement Most insulin treated patients will require continued insulin therapy Consider insulin therapy in any patient with random blood glucose > 180 mg/dl

Key Concepts of Insulin Therapy

Basal insulin
Controls hepatic glucose production

Food (prandial) insulin

Based on meal carbohydrate content

Correction (supplemental) insulin

Treats acute elevation in blood glucose

Bolus Basal

Indications for IV Insulin Therapy

DKA/ HHS Critical illness Major surgery
Cardiopulmonary bypass surgery Transplantation surgery Abdominal surgery (NPO post-op)

IV Insulin Therapy- Considerations

Define target blood glucose. Define threshold for initiating therapy. Determine starting dose (& bolus) based on glucose level. Adjust infusion rate based on rate of change in blood glucose. Infusion rates will vary depending on individual patients insulin sensitivity. Define when to interrupt therapy for low blood glucose.

IV to SC Insulin
Begin subcutaneous basal insulin while the patient continues to receive iv insulin. Add prandial insulin when the patient is able to resume oral intake. Taper iv insulin, maintaining predetermined targets. IV insulin can be discontinued when:
IV insulin requirements are <1 u/hr Glucose is <120 mg/dl on two consecutive determinations The patient is eating solid foods without difficulty

If the patient can immediately resume usual diet, and insulin requirements are known, iv insulin can be stopped after first injection of basal insulin.

Use of Subcutaneous Insulin in Hospital

Unpredictable Best choice for insulin treated patient who is able to eat Options:
Once daily NPH insulin (type 2 diabetes only) Twice daily split-mix insulin/pre-mix insulin MDI or CSII

Listen to the experienced patient

Starting Insulin in the Newly Diagnosed Patient

Calculate the total daily dose Determine basal insulin requirement
40 to 50% of total daily dose

Determine the mealtime insulin requirement

50 to 60% of total daily dose

Determine the correction dose

Based on estimate of insulin sensitivity

Daily Insulin Requirements

Patient Description
Trained athlete Mod. active man Sedentary man; 1st trimester of pregnancy Mod. stressed man; 2nd trimester of pregnancy

Insulin (units/kg.day)
0.5 0.6 0.7 0.8

Severely stressed man; 3rd trimester of pregnancy

Systemic bacterial infection; full term pregnancy Severely ill man

0.9
1.0 1.5-2.0

Oral Agents in the Hospital

Classes
Insulin secretagogues (sulfonylureas; meglitinides) Alpha-glucosidase inhibitors (acarbose; miglitol) Biguanides (metformin) Thiazolidinediones (pioglitazone; rosiglitazone)

Limitations
Mild glucose elevations Able to eat and ingest medicines No comorbid conditions that contraindicate use

Challenging Clinical Situations

The NPO patient The patient receiving corticosteroids The patient receiving TPN The patient on enteral nutritional support
Continuous Intermittent

The NPO Patient with Diabetes

Basal insulin as insulin glargine

Previous insulin: TDD Insulin nave: 0.4 units/kg (if on iv insulin, taper after insulin glargine is added)

Regular insulin supplement q4-6 hours

Corticosteroid Therapy and Diabetes

Minimal elevation of fasting glucose Exaggeration of postprandial hyperglycemia Lack of sensitivity to exogenous insulin

Consider:
Prandial insulin in patients without prior history of diabetes 70% prandial insulin, 30% basal insulin in patients with established diabetes history

TPN and Diabetes

TPN commonly leads to hyperglycemia in the absence of diabetes. Insulin requirements are increased in patients with diabetes; 75% of patients with type 2 diabetes not previously treated with insulin will require insulin with TPN. IV insulin should be infused separately until requirements are known; insulin can then be added to the TPN solution.

Enteral Nutrition and Diabetes

Enteral nutritional support can result in hyperglycemia, even in the absence of diabetes. In patients with established diabetes, insulin requirements increase substantially. High fat formulas (monounsaturated fats) achieve better metabolic control that traditional high carbohydrate preparations. Blood glucose control may be attainable with long acting subcutaneous insulin preparations- insulin glargine (with constant nutrition).
Previous diabetes: TDD Insulin nave: 0.6 units/kg

Intermittent Enteral Nutrition

Basal insulin as NPH at the start of nutritional support
Previous diabetes: TDD Insulin nave: 0.4 units/kg

Regular insulin usually required at start of feeding

25 to 50% of NPH dose

Summary
Aggressive glycemic control in hospitalized patients improves clinical outcomes. Management of diabetes in an inpatient setting requires familiarity with the use of both iv and sc insulin, both in intensive care units and on general nursing units. The time-honored traditions of sliding scale insulin, and of withholding insulin for procedures and euglycemia should be buried along with fractional urine testing.

Remember
Most hospitalized patients are discharged Inpatient diabetes treatment should transition smoothly to outpatient management Think ahead; plan early
? Dietary consultation ? Diabetes education consultation ? Endocrinology consultation