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Correction Insulin for Inpatient Hyperglycemia

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Many more patients will be initiated on insulin therapy When to pursue insulin therapy All DM I Most DM II receiving medication treatment Uncontrolled ... – PowerPoint PPT presentation

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Title: Correction Insulin for Inpatient Hyperglycemia


1
Correction Insulin for Inpatient Hyperglycemia
  • Estelle Lin
  • June 2012

2
Case Vignette
  • 45 year old obese female with DM type II is
    admitted for acute nausea, vomiting, and
    epigastric pain. CT Abdomen with IV contrast
    demonstrates acute pancreatitis. Her diabetes is
    usually controlled on metformin 1000mg BID and
    glyburide 10mg BID. Admission BMP shows a random
    glucose of 240. How do you manage her
    hyperglycemia?
  • A. Continue home regimen
  • Continue home glyburide and discontinue
    metformin
  • Start sliding scale insulin
  • Start correction insulin

3
Learning Objectives
  • Appreciate difference between sliding scale
    insulin vs correction insulin
  • Understand optimal glycemic control goals in ICU
    vs non ICU settings
  • Review the pharmacokinetics of different insulin
    preparations
  • Learn how to use correction insulin and initiate
    insulin therapy on UCI wards

4
The problem with sliding scale insulin
Typical day battling hyperglycemia
Time 0700 Break- fast 0800 1200 Lunch 1300 1700 Dinner 1800 2100
Blood Glucose 275 350 400 250
Sliding scale 6 units 10 units 12 units 6 units
  • Sliding Scale Insulin
  • - Treats hyperglycemia with only short/rapid
    acting insulin without long-acting basal insulin
  • Reactive therapy given AFTER meal
  • Treats current hyperglycemia, does not prevent
    future hyperglycemia
  • Can cause large swings in glucose levels
    throughout day

5
Correction Insulin
  • Correction Insulin
  • It is both a concept AND includes a correction
    scale insulin
  • Treats current hyperglycemia with the goal of
    preventing further hyperglycemic events during
    the hospital course
  • Administer correction scale insulin BEFORE the
    meal using a rapid or short acting insulin
  • For patients already receiving scheduled rapid
    acting insulin AND scheduled long acting insulin,
    this is an additional correction scale to treat
    hyperglycemia
  • For patients whose primary oral
    anti-hyperglycemic therapy has been discontinued,
    this is the initiation of a correction scale to
    control hyperglycemia and if needed, the
    initiation of long acting insulin

6
A better day when using correction insulin
Time 0700 EAT 0800 1200 EAT 1300 1700 EAT 1800 2100
Blood Glucose 170 275 210 350 250 400 250
Sliding Scale 6 10 12 6
Correct-ion Scale 2 units 4 units 6 units 6 units
Sliding scale 34 units of rapid/short acting
insulin administered Correction scale 18 units
of rapid/short acting insulin Remember, it is
the concept of correction insulin we want to
practice. If this patient remains
hyperglycemic, initiate longer acting insulin
therapy
7
AACE/ADA Consensus Statement on Management of
Inpatient Hyperglycemia
BG goals Avoid Tips
MICU 140-180 lt110 If gt180, initiate IV short acting insulin
General Wards Pre-meal lt140 Random lt180 lt100 In glucocorticoid therapy, initiate accuchecks for 48 hours and then initiate insulin therapy as appropriate Avoid routine use of corrective insulin at bedtime unless continuous nutrition/TPN
8
  • Rapid (Prandial,
  • Bolus)
  • Short (Prandial,
  • Bolus)
  • Intermediate
  • (Basal)
  • Long
  • (Basal)

9
Correction Insulin Tips
Start with If uncontrolled add
On insulin at home (DM I, some DM II) NPO Home basal insulin Correctional scale insulin
On insulin at home (DM I, some DM II) Eating Home basal insulin (reduce 50) Home prandial insulin (reduce doses by 25-50) Correctional scale insulin
Not on insulin (pre-DM, DM II) NPO Stop all oral anti-hyperglycemics. Start correctional scale Basal insulin
Not on insulin (pre-DM, DM II) Eating Cautiously use oral anti-hyperglycemics OR Start basal, prandial, AND correctional scale insulin Basal insulin Prandial insulin Correctional scale
10
Current UCI Glycemic Monitoring Protocol
  • UCI is aggressively pursuing the concept of
    correction insulin and preventing hyperglycemia.
    Many more patients will be initiated on insulin
    therapy
  • When to pursue insulin therapy
  • All DM I
  • Most DM II receiving medication treatment
  • Uncontrolled hyperglycemia gt 180 (2 episodes in
    24 hours)
  • If unsure, then monitor qAC/qHS glucose
    monitoring for 24 hours and then continue if BG gt
    180

11
How to Initiate Insulin Therapy (if not already
on insulin OR if uncontrolled diabetes)
Regimen Tracts Regimen Tracts Regimen Tracts Regimen Tracts
Dose Low (DM I, Lean DM II) Standard (Normal weight DM) Moderate (Overweight DM) Aggressive (Obese DM)
Total Daily Dose (TDD) 0.3 units/kg/day 0.4 units/kg/d 0.5unit/kg/d 0.6unit/kg/d
Basal ½ TDD ½ TDD ½ TDD ½ TDD
Prandial ½ TDD divided into 3 meals ½ TDD divided into 3 meals ½ TDD divided into 3 meals ½ TDD divided into 3 meals
Correction Scale Yup, they will also receive this too It should be the same rapid/short acting insulin as used for prandial insulin See next page Yup, they will also receive this too It should be the same rapid/short acting insulin as used for prandial insulin See next page Yup, they will also receive this too It should be the same rapid/short acting insulin as used for prandial insulin See next page Yup, they will also receive this too It should be the same rapid/short acting insulin as used for prandial insulin See next page
12
Correction Scale with Meals
Regimen Tracts Regimen Tracts Regimen Tracts Regimen Tracts
Dose Low (DM I, Lean DM II) Standard (Normal weight DM) Moderate (Overweight DM) Aggressive (Obese DM)
Total Daily Dose (TDD) 0.3 units/kg/d 0.4 units/kg/d 0.5unit/kg/d 0.6unit/kg/d
161-200 1 units 2 units 3 units 4 units
201-250 2 units 4 units 5 units 6 units
251-300 3 units 6 units 7 units 8 units
13
Insulin Dose Adjustment for CKD
  • No dose adjustment if GFR gt50
  • Use 75 of baseline insulin dose if GFR 10-50
  • Use 50 of baseline insulin dose if GFR lt10
  • Example At home takes 40 units of glargine qHS
  • If GFR 30 give 30 units of glargine qHS
  • If GFR lt10 give 20 units of glargine qHS

14
Long Beach VA Guidelines on Adjustment of Insulin
  • If glucose above target, increase insulin doses
    by 10-20 (2-5 units) every 1-2 days
  • Once patient clinically stable on insulin
    regimen, d/c correctional insulin and check
    glucose 2 hours after meals (target BS lt150 two
    hours after a meal)
  • How to Adjust
  • Patient on NPH/Regular insulin regimen
  • If fasting glucoses elevated, increase evening
    NPH
  • If pre-lunch or 2 hr post breakfast elevated,
    increase AM pre-breakfast regular
  • If pre-dinner or 2 hr post lunch elevated,
    increase AM NPH
  • If bedtime or 2 hr post-dinner elevated, increase
    pre-dinner regular
  • May need bedtime snack once glucoses are well
    controlled

15
Long Beach VA Guidelines on Adjustment of Insulin
  • Patient on Lantus with Regular/Aspart insulin
  • If fasting elevated, increase Lantus
  • If pre-lunch or 2 hr post breakfast elevated,
    increase pre-breakfast regular/Aspart
  • If pre-dinner or 2 hr post lunch elevated,
    increase pre-lunch regular/Aspart
  • If bedtime or 2 hr post-dinner elevated, increase
    pre-dinner regular/Aspart
  • If all glucoses elevated, may need to increase
    all insulins

16
Case Vignette
  • 45 year old obese female with DM type II is
    admitted for acute nausea, vomiting, and
    epigastric pain. CT Abdomen with IV contrast
    demonstrates acute pancreatitis. Her diabetes is
    usually controlled on metformin 1000mg BID and
    glyburide 10mg BID. Admission BMP shows a random
    glucose of 240. How do you manage her
    hyperglycemia?
  • A. Continue home regimen
  • Continue home glyburide and discontinue
    metformin
  • Start sliding scale insulin
  • Start correction insulin

17
Case Vignette Answer D
  • Answers A and B incorrect because patient likely
    to be NPO
  • Answer C, sliding scale insulin is no longer in
    favor.
  • CORRECT ANSWER(S)
  • Option 1
  • Initiate insulin therapy (basal, prandial,
    corrective scale) on admission
  • Option 2
  • Start q6 accuchecks with correction scale
    (regular insulin is commonly used). Correct BS
    per Aggressive Regimen since is obese DM type II
  • BS 160-200 4 units
  • BS 201-250 6 units, etc.
  • If BS is still gt180 after 1-2 days, then initiate
    longer insulin therapy (basal, prandial,
    corrective scale).
  • Note Option 2 less preferable because random
    BSgt180 and requires high doses of PO meds already
    so odds are she will have uncontrolled
    hyperglycemia

18
Last Question
  • 55 year old male with DM I comes from with cough
    and fevers with poor PO intake. Admitted for
    treatment of pneumonia. He normally takes 20
    units glargine qHS and 6 units aspart with each
    meal. How would you manage his blood sugar?
  • A. Continue home regimen
  • Give 10 units glargine qHS and 2 units aspart
    qAC
  • Give home glargine dose only
  • Give home aspart doses only

19
Correct Answer is B
  • Patient likely can eat, albeit he may eat less in
    setting of illness and restrictive hospital
    diets. He is DM type I so he needs continuous
    insulin coverage. The safest option is to
    decrease his insulin doses by 25-50 and monitor.
  • His goal BS is a FBG lt140 and random BS lt180. If
    he continues to experience hyperglycemia, then do
    the following.
  • Basal insulin uptitrate the glargine or redose
    based on a TDD of 0.3units/kg/day
  • Prandial insulin uptitrate the aspart or
    re-dose based on a TDD of 0.3 units/kg/day
  • Initiate correction scale Give additional
    aspart for BS gt160.

20
Take Home Points
  • Correction insulin is a concept to prevent
    hyperglycemia. It may include the initiation of
    insulin therapy (basal insulin, prandial insulin,
    AND correction scale)
  • Correction scale insulin is given before a meal,
    whereas sliding scale insulin is given after a
    meal
  • Avoid hypoglycemia. A safe inpatient BS goal is
    no lower than 100
  • Avoid severe hyperglycemia. A good target is a
    random BS lt180
  • Reassess insulin needs after any change in
    nutritional status (NPO, PO, tube feeds)

21
Easy self-directed learning materials
  • American Association of Clinical Endocrinologists
    and American Diabetes Association Consensus
    Statement on Inpatient Glycemic Control.
    Diabetes Care June 2009 32(6) 1119
  • Intensive insulin therapy in critically ill
    patients. NEJM 2001 345(19) 1359
  • Management of Hyperglycemia in the Hospital
    Setting. Inzucci et al. NEJM 2006 355
    1903-1911
  • The Nice-Sugar study investigators Normoglycemia
    in Intensive Care Evaluation Survival Using
    Glucose Algorithm Regulation Intensive vs
    conventional glucose control in critically ill
    patients. NEJM 2009 3601283
  • UpToDate Management of DM in hospitalized
    patients and General Principals in Insulin
    Management. Accessed on June 11, 2012.
  • UCI Inpatient Glycemic Monitoring and Treatment
    Guidelines. 2012
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