Management of Inpatient Type 2 Diabetes

Nathan R. Harmon, D.O.

Goals
Review ADA goals for blood glucose levels Importance of maintaining euglycemia Discuss why ISS is not acceptable for sole coverage Give options for insulin regimens Discuss inpatient education Discharge planning

Why are we concerned?

Prevalence of DM-2 in the U.S. increased by >55% from 1990 to 2000 Estimated 1 in 3 people born in the year 2000 will develop DM-2 in their lifetime Diabetes as a financial epidemic
Length of stay Long term complications

Sliding Scale Insulin

Studies have shown that:
Sole SSI coverage in the inpatient setting leads to:
Increased hyerglycemic and hypoglycemic episodes Increased length of stay

Improved BG control decreases mortality in

Critically ill patients (ICU) Acute MI patients

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

Goals of Treatment
Safety
The fear of HYPOglycemia is a barrier to adequate care BUT HYPOglycemia is a major safety issue As orders become more complex, the risk of error increases
Need for protocols and system based approaches

Goals of Treatment
Glycemic Control upper limits
Intensive Care 110 mg/dL Non-Critical Care
Preprandial 110 mg/dL Post-Prandial / MAX 180 mg/dl
American College of Endocrinology. Position Statement on Inpatient Diabetes and Metabolic Control. Endocr Pract 2004; 10:77-82

Barriers to Reaching Goals

Staffing Timing of meals Education
Staff Patients

Discharge Planning

Assessing the Diabetic Patient

History
Current medications recent changes
Insulin time of day, relation to meals Orals relation to meals COMPLIANCE???? Other medication which may affect control (B-blockers, Steroids) History of episodes of hypoglycemia

Diet
Caloric intake Are they counting calories? Do they eat a regular diet?

Assessing the Diabetic Patient

Physical Exam
Vital Signs
Weight for insulin calculations

Retinopathy Neuropathy

Labs
HgA1c Renal function

Inpatient Monitoring
Bedside glucose monitoring
At least QID (before meals and at HS) May obtain 3AM level If pt NPO check every 6 hours Continuous tube feedings check q 6 hours Bolus tube feedings check pre-feeding and 2 hours post- PM feeding (post prandial)

Inpatient Monitoring
Understand how your orders are followed
QID Accuchecks
Done at 600, 1100, 1600 and 2100 unless otherwise specified

Insulin Dosing
With meals 0800, 1200, 1700 HS = 2100

Inpatient Glycemic Management

Oral Medications
Generally not adequate for sole treatment May need to hold oral medications (see individual medications) Do not use if NPO or eating poorly

Biguanides (Metformin)
MOA: Decreases hepatic glucose output / increases peripheral glucose uptake Pros: May facilitate weight loss, does not cause hypoglycemia Cons:
Lactic Acidosis
Contrast media

Sulfonylureas
MOA: Close ATP / K+ channel in the Bcell Insulin release Cons:
Can cause hypoglycemia Metabolism affected by Renal / Hepatic impairment Glyburide should be avoided
Renal Insufficiency Blocks Ischemic Preconditioning

Thiazolidinediones (TZDs)
MAO: Enhance peripheral insulin sensitivity Cons:
Concerns for increased fluid retention Should not be used in setting of Hepatic Impairment

Other Oral Agents

Meglitinides and Alpha-Glucosidase Inhibitors
Not well studied in the inpatient setting Potential for hypoglycemia is low Mainly act by affecting post-prandial glycemic levels, thus role in patient with reduced PO or NPO is limited.

Inpatient Insulin Management

Review History
Dietary habits Usual weight HgA1C History of episodes of Hypoglycemia

Inpatient Insulin Management

Insulin Regimens where to START

History -- home dosing? Weight based dosing (SQ administration)
Type 2 DM
0.3-0.6 Units/kg/day for most patients 0.6 to 1.0 Units/kg/day if insulin resistant IF NPO, cut dose in half, and do not use Ultrashort acting Insulin

You have the dose, now where to go?

How many times per day?
Once daily (ie Lantus) generally not adequate Twice daily
2/3 Total in AM (preprandial), of which 2/3 NPH and 1/3 regular (a good place for 70/30 mix) 1/3 in PM (before evening meal), of which 50% NPH and 50% regular A 70 kg man dosed at 0.5 Units/kg/day would get
AM 16 Units NPH, 8 Units Regular PM 6 Units NPH , 6 Units Regular

Twice Daily Dosing

Three Times per day

Generally not used if NPO Useful if experiencing fasting hyperglycemia 2/3 in AM, of which 2/3 NPH, 1/3 Regular 1/6 before evening meal, all Regular 1/6 as NPH at bedtime 70 kg patient at 0.5 Units/kg/day
24 Units in AM; 16 NPH, 8 Regular 6 Units Regular before evening meal 6 Units NPH at bedtime

Three Times per day

Four Times per day

Two options NPH and Regular
of total daily dose as Regular before Breakfast, Lunch and Dinner of total daily dose as NPH before bedtime

Ultra Short and Long (peakless) Acting

1/6 of total daily dose as Ultra short before Breakfast, Lunch and Dinner (3 x 1/6 = 3/6 = 50% of total daily dose) 1/2 (50%) of total daily dose given as long acting (ie Lantus) before bedtime.

Four Times per day

Which One to Use?

Things to remember
Insulin Nave or Resistant? Hx of Hypoglycemic Episodes Home dose? Patient NPO? Dont use TID or Ultra short Easy of administration and management

Adding a sliding scale (what?)

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

Adding a sliding scale

Different Methods
Based on a % of the Total Daily Schedule Insulin Based on Insulin Resistance

Adding a Sliding Scale

5% of the Total Daily Scheduled Insulin (eg pt requiring 100 Units per day)
70- 150 151-200 201-250 251-300 Etc. Schedule only 5 Units (ie 5% of 100) 10 Units 15 Units

Adding a sliding scale

<= 40 Units per day Pre-Meal BG 150-199 200-249 250-299 300-349 >349 40-80 Units per day > 80 Units per day Additiona l Units 2 4 7 10 12 Additiona Pre-Meal l Units BG 1 2 3 4 5 150-199 200-249 250-299 300-349 >349 Additiona Pre-Meal l Units BG 1 3 5 7 8 150-199 200-249 250-299 300-349 >349

Case Example
70 y/o WM Hx of CAD, COPD, DM-2, HTN and obesity Admitted for Recurrent Pneumonia Current Meds: Metoprolol, Metformin 1000mg BID, Glyburide 5 mg daily, ASA, Lisinopril VS T 100.1, B/P 150/90, P 90, RR 24, Wt 250 lbs, Ht 58 Physical: Early peripheral neuropathy, no retinopathy LABS: WBC 15K, BG 250, HgA1c (3 months ago) 8.2 Cr 1.4 (baseline), BUN 28, Alb 2.7

Case continued
History what else do you want to know?
Diet at home I eat whatever I want! Recent change in medications? Glyburide was just added one month ago Hx of hypoglycemic episodes? NO Medication Compliance? I take whatever the give me Recent BG at home? When does he check? Creatinine Clearance?

ORDERS
Meds to stop BG monitoring Insulin orders
Wt in Kg Insulin Dosing
Insulin resistant vs. Insulin Naive? QID dosing

Sliding scale

Four Times per day

Two options NPH and Regular
of total daily dose as Regular before Breakfast, Lunch and Dinner of total daily dose as NPH before bedtime

Ultra Short and Long (peakless) Acting

1/6 of total daily dose as Ultra short before Breakfast, Lunch and Dinner (3 x 1/6 = 3/6 = 50% of total daily dose) 1/2 (50%) of total daily dose given as long acting (ie Lantus) before bedtime.

ORDERS
250 lb = 114 kg Total Daily Dose of Insulin
114kg x 0.3 Units/kg/Day = 34 Units/Day

QID (Lantus and Lispro)

5.6 5 Units Lispro before each meal 17 Units Lantus at HS

Sliding Scale 5% of total daily dose as a scale

Adding a Sliding Scale

5% of the Total Daily Scheduled Insulin (eg pt requiring 34 Units per day)
70- 150 150-200 201-250 251-300 Etc. Schedule only 1.7->2 Units (ie 5% of 34) 4 Units 6 Units

Goals of Treatment
Glycemic Control upper limits
Intensive Care 110 mg/dL Non-Critical Care
Preprandial 110 mg/dL Post-Prandial / MAX 180 mg/dl
American College of Endocrinology. Position Statement on Inpatient Diabetes and Metabolic Control. Endocr Pract 2004; 10:77-82

Diabetes as an Active Issue

Which dose would you change if: His AM fasting glucose was 250? His 11 AM sugar is 250?
Rapid Acting: 1800/TDD = drop in BG (mg/dL) per Unit of short acting insulin given
To drop the 11 AM sugar to 180, you would give: 1800/34 = 70/x x = (70x34)/1800 = 1.3 Units

Regular: 1500/TDD = drop in BG (mg/dL) per Unit of regular insulin given

Four Times per day

A Word On Dietary Orders

ADA Diet is a misnomer Caloric Restriction vs. Consistent Carbohydrate Method Caloric Needs
Avg hospitalized pt: 25-35 kcal/kg/day 1.0-1.5 g/kg of protein (unless Hepatic/Renal insufficiency)

A Word On Dietary Orders

Clear or Full Liquid Diets
At least 200g of Carbohydrates divided in equal doses

Low or no sugar diets are not acceptable Prompt Dietary consultation is recommended Remember D/C planning

Inpatient Education
Let your patient know what you have changed Educate on Symptoms of hypoglycemia Dietary Consultation Insulin education if new or different dose Close f/u as out-patient

D/C Planning
Try to have the patient on what will be his home medications / diet for at least 24 hours prior to D/C Close out-pt f/u Referral to Diabetes and Nutrition
Any admission with diabetes as an active issue qualifies Medicare for referral.

Goals
Review ADA goals for blood glucose levels Importance of maintaining euglycemia Discuss why ISS is not acceptable for sole coverage Give options for insulin regimens Discuss inpatient education Discharge planning

References
Abourizk, N., Inpatient Diabetology:The New Frontier, Journal General Internal Medicine, 19:466-471 American Diabetes Association, Translation of the Diabetes Nutrition Recommendations for Health Care Institutions, Diabetes Care 25: S1, S61-63 American Diabetes Association, American College of Endocrinology and American Diabetes Association Consensus Statement on Inpatient Diabetes and Glycemic Control, Diabetes Care, 29:1955-1962, 2006. Bloomgarden, Z., Inpatient Diabetes Control: Approaches to Treatment, Diabetes Care, 27:9, 2272-2277 Lien, L. In-hospital Management of Type 2 Diabetes Mellitus, Med Clin N Am, 88 (2004): 1085-1105 Moghissi, E, et. al, Hospital Management of Diabetes, Endocrinol Metab Clin N Am, 34 (2005): 99-116 Swift, C, et. al, Nutrition Care For Hospitalized Individuals with Diabetes, Diabetes Spectrum 18:1, 34-38