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DIABETES CARE IN

HOSPITALIZED
Dr. WIDYATI, MClinPharm, Apt
Farmasis Klinik RSAL Dr. Ramelan
Magister Farmasi Klinik Ubaya

Background Setting

DM in
hospitalize
d

Main
Diseases

Uncontrolle
d DM
Complicatio
ns

Underlying
Diseases

Acute
diseases
Chronic
diseases
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Uncontrolled DM

Non-adherence
Inadequate OAD
Inadequate insulin
Inappropriate OAD
Inappropriate insulin
Insulin resistence
Insulin tolerance
Infection
Kegagalan OAD

Hiperglikemia
Hipoglikemia

HYPERGLYCEMIA

Symptoms: 3P, weight loss, lethargy,


pruritus vulvae, skin infection, visual,
mual, muntah.
Pertimbangan Klinik: Non-adherence,
insulin resistance, ketidakcukupan OAD
or insulin, pemilihan OAD yang kurang
tepat.
Patients with hyperglycemia fall into
three categories:
Medical history of diabetes
Unrecognized diabetes: hyperglycemia
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occurring during hospitalization and
confirmed

HYPOGLYCEMIA

Definition Blood glucose concentration


<60 mg/dL: Patient may or may not be
symptomatic. Blood glucose <40 mg/dL:
Patient is generally symptomatic. Blood
glucose <20 mg/dL can be associated
with seizures and coma.
Signs and Symptoms Blurred vision,
sweaty palms, generalized sweating,
tremulousness, hunger, confusion, anxiety,
circumoral tingling, and numbness.
Patients vary with regard to their
symptoms. Behavior can be confused with
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inebriation. Patients become combative

Hypoglycemia
Clinical Considerations:
Irregular eating patterns
Physical exercise
Gastroparesis (delayed gastric emptying)
Excessive dose of sulfonylurea
Alcohol ingestion
Drugs Treatment : Ingest 1020 g
rapidly absorbed carbohydrate. Repeat
in 1520 min if glucose remains <60
mg/dL or if patient is symptomatic.
If patient is unconscious : Glucagon 1 mg
SC, IM, or IV (response time, 6.5

Non-Adherence

Patient-Related: needle phobia; fear of


initiating insulin; nonadherence to selfmonitoring of blood glucose (SMBG), diet,
exercise, or medications; lack of motivation;
depression; low socioeconomic status; and
limited access to specialized care such as a
diabetes or endocrinology clinic.

Treatment Related: ineffective diet/nutrition


regimens, complex drug regimens, mode of
delivery of insulin therapy, failure of clinicians
in treating aggressively in a treat-to-target
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approach, underutilization of insulin
therapy,

Acute
Metabolic
complicatio
ns
Hyperosmolar
Hyperglycemia
State (HHS)

Ketoacidosis

Chronic
Complicatio
ns
Makrovaskuler:
cardiovascular
disorders,
Peripheral
Vascular Disease

Mikrovaskuler:
Retinopati,
Nefropati,
Neuropati
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HYPERGLYCEMIC CRISES
Hyperosmol
ar
Hyperglyce
mia:
Diabetic
ketoacidosis
:

Criteria: FPG> 600mg/dl,


pH >7,30, HCO3 > 15,
ketonuria dan serum
minimal, osmolaliltas
serum > 320, stupor/coma

Common acute
complication of DM Type1
Criteria: FPG>250 mg/dl,
pH < 7 (severe)-7,3; Keton
(+) dlm urin/serum,
osmolalitas variable; alert9
coma

DKA & HHS TREATMENT

Requires correction of :
dehydration,
hyperglycemia,
electrolyte imbalances;
identification of comorbid
precipitating events

Insulin Therapy

Hypokalemia must be excluded


Bolus of regular insulin at 0.15 units/kg
body weight, followed by a continuous
infusion of regular insulin at a dose of 0.1
unit/kg/jam (5 to 7 units per hour in adults)
If plasma glucose does not fall by 50 mg/dL
from the initial value in the first hour,
check hydration status; if acceptable, the
insulin infusion may be doubled every hour
until a steady glucose decline between 50
and 75 mg/hour

Chronic
Complications

1. CARDIOVASCULAR
DISEASE

CVD is the major cause of mortality in


DM, major contributor to morbidity of DM
Type 2 DM is independent risk factor(RF)
for CVD
Emphasis should pleced on reducing RF:
BLOOD PRESSURE CONTROL
MANAJEMEN DISLIPIDEMIA
ANTI-PLATELET
SMOKING CESSATION
CHD SCREENING & TREATMENT
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BLOOD PRESSURE
CONTROL

Target : BP < 130/80 mmHg


Pt w/ 130-139 / 80-89 mmHg should be given
lifestyle and behavioral therapy for 3 months, if
targets are not achieved start drug therapy.
Initial drug therapy: ACE, ARB, diuretics, CCB
Multiple drugs generally is required
Type 1, HT, albuminuria: ACE delay the
progression of nephropathy
Type 2, HT, microalbuminuria: ACE and ARB
delay the progression to macroalb
Type 2, HT, macroalb: ARB delay the progression
of nephropathy
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MANAJEMEN
DISLIPIDEMIA

Type 2, test for lipid disoreders


annually
Reduction of saturated fat and
cholesterol intake, weight loss, phys
act shown to improve lipid profile
Goal: LDL < 100 mg/dl

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MANAJEMEN
DISLIPIDEMIA
Lipid Profile

Monoterapi

Terapi
Kombinasi

LDL, HDL (N), Resin or Statin


TG (N)
or Niacin

Resin+Niacin/St
atin or Statin +
Niacin

LDL , TG
TG

Statin
Niacin
Fibrate

Statin+Niacin
Niacin + Fibrate

LDL , HDL

Niacin
Statin

Statin+ Niacin
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Terapi Anti-Platelet

Use Aspirin (75-162mg/day) as a


secondary prevention in DM w/ MI, CABG,
stroke or TIA, PVD, Claudication , Angina
Use Aspirin (75-162mg/day) as a primary
prevention in Type 2 w/ over 40 y.o., HT,
CVD, dyslipidemia, smoking, albuminuria
People who allergy, bleeding tendency,
receiving anticoagulant, recent GI
bleeding, clinically active hepatic disease
are not candidates for aspirin and should
have other anti-platelet
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2. NEPHROPATHY

Occurs in 20-40% of DM and major


cause of ESRD
Micro alb (30-299mg/24h) early
stage of nephropathy in type 1 and
marker for nephropathy
development in type 2
Treatment of both micro & macroalb
using ACE or ARB except during
pregnancy
With presence of nephropathy,
initiate protein restriction
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3. RETINOPATHY

The prevalence related to to the duration


of Diabetes
Optimal glycemic control can
substantially reduce the risk and
progression of Diabetic Nephropathy
Optimal BP control reduce the risk and
progression of Diabetic retinopathy
Adults with Type 1 should have eye exam
within 5 years, Type 2 shortly after
diagnosis of DM
Laser therapy can the risk of vision loss
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4. NEUROPATHY

Peripheral diabetic neuropathy may result


in pain, loss of sensation, and muscle
weakness
Autonomic involvement can affect
gastrointestinal, cardiovascular, and
genitourinary function
Improvement in neuropathy should be
sought by increased attention to blood
glucose control.
Relief can be provided by various
medications, alterations in medical
nutrition therapy, or specialized
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procedures.

Intercurr
ent
illness:
Trauma,
surgery

Acute
events:
Stroke,
ACS,
Sepsis

Acute
Disease
s+
DM
Comorbid
:
dislipide
mia, HT
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INTERCURRENT
ILLNESS

Intercurrent illness: Trauma,


surgery, infections, acute event, CH,
gagal ginjal
The Stress of illness aggravate
glycemic control, precipitate
hyperglycemic crises
Aggressive management w/ insulin
may reduce morbidity in severe
acute illness.

9-8-15

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Comorbid Conditions

Atherosclerosis

Dyslipidemia

Hypertension

Associated with
cholesterol (esp. LDL)
Occur primarily in large
& medium arteries
Aggressive treatment
include plaque
stabilization with aspirin
or ACE

Intensive treatment is
important for protection
from macrovascular
complications
Treatment:Statins,
Fibrates, Bile acid
sequestrant, Nicotinic
acid,Ezetimib

UKPDS: Intensive
control of BP reduces
Diabetic complications
by 24%
Diabetes related deaths
by 32%
Strokes by 44%
Heart Failure by 56%
Microvascular
Complication by 37%
Treatment: ACE or blocker
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DM in Acute Events

Seps
is

Stro
ke

ACS

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DM in Chronic Diseases

CH, CKD : mungkin sudah tidak


perlu OAD/insulin
Bila hiperglikemi masih ada, maka
pilihan: insulin, gliquidone
Cancer exacerbate insulin resistance
syndrome

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BLOOD GLUCOSE
TARGET

Ada hubungan antara hiperglikemi dengan


peningkatan mortalitas.
Pada pasien penyakit dalam dan bedah kadar
gula> 220mg/dl memiliki laju infeksi tinggi
Ada hubungan antara kadar gula dengan
mortalitas pada AMI
Pencapaian kadar gula target berkaitan dengan
menurunnya mortalitas dan laju infeksi pada
bedah jantung
Kadar Gula < 110mg/dl meningkatkan survival
rate pada critically ill.

TREATMENT OPTIONS
OAD:
Sulfonilurea dan meglitinide tidak
direkomendasikan karena risiko hipoglikemia
pada pasien yang tidak mengkonsumsi diet
normal, sulitnya penyesuaian dosis
Metformin memberikan risiko lactic acidosis
khususnya pada COPD, renal insuff,hipoperfusi,
CHF, manula.
Thiazolidinedion: delayed onset, mevolume
intravaskuler
Insulin

Insulin Therapy in the


Hospital

Subcutaneous insulin therapy:


Dapat digunakan untuk hampir semua
pasien hospitalisasi
Scheduled insulin
Correction-dose insulin
Tidak ada studi membandingkan antara
reguler dengan lispro sebagai dosis
koreksi

Dosis Insulin
TDD Estimation

Patient Characteristics

0.3 units/kg body weight

Underweight
Older age
Hemodialysis

0.4 units/kg body weight

Normal weight

0.5 units/kg body weight

Overweight

0.6 units/kg body weight

Obese
Insulin resistant
Glucocorticoids

Insulin Therapy in the


Hospital

Intravenous insulin infusion:


Tidak ada keuntungan menggunakan
lispro or aspart dibanding reguler
Indikasi: DKA, HHS, intraops,
critically ill

Insulin Therapy in the


Hospital

Transisi Dari i.v. ke s.c.


Tidak ada lit spesifik yang menemukan
bagaimana transisi
Pasien yg akan beralih ke s.c. perlu
disuntikkan reguler or lispro 1-2 jam s.c.
sebelum iv berakhir
Pasien yg akan beralih ke intermediate or
long acting perlu disuntikkan intermediate
or long acting 2-3 jam sebelum iv berakhir

Current
Recommendation

Recommendation 1: The American


College of Physicians recommends
not using intensive insulin therapy to
strictly control blood glucose in nonsurgical intensive care unit/medical
intensive care unit (SICU/MICU)
patients with or without diabetes
mellitus (Grade: strong
recommendation, moderatequality evidence). (ACP, 2011)

Why?

Current evidence does not show any reduction in


mortality with a target blood glucose level of 4.4 to
10.0 mmol/L (80 to 180 mg/dL)
IIT was associated with an excess risk for
hypoglycemia in almost all trials and no clear
differences in mortality were observed at any
target level.
Evidence from some studies showed an increase in
mortality associated with IIT and hypoglycemia.
Data on the effects of IIT targeted to
normoglycemia on reduction in length of ICU stay
are mixed.

Current
Recommendation (cont.)

Recommendation 2: ACP recommends not


using intensive insulin therapy to normalize
blood glucose in SICU/MICU patients with or
without diabetes mellitus (Grade: strong
recommendation, high-quality evidence).
Recommendation 3: ACP recommends a
target blood glucose level of 7.8 to 11.1
mmol/L (140 to 200 mg/dL) if insulin therapy
is used in SICU/MICU patients (Grade: weak
recommendation, moderate-quality
evidence).(ACP, 2011)

DRUG INDUCED
HYPERGLYCEMI
A

Glucocorticoids

Mechanism: primarily by inhibiting glucose


uptake into muscle.
Postprandial glucose levels are generally most
affected
Patients who are treated with a basal/bolus
regimen will probably require a higher
percentage of their TDD as bolus insulin while
on glucocorticoids.
It is important to reduce insulin doses as
glucocorticoids are tapered to avoid
hypoglycemia.

Drugs that can increase


blood glucose level

2-Agonists, -Adrenergic blockers

Corticosteroids
Diuretics
Diazoxide
Pentamidine
Protease inhibitors
Cyclosporine

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Drugs that can decrease


blood glucose level

2-Agonists, -Adrenergic blockers

Disopyramide
Ethanol
Pentamidine:occurs days to 2 weeks
after initiation of therapy
SU, Insulin

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Case 1

Ny HT, 58 th, 65 kg, TB150 cm


PC: unconscious, ascites, RBG 75
mg/dl
RP: DM 15 th
RO: Metformin 3 x 500 mg,
Glibenclamide 1-1-0
Dx: Hypoglycemia + CH

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Case 2

Tn H, 59 th, 50 kg TB 163 cm
MRS dengan DM Hiperglikemi, luka di kaki
yang kotor. Obat DM yang terakhir diminum
adalah Glucodex 1-1-0, metformin 3x850mg
disertai riwayat hipertensi yang terkontrol dg
Diltiazem 3 x 30 mg; Captoril 3x25mg,
Aspirin1x100mg
BP: 170/110 mmHg, GDA 529 mg/dl
Apa rencana farmasis?
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Online Resources

Texas Diabetes
Council:www.tdctoolkit.org/algorith
ms-guidelines/
ADA
NDEP

Summary

Managing diabetes and hyperglycemia


during hospitalization is vital for optimal
clinical outcomes.
Insulin is the best treatment for inpatient
management but can be very challenging
given the stress of illness, frequently
changing caloric intake throughout the
hospital stay, and limitations to care
provided by hospital personnel.