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Field Guide to Hospital Diabetes Care (A Primer for the Internist)

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Title: Field Guide to Hospital Diabetes Care (A Primer for the Internist)


1
Field Guide to Hospital Diabetes Care (A Primer
for the Internist)
  • Brandon Allard, M.D.
  • Sanford Clinic - Endocrinology
  • September 14, 2012

2
Overview
  • Introduction
  • Pitfalls and Common Mistakes
  • Procedure and Process
  • Therapeutic Goals
  • Treatment Options
  • Special Circumstances
  • Summary

3
Overview
  • I will be happy discuss outpatient diabetic
    management free-form as time allows with no
    power-point (after inpatient management module)
  • I have chosen not to discuss DKA management as
    this topic is less nuanced, familiar to all
    hospital internists and is generally well treated
    by algorithm/template

4
Overview
  • I anticipate the formal presentation will be well
    within our time allotment and will make every
    effort to leave ample time for Q A throughout
    the program

5
Introduction
6
Introduction (scope of problem)
  • Explosive growth of type 2 diabetic population
  • 25-35 of adult hospital patients have diabetes
    and many non-diabetic patients have hyperglycemia
    when ill
  • Regardless of medical specialty, core competence
    in diabetes care will be an asset

7
Introduction (scope of problem)
  • Typical knowledge base for inpatient /
    outpatient medical professionals (physician and
    nursing) woefully inadequate
  • Little or no time dedicated to the practical
    aspects of caring for persons with diabetes
    during medical training

8
Introduction (definitions)
  • Hyperglycemia
  • Fasting glucose gt100
  • Postprandial gt140
  • This term can be used in both diabetic and
    non-diabetic
  • persons

9
Introduction (definitions)
  • Hyperglycemia
  • Common in non-diabetic hospital patients for a
    variety of reasons
  • Steroid-induced
  • Nutritional support
  • Illness/ Physiologic stress
  • Pancreatitis
  • Peritoneal dialysis

10
Introduction (definitions)
  • Type 2 Diabetes
  • The most common form of diabetes in adults
  • Caused by insulin resistance (/-obesity)
  • Outpatient diagnostic criteria not relevant in
    hospital setting

11
Introduction (definitions)
  • Type 2 Diabetes
  • Treated with diet alone, oral medications,
    orals plus insulin or all-insulin based programs
  • The use of insulin doesnt define diabetes
    sub-type
  • (many type 2 patients use multi-dose insulin
    programs)

12
Introduction (definitions)
  • Type 1 Diabetes
  • Autoimmune destruction of pancreatic beta cell
  • Treated exclusively with insulin-based programs
  • Age and body type do not define sub-type
  • (Type 1 can occur at any age and with any body
    type)

13
Introduction (definitions)
  • Gestational Diabetes
  • Type 2 variant that occurs during pregnancy
  • Highly predictive of future type 2 DM
  • Usually resolves with delivery

14
Introduction (definitions)
  • Basal Insulin Long-Acting Insulin
  • Bolus Insulin Rapid-Acting Insulin

15
Introduction (definitions)
  • Insulin to Carbohydrate Ratios
  • Definition mathematical approach to selecting a
    meal-time rapid-acting insulin bolus
  • Purpose to precisely match the carbohydrate
    consumed to the appropriate dose of rapid-acting
    insulin (example 1 unit per 15grams carbohydrate)

16
Introduction (definitions)
  • Correction Factor/ Sliding scale
  • Definition temporary additions/ subtractions to
    usual short acting insulin doses (boluses)
  • Purpose to respond to glucose values that fall
    outside of goal range (reactive)

17
Pitfalls and Mistakes
18
Pitfalls and Mistakes
  • Cessation of all therapy
  • A diabetic patient sufficiently ill for
    hospitalization will almost always require
    diabetes-specific therapy
  • NPO status does not preclude the need for therapy
  • It is often appropriate to stop oral diabetic
    medications at admission (but you need to replace
    this deficit with insulin)

19
Pitfalls and Mistakes
  • Cessation of all therapy (continued)
  • It is critical to identify patients with type 1
    diabetes at hospital admission
  • Type 1 patients ALWAYS require scheduled insulin
    (even when NPO)
  • Failure to do so will result in DKA

20
Pitfalls and Mistakes
  • Over-reliance on Sliding Scale (SS)
  • SS is a nursing tool to react to high blood
    sugars
  • Should rarely be used in isolation for diabetic
    inpatients
  • Your goal as a provider should be to craft a
    management program so effective that SS is never
    used

21
Pitfalls and Mistakes
  • Transition off insulin drip
  • When transitioning off an insulin drip, it must
    be replaced with something (usually injected
    insulin)
  • The replacement should be proportional to insulin
    infusion being stopped
  • Remember, a sliding scale by itself is nothing

22
Pitfalls and Mistakes
  • Oral medication snafus
  • Metformin must be stopped for iodinized contrast
  • Metformin and sulfas are unsafe in renal failure

23
Pitfalls and Mistakes
  • Oral medication snafus
  • TZDs contraindicated with advanced CHF and
    unwise with significant edema
  • Byetta, Victoza, Bydureon, Symlin, and metformin
    can all cause upper GI symptoms so consider
    stopping for any upper GI admission

24
Pitfalls and Mistakes
  • Benign neglect - ignorance is not bliss!
  • Review glucose data daily to look for trends
  • Have situational awareness (impending NPO,
    nutritional support, steroid start)

25
Pitfalls and Mistakes
  • One-size-fits-all treatment
  • Avoid overly simplistic / uniform approach to
    diabetic management
  • Optimal care of diabetes requires thoughtful
    tailoring
  • No single type of program will perform well in
    all settings

26
Stay Flexible!
27
Procedure and Process
28
Procedure and Process
  • Patient History
  • Diabetes sub-type
  • Home program (the details matter)
  • Efficacy of home program
  • (last A1C, hypoglycemia, glucose data)
  • Assess compliance with program and glucose
    monitoring
  • Duration of diabetes / complications

29
Procedure and Process
  • Physical Exam
  • Special attention to manifestations of vascular
    disease
  • Foot exam for wound care issues
  • Peripheral neuropathy assessment
  • Injection / infusion site inspection
  • Identification of special limitations (tremor,
    CVA, cognitive)

30
Procedure and Process
  • Daily rounds
  • Review past 24 hour glucose data for events and
    control
  • Use multi-day trends to guide therapy
  • Talk to RN
  • Caution when writing insulin orders (1 error in
    hospital)
  • Consider educational needs of patient (DM Ed,
    dietary)

31
Procedure and Process
  • Discharge planning
  • Always keep discharge planning in mind
  • A program should be tuned to more closely
    approximate the planned outpatient program as
    discharge nears
  • If outpatient control (based on A1C data) is
    good (A1C lt8.0) it is reasonable to plan DC on
    admission Rx unless contraindications

32
Procedure and Process
  • Discharge planning
  • If outpatient control is suboptimal (A1C
    8.0-9.0) an inpatient care provider should feel
    free to change an outpatient program and obtain
    diabetic educator input
  • If outpatient control is very poor (A1C gt9.0)
    an inpatient care provider should feel obliged to
    intervene in order to improve outpatient diabetic
    control and avoid readmission

33
Therapeutic Goals
34
Therapeutic Goals
  • Glycemic targets in the hospital setting differ
    by disease state
  • Recent consensus has shifted away from tight
    control in the general hospital population (but
    tight control was defined as 80-110 and poor
    inpatient DM control is clearly associated with
    increased length of stay and increased
    readmission rates)
  • Avoidance of hypoglycemia is a priority

35
Therapeutic Goals
  • A target of 100-150 is appropriate for most
    hospital patients
  • CV surgical patients (CABG) have good evidence to
    support more aggressive management with a target
    of 80-110 peri-operatively

36
Questions?
37
Treatment Options
38
Treatment Options Basal Insulin Only
  • Basal insulins include Lantus (glargine) and
    Levemir (detemir)
  • These insulins approximate 24 hour clinical
    activity and have no peaks
  • An attractive option for replacing a simple oral
    program while hospitalized

39
Treatment Options Basal Insulin Only
  • 10 20 units daily would be a typical starting
    dose in an insulin naïve patient
  • Caution with single doses above 50 units
  • Divided dose offers more flexibility

40
Treatment Options Basal Insulin Only
  • Consider adding scheduled short acting insulin
    (R) when basal dose over 50 units daily to allow
    more flexibility for dose adjustment
  • Basal insulin oral Rx an effective option for
    some relatively stable hospital patients
  • Basal only programs never work in steroid-fueled
    hyperglycemia and cannot address post-prandial
    hyperglycemia

41
Treatment Options Split Mixed
  • The term split-mixed refers to the combination
    of NPH and Regular insulins
  • They can be mixed together in one injection
  • The total daily dose is split into an AM and a
    second PM dose

42
Treatment Options Split Mixed
  • Can be very effective in hospitalized Type2
  • Avoid with Type 1
  • Lower cost and less complex for outpatient use

43
Treatment Options Split Mixed
  • Classically 2/3 total daily dose in AM, 1/3 in PM
    for outpatients but typically closer to 50/50 for
    inpatients
  • This program has insulin peaks between meals and
    generally benefits from light snacks (mid-morning
    and HS)
  • Can use custom mix of NPH/R or use pre-mixed
    70/30 or 50/50 blends

44
Insulin ( Split Mixed Programs )
.
45
Treatment Options Basal-Bolus
  • Basal-Bolus programs utilize two different types
    of insulin to mimic physiologic insulin release
  • Long Acting Insulin ( Basal )
  • Rapid Acting Insulin ( Bolus )

46
Treatment Options Basal-Bolus
  • Rapid-acting (Bolus) insulin
  • Synthetic Source with rapid absorption
  • Onset of action within 15 minutes
  • Peak action in 1h with duration of 3 - 4h
  • Novolog(aspart ), Humalog (lispro), Apidra
    (glulisine)

47
Treatment Options Basal-Bolus
  • Basal (long-acting) insulin
  • Synthetic source
  • Duration of action is about 24 hours
  • Typically about one-half of total daily insulin
  • Lantus/ Levemir

48
Treatment Options Basal-Bolus
  • Default program for Type 1 patients
  • Sometimes useful for Type 2 as well
  • Least practical at discharge for insulin naïve
    patients due to higher complexity (education
    intensive)

49
Treatment Options Basal-Bolus
  • Bolus insulin can be a fixed dose or float with
    carbohydrate intake (insulin to carb ratio)
  • In general 50 basal, 50 bolus as outpatient
    (less predictable as inpatient)
  • Insulin to carb ratios tend to perform poorly in
    the hospital setting (imprecise carb counts,
    timing of insulin meals) but can be best option
    available
  • Insulin to carb ratios are useful if P.O. intake
    unpredictable

50
Treatment Options Basal-Bolus
  • Most Type 1 diabetic patients use insulin to carb
    ratios to select meal-time insulin
  • When practical, you should allow any patient
    using insulin to carb ratios at home to actively
    participate their dose selection as they will
    tend to out-perform nursing/ dietary

51
Treatment Options Basal-Bolus
  • Nursing must be instructed to record all
    glucometer readings and insulin doses in the
    medical record when patients are allowed
    self-management
  • You are ultimately responsible for a patients
    hospital diabetes even when they are actively
    involved in the process

52
Insulin ( MDI programs )
__ Rapid-acting Bolus insulin __ Long-acting
Basal insulin
Bolus
Basal
Supper
Breakfast
Lunch
53
Treatment Options Insulin Pumps
  • Used extensively in Type 1 and occasionally in
    type 2
  • A pager sized device that delivers rapid acting
    insulin through a temporary subcutaneous catheter
  • Nothing surgically implanted

54
Insulin Pump
55
Treatment Options Insulin Pumps
  • Device is brainless and does not passively
    manage a patient
  • Continuous flow of rapid acting insulin (basal)
    with patient selecting boluses for meals (bolus)
  • Insulin pumps are most useful in motivated,
    educated patients who actively manage their
    disease
  • Not useful to address non-compliance

56
Treatment Options Insulin Pumps
  • Infusion sets must be changed every three days
  • Past activity is stored in pump memory (useful
    for suspected non-compliance or hypoglycemic
    event) and should be downloaded at outpatient
    appointments
  • Must be managed by a competent, alert patient
  • (RNs cant manage, careful when sedate or on
    narcotics)

57
Are We Finished Yet ?
58
Special Circumstances
59
Special Circumstances Insulin Infusions
  • Most hospitals have insulin drip protocols to
    minimize risk/ errors with IV insulin
  • Factors that influence the initial drip rate
    selected should be
  • Home insulin doses
  • Response to injected insulin while hospitalized
  • Body weight
  • Current blood sugar
  • Outside therapeutics (steroids, TPN, Tube feeds)

60
Special Circumstances Insulin Infusions
  • Insulin drips are generally stopped when patients
    begin eating as they do not perform well with
    significant carb intake
  • Insulin drips are generally stopped when a
    patient is ready for transfer to the floor
  • No need to overlap drip with injected insulin

61
Special Circumstances Insulin Infusions
  • Transitioning from insulin infusion to injected
    insulin involves the following
  • Assessment of clinical circumstance (eating/ not
    eating/ steroids/ nutritional support)
  • Estimate of daily insulin consumption while on
    drip (pay attention to trends, 20 plus reduction
    for safety)

62
Special Circumstances Insulin Infusions
  • Type of injected insulin program selected should
    be tailored to patient characteristics / needs
  • Sliding scale alone is never a good choice to
    replace an insulin drip
  • There is no universal formula for transitioning
    off an insulin infusion avoid one-size-fits-all
    algorithms

63
Special Circumstances Insulin Infusions
  • Basal insulin alone will often perform well when
    the drip rate has been low (2 units per hour or
    less)
  • If total daily dose insulin on infusion greater
    than 50 units, consider a multi-dose program
    (split mixed, basal plus fixed bolus)
  • I generally avoid insulin to carb ratios in type
    2 patients coming off drip (ineffectual, usually
    very limited PO)

64
Special Circumstances Steroids
  • In general steroids have a disproportionate
    impact on post-prandial glucose excursions
  • Less impact on basal insulin needs.
  • Meal-time bolus insulin almost always needed

65
Special Circumstances Steroids
  • Regular insulin is equal or superior to ultra
    rapid-acting analogues with steroid usage
  • Insulin to carb ratios perform poorly at very
    high insulin doses
  • Consider restricting between meal snacking

66
Special Circumstances Steroids
  • Be careful with aggressive sliding scale insulin
    at bedtime (may need different sliding scales for
    meals/ bedtime)
  • As steroids wean, anticipate the need for
    downward dose titration (dont wait for a
    hypoglycemic event)

67
Special Circumstances TPN
  • IV nutrition with high glucose content
  • Generally continuous but occasionally on/off
  • Can lead to extreme insulin needs

68
Special Circumstances TPN
  • Often use insulin infusion in the ICU
  • (especially while dose finding)
  • When continuous, basal insulin provides a good
    foundation for treatment
  • Dividing basal doses offers the possibility of
    changing insulin dosage multiple times daily

69
Special Circumstances TPN
  • Can add insulin to TPN (but cant adjust infusion
    rate)
  • 15-20 units per bag TPN a good starting point
  • Be careful not to add too much insulin as TPN
    would need to be held for hypoglycemia

70
Special Circumstances TPN
  • Bridging fixed doses of regular insulin can
    allow for even more titration opportunities.
  • Overnight TPN (on 8-12 hours) often treated with
    a single dose of NPH/ Regular at the onset of TPN
  • Be aware of clinical events! A giant dose of
    basal insulin on-board plus TPN unexpectedly
    placed on hold equals big, big trouble!

71
Special Circumstances Tube Feeds
  • Liquid enteric nutrition which contains glucose
  • May be continuous or intermittent
  • Even more likely than TPN to be stopped abruptly
    (NPO for procedure or high residuals)

72
Special Circumstances Tube Feeds
  • Split mixed (NPH/R), or basal with bridging doses
    of Regular insulin often good options if
    continuous
  • Single dose NPH/R if overnight feeds
  • Bolus only program sometimes used with TID
    meal-time feedings
  • No role for insulin to carb ratios

73
Special Circumstances Peritoneal Dialysis
  • PD fluid contains glucose to create an osmotic
    gradient (Bags are color coded for glucose
    content)
  • I treat this situation similarly to an
    intermittent tube feed or TPN with NPH/R at time
    of the PD run
  • Many PD patients are diabetic so the PD insulin
    dose is often superimposed onto their normal
    program

74
Summary
75
Summary
  • Hospital diabetes management is very different
    from outpatient diabetes management
  • Hospital patients are dynamic and have special
    circumstances that tend to exacerbate
    hyperglycemia
  • Coordinating inpatient insulin administration,
    diet, and glucometer testing is surprisingly
    difficult and prone to error

76
Summary
  • Glucose data should be reviewed daily and trends
    used to improve management
  • Diabetes treatment must be tailored to each
    patient and circumstances
  • One-size-fits-all diabetic algorithms do not
    result in good diabetes care

77
Summary
  • The simplest diabetes program that meets a
    patients needs is generally best
  • Cost, hypoglycemic risk, patient characteristics
    and co-morbid medical conditions must be
    considered
  • Hospital patients eventually become outpatients.
    Begin to transition to a viable outpatient
    diabetes program as discharge nears

78
(No Transcript)
79
Questions?
80
Field Guide to Hospital Diabetes Care (A Primer
for the Internist)
  • Brandon Allard, M.D.
  • Sanford Clinic - Endocrinology
  • September 14, 2012
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