DIABETIC MANAGEMENT UPDATE :

HOSPITALYZED TO DAILY CARE

Supriyanto Kartodarsono

Endocrinology Division
Internal Medicine Department
Faculty of Medicine Sebelas Maret University/
Moewardi General Hospital
Surakarta

1
RECOGNITION AND DIAGNOSIS OF
HYPERGLYCEMIA IN NONCRITICALLY ILL
HOSPITALIZED PATIENTS

2
 Number of US Hospital Discharges With
Diabetes as Any-Listed Diagnosis

196.4%

From 1988 to 2009, the number of hospital discharges with diabetes as any-listed
diagnosis increased from 2.8 million to nearly 5.5 million.

CDCP. Diabetes Data and Trends. Available at: http://www.cdc.gov/diabetes/statistics/dmany/fig1.htm. 3

 Distribution of Patient-Day-Weighted
Mean POC-BG Values for ICU

~12 million BG readings from 653,359 ICU patients; mean POC-BG: 167 mg/dL.
Swanson CM, et al. Endocr Pract. 2011;17:853-861. 4
 Recognition and Diagnosis
of Hyperglycemia and Diabetes
in the Hospital Setting
All patients
History of diabetes
Test BG
Patients without a history of diabetes
BG >140 mg/dL: Monitor with POC testing for 24-48 h
BG >140 mg/dL: Ongoing POC testing
Patients receiving therapies associated with
hyperglycemia (eg, corticosteroids): monitor with POC
testing for 24-48 h
BG >140 mg/dL: continue POC testing for duration of hospital
stay
Patients with known diabetes or with hyperglycemia
Test A1C if no A1C value is available from past 2-3 months
BG, blood glucose; POC, point of care.
Moghissi ES, et al. Endocrine Pract. 2009;15:353-369.
Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 5
 Recognition and Diagnosis
of Hyperglycemia and Diabetes
in the Hospital Setting
Upon admission
Assess all patients for a history of diabetes
Obtain laboratory blood glucose testing

No history of diabetes No history of diabetes History of diabetes

BG <140 mg/dL BG >140 mg/dL
(7.8 mmol/L)

Start POC
Initiate POC BG BG monitoring
BG monitoring x 24-48 h
monitoring according Check A1C
to clinical status

A1C 6.5%
BG, blood glucose; POC, point of care.
Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 6
 A1C for Diagnosis of Diabetes
in the Hospital
Implementation of A1C testing can be useful
Assist : diabetes VS stress hyperglycemia
Assess glycemic control prior to admission
Facilitate design of an optimal regimen at the time of
discharge
A1C >6.5% indicates diabetes

Moghissi ES, et al. Endocrine Pract. 2009;15:353-369.

Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 7
8
GLYCEMIC GOALS FOR
NONCRITICALLY ILL PATIENTS

9
 Inpatient Glycemic Management:
Definition of Terms

Hospital hyperglycemia Any BG >140 mg/dL

Elevations in blood glucose levels that occur in patients with no

Stress hyperglycemia prior history of diabetes and A1C levels that are not significantly
elevated (<6.5%)

A1C value >6.5% Suggestive of prior history of diabetes

Hypoglycemia Any BG <70 mg/dL

Severe hypoglycemia Any BG <40 mg/dL

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 Glycemic Targets in Noncritical Care
Setting
Maintain fasting and preprandial BG <140 mg/dL
Modify therapy when BG <100 mg/dL to avoid
risk of hypoglycemia
Maintain random BG <180 mg/dL
More stringent targets may be appropriate in
stable patients with previous tight glycemic
control
Less stringent targets may be appropriate in
terminally ill patients or in patients with severe
comorbidities
Moghissi ES, et al. Endocrine Pract. 2009;15:353-369.
Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 11
Glucose Monitoring
ACHIEVING GLYCEMIC GOALS IN THE
NONCRITICALLY ILL WHILE MINIMIZING
HYPOGLYCEMIA RISK

12
 Monitoring Glycemia in the Noncritical
Care Setting
POC testing
Preferred method for guiding ongoing glycemic
management of individual patients
Use BG monitoring devices with demonstrated accuracy in
acutely ill patients
Timing of glucose measures should match patients
nutritional intake and medication regimen
Recommended schedules for POC testing
Before meals and at bedtime in patients who are eating
Every 4-6 h in patients who are NPO or receiving
continuous enteral feeding
BG, blood glucose; POC, point of care.
Moghissi ES, et al. Endocrine Pract. 2009;15:353-369.
Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 13
 Pharmacological Treatment of
Hyperglycemia in Non-ICU Setting

Antihyperglycemic Therapy

OADs
SC Insulin Not generally
recommended
Recommended for most
medical-surgical patients
Continuous IV Infusion
Selected medical-surgical
patients

Moghissi ES, et al. Endocrine Pract. 2009;15:353-369.

Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38.
Smiley D, et al. J Hosp Med. 2010;5:212-217. 14
 Glycemic Management Strategies
in Noncritically Ill Patients
Insulin therapy preferred regardless of type of
diabetes
Discontinue noninsulin agents at hospital admission of
most patients with type 2 diabetes with acute illness
Use scheduled SC insulin with basal, nutritional, and
correction components
Modify insulin dose in patients treated with insulin before
admission to reduce risk for hypoglycemia and
hyperglycemia
Avoid prolonged therapy with sliding scale insulin
alone
Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 15
 Noninsulin Therapies in the Hospital

Time-action profiles of oral agents can result in delayed

achievement of target glucose ranges in hospitalized patients
Sulfonylureas are a major cause of prolonged hypoglycemia
Metformin is contraindicated in patients with decreased renal
function, use of iodinated contrast dye, and any state
associated with poor tissue perfusion (CHF, sepsis)
Thiazolidinediones are associated with edema and CHF
-Glucosidase inhibitors are weak glucose-lowering agents
Pramlintide and GLP-1 receptor agonists can cause nausea
and exert a greater effect on postprandial glucose
DPP4 inhibitors may provide safe and effective blood glucose
control when used alone or in combination with basal insulin
Insulin therapy is the preferred approach
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 Subcutaneous Insulin Options

Controls blood glucose in the fasting state

Basal insulin
Detemir (Levemir), glargine (Lantus), NPH
Blunts the rise in blood glucose following nutritional
intake (meals, IV dextrose, enteral/parenteral nutrition)
Nutritional
Rapid-acting: aspart (NovoLog), glulisine (Apidra),
(prandial) insulin
lispro (Humalog)
Short-acting: regular (Humulin, Novolin)
Corrects hyperglycemia due to mismatch of nutritional
Correction insulin intake and/or illness-related factors and scheduled insulin
administration

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Initiating Insulin Therapy in the Hospital
Obtain patient weight in kg

Calculate total daily dose (TDD)

as 0.2-0.4 units per kg/day

Choose the dosing schedule

Give 50%-60% of TDD as basal insulin
Give 40%-50% of TDD as nutritional insulin
Use correction insulin for BG above goal range

Adjust according to results of bedside glucose monitoring

Adjust dose for NPO status or changes in clinical status
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 Insulin Therapy in Patients With
Type 2 Diabetes
Discontinue noninsulin agents on admission
Insulin nave: starting total daily dose (TDD):
0.3 U/kg to 0.5 U/kg
Lower doses in the elderly and patients with renal
insufficiency
Previous insulin therapy: reduce outpatient
insulin dose by 20%-25%
Half of TDD as basal insulin given at the same
time of day and half as rapid-acting insulin in
3 equally divided doses (AC)
Umpierrez GE, et al. Diabetes Care. 2007;30:2181-2186. 19
 Pharmacokinetics of Insulin Preparations
Insulin Onset Peak Duration
Nutritional
Rapid-acting analog 5-15 min 1-2 hours 4-6 hours
(aspart, glulisine, lispro)
Regular 30-60 min 2-3 hours 6-10 hours
Basal
Degludec 1 hour Relatively peakless >42 hours
Detemir U100 2 hours Relatively peakless 16-24 hours
Detemir U200 2 hours Relatively peakless 16-24 hours
Glargine U100 2-4 hours Relatively peakless 20-24 hours
Glargine U300 6 hours Relatively peakless ~32 hours
NPH 2-4 hours 4-10 hours 12-18 hours

Heise T. Diabetes Obes Metab. 2017;19:3-12. Hirsch I. N Engl J Med. 2005;352:174-183. Porcellati F, et al.
Diabetes Care. 2007;30:2447-2552.
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 Pharmacokinetics of Insulin Products

Rapid (lispro, aspart, glulisine)

Insulin
Level Short (regular)

Intermediate (NPH)
Long (glargine)
Long (detemir)

0 2 4 6 8 10 12 14 16 18 20 22 24
Hours

Adapted from Hirsch I. N Engl J Med. 2005;352:174183. 21

 Basal-Bolus Insulin Therapy in Inpatients
With Type 2 Diabetes (RABBIT 2 Trial)
130 nonsurgical insulin-nave patients age 18-80
with known type 2 diabetes admitted to
noncritical care unit
Randomly assigned to sliding scale insulin (SSI)
or a basal-bolus regimen with glargine and
glulisine
0.4 units per kg/day for BG 140-200
0.5 units per kg /day for BG >200
50% given as glargine and 50% as glulisine
Oral antidiabetic drugs discontinued
2 hypoglycemic events (BG <60 mg/dL) in each
group
Umpierrez GE, et al. Diabetes Care. 2007;30:2181-2186. 22
 Basal-Bolus Insulin Therapy in Inpatients
With Type 2 Diabetes (RABBIT 2 Trial)
Blood Glucose (BG) Concentration Over Time for Both Groups

240 SSRI Basal-bolus

220
Blood Glucose (mg/dL)

200 *
* *
180

160

140

120

100
Admit 1 2 3 4 5 6 7 8 9 10
Days of Therapy
* P<0.01; P<0.05.
SSRI, sliding scale regular insulin.
Umpierrez, et al. Diabetes Care. 2007;30:2181-2186.
23
 Basal-Bolus Insulin Therapy in Inpatients
With Type 2 Diabetes (RABBIT 2 Trial)
Adjusting scheduled insulin regimen
If fasting and premeal BG >140 mg/dL, dose of
glargine increased by 20%
For BG <70 mg/dL, glargine reduced by 20%

Umpierrez GE, et al. Diabetes Care. 2007;30:2181-2186. 24

 Risk Factors for Hypoglycemia

P value
Variable
Univariate Analysis Multivariate Analysis*

Age <0.001 <0.001

GFR <60 mL/s 0.005 0.11
TDD 0.5 U/kg 0.006 0.31
Previous insulin use <0.001 0.02
Insulin regimen
<0.001 0.001
(basal-bolus vs SSI)

* Adjusted for age, total daily insulin dose (TDD) >0.5 U/kg, glomerular filtration rate (GFR) <60 mL/second, insulin regimen
(basal-bolus vs sliding scale insulin [SSI]), and previous insulin therapy.
Farrokhi F, et al. ADA Scientific Sessions. 2011. Abstr. 2060-PO.
25
 Strategies for Reducing Risk
for Hypoglycemia in Noncritical Care
Settings

Avoidance of sliding-scale insulin alone

Use caution in prescribing oral
antihyperglycemic agents
Modify outpatient insulin doses in patients
treated with insulin prior to admission

Braithwaite SS, et al. Endocr Pract. 2004;10(suppl 2):89-99.

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Inpatient Management of Hyperglycemia:
Managing Safety Concerns
Both undertreatment and overtreatment of
hyperglycemia create safety concerns
Areas of risk
Changes in carbohydrate or food intake
Changes in clinical status or medications
Failure to adjust therapy based on BG patterns
Prolonged use of SSI as monotherapy
Poor coordination of BG testing with insulin
administration and meal delivery
Poor communication during patient transfers
Errors in order writing and transcription
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 Strategies for Effective Discharge
Planning for Hospitalized Patients With
Diabetes

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 Discharge Planning Challenges

Pressures to discharge patient early

Shorter hospital stays
Competing priorities
Lack of primary care physician
Nursing workload
Lack of diabetes specialist educator
Weekend discharges

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 Transition From Hospital
to Outpatient Care
Preparation for transition to the outpatient setting
should begin at the time of hospital admission
Multidisciplinary team
Bedside nurse
Clinical pharmacist
Registered dietitian
Case manager
Clear communication with outpatient providers is
critical for ensuring safe and successful
transition to outpatient management

Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 30

 Discharge Considerations

What are your discharge plans for this patient?

Will they be discharged on insulin therapy?
When and where will follow-up take place?
What education do they need prior to discharge?

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 Preadmission Factors to Be Considered
in Discharge Planning
Physical/self-care limitations: blindness, stroke,
amputation, dexterity
Socioeconomic factors: insurance coverage,
family support
Access to follow-up care: PCP, other HCPs
Degree of glycemic control prior to admission
and severity of hyperglycemia
Learning issues: language, cognition,
competence related to diabetes self-
management
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 Relationship Between Inpatient and
Outpatient Diabetes Management

Care received in the

outpatient setting can
affect need for Outpatient
hospitalization
Compliance with glycemic
goals depends on the
patient
Inpatient
Compliance with glycemic Lessons learned
goals depends on in the hospital can
impact patient
physicians, nursing, and self-care behavior
hospital staff at home
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 Predischarge Checklist

Diet information
Monitor/strips and prescription
Prescription for/supplies of medications, insulin,
needles
Treatment goals
Contact phone numbers
Medi-alert bracelet
Survival skills training

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 Nursing + Care Coordination:
Survival Skills to Be Taught Before
Discharge
How and when to take Sick-day management
medication/insulin plan
Effects of medication Date/time of follow-up
How/when to test blood visits
glucose (SMBG) Including diabetes
Target glucose levels education
Meal planning basics When and whom to call
How to treat on the healthcare team
hypoglycemia Available community
resources

Moghissi ES, et al. Endocr Pract. 2009;15:353-369. 35

 Discharge Planning Depending
on Etiology of Hyperglycemia

Inpatient
Temporary Hyperglycemia Previously
Hyperglycemia Undiagnosed
Resolves in hospital Diabetes
Requires follow-up
Plan to confirm
testing
diagnosis, implement
therapy and education

Previously Diagnosed
Diabetes
Assess level of control
Adjust therapy as needed
Assess for complications
Outpatient follow-up
Fonseca V. Endocr Pract. 2006;12(suppl 3):108-111.
Garber A, et al. Endocr Pract. 2004;10:77-82. 36
37
 A1C Is Helpful in Determining
Post-discharge Treatment
Patients Without Previously Diagnosed
A1C Indication Diabetes
6.5% Incipient diabetes
Refer to diabetes educator to begin self-management
education prior to discharge
5.5%-6.4% Increased risk for diabetes
Prior to discharge, address implementation of lifestyle
interventions that promote weight loss and increased
activity

Differentation between hospital-related hyperglycemia and

undiagnosed diabetes requires follow-up testing (FPG, 2-h
OGTT) once patient is metabolically stable using established
criteria
AACE. Endocr Pract. 2011;17(suppl 2):1-53.
ADA. Diabetes Care. 2013;36(suppl 1):S11-S66. 38
 Patients Newly Diagnosed With
Diabetes During Hospitalization
Develop a diabetes education plan prior to hospital
discharge that addresses the following:
Understanding of the diagnosis of diabetes
SMBG and explanation of home blood glucose goals
Definition, recognition, treatment, and prevention of
hyperglycemia and hypoglycemia
Identification of healthcare provider who will provide
diabetes care after discharge
Information on consistent eating patterns
When and how to take medication, including proper
disposal of needles and syringes
Sick-day management

ADA. Diabetes Care. 2013;36(suppl 1):S11-S66.

Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53. 39
 Discharging Patients With
Previously Diagnosed Diabetes
Resume preadmission diabetes regimen at time of
discharge for patients with acceptable preadmission
glycemic control and no contraindication to prior therapy
Modify preadmission therapy for patients identified as
being in poor control
Provide patient and family members/caregivers with
written and oral instructions regarding glycemic
management regimen at time of hospital discharge

Umpierrez GE, et al. J Clin Endocrinol Metab. 2012;97:16-38. 40

 A1C Is Helpful in Determining
Post-discharge Treatment
Patients With Previously Diagnosed
A1C Indication Diabetes
6.5%-7.5% Options:
Increase dose of home noninsulin agents
Add third agent
Add basal insulin at bedtime
7.6%-9.0% If already on 2 noninsulin agents, add once daily basal insuin at
bedtime
9% Discharge home on basal and bolus insulin regimen
May use amount of basal insulin required in hospital as once
daily glargine/detemir or twice daily NPH dose
Continue multiple daily doses as started in the hospital if
appropriate
Twice daily premixed insulin may be considered for less
complex insulin regimens, particularly in elderly patients
Handelsman Y, et al. Endocr Pract. 2011;17(suppl 2):1-53.
Rodbard HW, et al. Endocr Pract. 2009;15:540-559. 41
 A1C 6.5%-7.5%** A1C 7.6%-9.0% A1C >9.0%
Drug Naive Under Treatment

Symptoms No Symptoms

Monotherapy Dual Therapy8

MET DPP41 GLP-1 TZD2 AGI3 GLP-1
GLP-1 or DPP41
or DPP41 SU7
or TZD2 INSULIN INSULIN
2-3 Mos.*** MET +
+ TZD2
Other MET Other
SU or Glinide4,5 Agent(s)6 Agent(s)6
Dual Therapy GLP-1
TZD2
1 *** or DPP41
GLP-1 or DPP4 2-3 Mos.
MET + TZD2
Triple Therapy 9 * May not be appropriate for all patients
Glinide or SU5
** For patients with diabetes and A1C <6.5%,
TZD + GLP-1 or DPP41 GLP-1 pharmacologic Rx may be considered
+ TZD2
or DPP41 *** If A1C goal not achieved safely
Colesevelam Preferred initial agent
MET + MET + GLP-1 AACE/ACE Algorithm for Glycemic 1 DPP4 if PPG and FPG or GLP-1 if PPG
AGI3 Control Committee
or DPP41 + SU7
2 TZD if metabolic syndrome and/or
*** Cochairpersons: nonalcoholic fatty liver disease (NAFLD)
2-3 Mos. TZD 2 Helena W. Rodbard, MD, FACP, MACE 3 AGI if PPG
Paul S. Jellinger, MD, MACE 4 Glinide if PPG or SU if FPG
Triple Therapy
*** Zachary T. Bloomgarden, MD, FACE 5 Low-dose secretagogue recommended
2-3 Mos. Jaime A. Davidson, MD, FACP, MACE
MET + TZD2 6 a) Discontinue insulin secretagogue
Daniel Einhorn, MD, FACP, FACE with multidose insulin
GLP-1 or + Alan J. Garber, MD, PhD, FACE b) Can use pramlintide with prandial insulin
DPP4 1 Glinide or SU4,7 James R. Gavin III, MD, PhD
7 Decrease secretagogue by 50% when added
INSULIN George Grunberger, MD, FACP, FACE
to GLP-1 or DPP-4
*** Yehuda Handelsman, MD, FACP, FACE
2 - 3 Mos. Other
Edward S. Horton, MD, FACE 8 If A1C <8.5%, combination Rx with agents
Agent(s)6 Harold Lebovitz, MD, FACE that cause hypoglycemia should be used
Philip Levy, MD, MACE with caution
Etie S. Moghissi, MD, FACP, FACE 9 If A1C >8.5%, in patients on dual therapy,
INSULIN
Stanley S. Schwartz, MD, FACE insulin should be considered
Other
Agent(s)6
42
AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE.
Benefits are classified according to major effects on fasting glucose, postprandial glucose, and nonalcoholic fatty liver disease (NAFLD). Eight
broad categories of risks are summarized. The intensity of the background shading of the cells reflects relative importance of the benefit or risk.*

* The abbreviations used here correspond to those used on the algorithm (Fig. 1).
43
** The term glinide includes both repaglinide and nateglinide. AACE December 2009 Update. May not be reproduced in any form without express written permission from AACE
 Recommended Educational Strategies
for Inpatients Prior to and at Discharge
Begin education on day 1 or as soon as the patient is
able to participate
Initiate inpatient diabetes educator consult as early as
possible
Nursing to reinforce the education as many times as
possible utilizing every opportunity (medications, BG
result, diet, etc.)
Involve family members whenever appropriate
Provide education materials to reinforce teachings and
provide community and Web resource lists
Continue education on an outpatient basis if needed by
referring through appropriate channels
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 Continuum of Care:
Patients New to Insulin
Refer to an outpatient diabetes education program
shortly after discharge to discuss ongoing diabetes
control
Provide discharge information
When to check BG
Timing of insulin administration
When to call PCP (eg, symptoms of hypoglycemia)
Communicate with patients PCP
Changes made to patients treatment regimen during
hospitalization
Complete medication list
Assess need for home health care
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 Timely Discharge Information Required
by the Receiving PCP
Primary and secondary diagnoses and
diagnostic findings
Dates of hospitalization, treatment provided, and
a summary of hospital course
Discharge medications
Patient or family counseling
Tests pending at discharge
Details of follow-up arrangements
Name and contact information of the responsible
hospital physician
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 Summary

Target BG: 140-180 mg/dL for most noncritically

ill patients
Insulin therapy preferred method of glycemic
control in the hospital
Scheduled SC basal-bolus insulin therapy is effective
and safe for treatment of hyperglycemia in
noncritically ill patients
Sliding scale regular insulin alone is inappropriate
once an insulin requirement is established

47
 Summary
Discharge Checklist for Patients with Inpatient
Hyperglycemia
Patients need for diabetes education has been
assessed (preferably upon admission)
Patient has received the necessary skills and training
Patient is provided with post-discharge plan for diabetes
Patient has received clear instructions about medications
Name
Dosage
When to take them
Patient has a scheduled follow-up appointment at time of
discharge
Written documentation for PCP is completed at time of
discharge

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