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Management of Inpatient Type 2 Diabetes

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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 ... – PowerPoint PPT presentation

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Title: Management of Inpatient Type 2 Diabetes


1
Management of Inpatient Type 2 Diabetes
  • Nathan R. Harmon, D.O.

2
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

3
Why are we concerned?
  • Prevalence of DM-2 in the U.S. increased by gt55
    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

4
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

5
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

6
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

7
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 1077-82

8
Barriers to Reaching Goals
  • Staffing
  • Timing of meals
  • Education
  • Staff
  • Patients
  • Discharge Planning

9
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?

10
Assessing the Diabetic Patient
  • Physical Exam
  • Vital Signs
  • Weight for insulin calculations
  • Retinopathy
  • Neuropathy
  • Labs
  • HgA1c
  • Renal function

11
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)

12
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

13
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

14
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

15
Sulfonylureas
  • MOA Close ATP / K channel in the B-cell
    ?Insulin release
  • Cons
  • Can cause hypoglycemia
  • Metabolism affected by Renal / Hepatic impairment
  • Glyburide should be avoided
  • Renal Insufficiency
  • Blocks Ischemic Preconditioning

16
Thiazolidinediones (TZDs)
  • MAO Enhance peripheral insulin sensitivity
  • Cons
  • Concerns for increased fluid retention
  • Should not be used in setting of Hepatic
    Impairment

17
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.

18
Inpatient Insulin Management
  • Review History
  • Dietary habits
  • Usual weight
  • HgA1C
  • History of episodes of Hypoglycemia

19
Inpatient Insulin Management
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24
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
    Ultra-short acting Insulin

25
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

26
Twice Daily Dosing
27
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

28
Three Times per day
29
Four Times per day
  • Two options
  • NPH and Regular
  • ¼ of total daily dose as Regular before
    Breakfast, Lunch and Dinner
  • ¼ 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.

30
Four Times per day
31
Which One to Use?
  • Things to remember
  • Insulin Naïve or Resistant?
  • Hx of Hypoglycemic Episodes
  • Home dose?
  • Patient NPO? Dont use TID or Ultra short
  • Easy of administration and management

32
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34
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

35
Adding a sliding scale
  • Different Methods
  • Based on a of the Total Daily Schedule Insulin
  • Based on Insulin Resistance

36
Adding a Sliding Scale
  • 5 of the Total Daily Scheduled Insulin (eg pt
    requiring 100 Units per day)
  • 70- 150 Schedule only
  • 151-200 5 Units (ie 5 of 100)
  • 201-250 10 Units
  • 251-300 15 Units
  • Etc.

37
Adding a sliding scalelt 40 Units per day 40-80
Units per day gt 80 Units per day
38
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

39
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?

40
ORDERS
  • Meds to stop
  • BG monitoring
  • Insulin orders
  • Wt in Kg
  • Insulin Dosing
  • Insulin resistant vs. Insulin Naive?
  • QID dosing
  • Sliding scale

41
Four Times per day
  • Two options
  • NPH and Regular
  • ¼ of total daily dose as Regular before
    Breakfast, Lunch and Dinner
  • ¼ 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.

42
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

43
Adding a Sliding Scale
  • 5 of the Total Daily Scheduled Insulin (eg pt
    requiring 34 Units per day)
  • 70- 150 Schedule only
  • 150-200 1.7-gt2 Units (ie 5 of 34)
  • 201-250 4 Units
  • 251-300 6 Units
  • Etc.

44
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 1077-82

45
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

46
Four Times per day
47
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)

48
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

49
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

50
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.

51
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

52
References
  • Abourizk, N., Inpatient DiabetologyThe New
    Frontier, Journal General Internal Medicine,
    19466-471
  • 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,
    291955-1962, 2006.
  • Bloomgarden, Z., Inpatient Diabetes Control
    Approaches to Treatment, Diabetes Care, 279,
    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
    181, 34-38
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