Professional Documents
Culture Documents
31%
History of diabetes
No history of diabetes
69%
50 Diabetes 50 No Diabetes
40 40 26%
78%
Patients,
30 30
%
20 20
10 10
0 0
<110 110-140 140-170 170-200 >200 <110 110-140 140-170 170-200 >200
~4x
45 ~3x
40
~2x
Mortality Rate (%)
35
30
25
20
15
10
5
0
80-99 100-119 120-139 140-159 160-179 180-199 200-249 250-299 >300
Patient Patient
Centered Safety
TEAM WORK
Managing Diabetes in the Hospital Presents Different
Challenges than Managing Diabetes in the Outpatient.
Umpierrez et al. Journal of Clinical Endocrinology and Metabolism 2002; 87: 978-82.
Hyperglycemia is Undesirable!
(Diabetes Care 2004; 27: 553-91, Endocrine Practice 2004; 10: 77-82, and
Diabetes Care 2006; 29: 1955-62)
Hyperglycemia and Poor Hospital Outcome
Metabolic stress response
Glucose
Insulin
Reactive O2 species
Immune dysfunction
FFA
Transcription factors
Ketones
Lactate
Infection dissemination Secondary mediators
Cellular injury/apoptosis
Inflammation
Tissue damage
Altered tissue wound repair
Slow-acting/difficult to titrate
Disadvantages of insulin secretagogues (e.g.
sulfonylureas and meglitinides such as glyburide,
glypizide, repaglinide, etc.):
Hypoglycemia if caloric intake is reduced
Some are long-acting (hypoglycemia may be prolonged)
Disadvantages of metformin:
Lactic acidosis can occur when used in the setting of renal
dysfunction, circulatory compromise, or hypoxemia
Slow onset of action
GI complications: Nausea, diarrhea
Oral Antidiabetes Agents in the Hospital,
continued
Controversial!
NonICU setting:
Premeal glucose targets <140 mg/dL
Random BG <180 mg/dL
To avoid hypoglycemia, reassess insulin regimen if
BG levels fall below 100 mg/dL
Occasional patients may be maintained with a glucose range
below and/or above these cut-points
Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4).
http://www.aace.com/pub/pdf/guidelines/InpatientGlycemicControlConsensusStatement.pdf
Selecting a Non-ICU Glycemic Target For Your
Practice/Institution
90-150 mg/dL
Pre-prandial target 90-130 mg/dL; Random glucose < 180 mg/dL
Pre-prandial target 80-130 mg/dL for most patients; pre-prandial
target 90-150 mg/dL for patients with hypoglycemia risk factors
Current Practice Best Practice
Dependence on non-physiologic insulin prescribing (as
opposed to insulin that mimics physiologic insulin
secretion)
Dependence on reactive strategies (e.g. sliding-scale
insulin)
Overemphasis on simplicity (particularly simplicity
from the perspective of the ordering physician)
Overemphasis on avoidance of hypoglycemia
Lack of standardization of insulin use in the hospital
What is the Best Practice for Managing Diabetes and
Hyperglycemia in the Hospital?
anticipatory
physiologic insulin dosing
prescribed as a basal/bolus insulin regimen
Nutritional Correctional
Basal insulin
insulin insulin
Physiologic Insulin Secretion:
Basal/Bolus Concept
Nutritional (Prandial) Insulin
50
(U/mL)
Insulin
25 Suppresses Glucose
Production Between
0 Basal Insulin Meals & Overnight
Breakfast Lunch Supper
Regular
Lispro (Humalog)
Aspart (Novolog)
Glulisine (Apidra)
Inhaled insulin
0 6 12 18 24
Time (hours)
Providing Exogenous Nutritional Insulin
Regular
Lispro (Humalog)
Aspart (Novolog)
Glulisine (Apidra)
Inhaled insulin
0 6 12 18 24
Time (hours)
Providing Exogenous Correctional Insulin
Correctional insulin is extra insulin that is given to correct
hyperglycemia
Weight-based estimate:
TDD = 0.4 units x Wt in Kg
NPO
STEP 3: Decide Which Components of
Insulin the Patient Will Require, and Which Percentage of
the TDD Each Should Represent
- Weight: 100 kg
- Home medical regimen: Glipizide 10 mg po qd, Metformin
1000 mg po bid, and 20 units of NPH q HS
- Control: A recent HbA1c is 10%, POC glucose in ED 240 mg/dL
What are your initial orders for basal and nutritional insulin?
How would you manage the oral agents?
Case 1: Solution
Bedside glucose testing AC and HS
Discontinue oral agents
Total daily dose 100 kg x 0.6 units/kg/day = 60
Patient education
Changes made in the hospital
Diabetes/insulin survival skills
Protocols