View
217
Download
0
Category
Preview:
Citation preview
In-Hospital
Management of
Diabetes
Dr Benjamin Schiff
Assistant Professor McGill University
No conflict of interest to declare
CLINICAL SCENARIO
62 y/o male with hx of DM 2, COPD, and HT is admitted with 2
days of cough and fever
He is taking metformin, glyburide and saxigliptin
Home sugars usually in the 8-10 range (well controlled, as per
patient)
Patient is generally well, though appetite has been a bit
diminshed in the past 2-3 days
Random glucose on admission is 11.1, Cr is 70, eGFR of 80 ml/min
Treatment includes antibiotic, bronchodilators and oral steroids
How should you manage his diabetes?
Outline
Goals of therapy
Factors affecting glucose
Brief review of medications
Co-morbid conditions
Approach to management
Sliding scales
Steroids
Tips and Pitfalls
D/C planning
In-Hospital Hyperglycemia is
Common Approximately 1/3 of in-
patients have been
found to have
hyperglycemia
Many have pre-existing
diabetes prior to
admission
Hyperglycemia
Hyperglycemia
Increases risks
of postoperative
infections and delirium
Prolonged
hospital stay,
resource utilization
Increased renal
dysfunction and
renal allograft
rejection in
transplant
Adverse Effects of Hyperglycemia
In-Hospital Glycemic Targets
Patient Type Glucose Target
(mmol/L)
Therapy of
choice
Non-critically ill Fasting 5-8
Random <10
Pre-hospital
regimen OR
basal-bolus-
correction
Critically ill 8-10 IV insulin infusion
CABG intraop 5.5-10 IV insulin infusion
Other periop 5-10 As appropriate
CABG = coronary artery bypass graft; IV = intravenous; Intraop = intraoperative;
periop = perioperative
FACTORS INFLUENCING GLYCEMIC
CONTROL
Diet ( )
Mobility/Exercise
Acute illness
IV (D5W)
Artificial feeding (TPN)
Medications
Co-morbidities (renal failure, liver failure)
Medication Review: Metformin
First line in Type 2 Diabetes
Lactic Acidosis main concern
Liver disease; hold
Renal Failure (CrCL<30, or 30-60 and conditions
associated with hypoperfusion/hypoxemia);
hold or adjust dose
Acute and/or unstable CHF; hold
IV contrast: Hold before and 48hr post
Add another class of agent best suited to the individual (agents listed in alphabetical order):
Class RelativeA1C Lowering
Hypo-glycemia
Weight Effect in Cardiovascular Outcome Trial
Other therapeutic considerations Cost
-glucosidase inhibitor (acarbose)
Rare neutral to Improved postprandial control, GI side-effects
$$
Incretin agents:DPP-4 InhibitorsGLP-1R agonists
to RareRare
Neutral to
Neutral (alo, saxa, sita)Neutral (lixi)
Caution with saxagliptin in heart failureGI side-effects
$$$$$$$
Insulin Yes Neutral (glar) No dose ceiling, flexible regimens $-$$$$
Insulin secretagogue:Meglitinide
Sulfonylurea
Yes
Yes
Less hypoglycemia in context of missed meals but usually requires TID to QID dosingGliclazide and glimepiride associated with less hypoglycemia than glyburide
$$
$
SGLT2 inhibitors to Rare Superiority (empa in T2DM patients with clinical CVD)
Genital infections, UTI, hypotension, dose-related changes in LDL-C, caution with renal dysfunction and loop diuretics, dapagliflozin not to be used if bladder cancer, rare diabetic ketoacidosis (may occur with no hyperglycemia)
$$$
Thiazolidinediones Rare Neutral CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect
$$
Weight loss agent (orlistat)
None GI side effects $$$
2016
Types of Insulin
Insulin Type (trade name) Onset Peak Duration
Bolus (prandial) Insulins
Rapid-acting insulin analogues (clear):
• Insulin aspart (NovoRapid®)
• Insulin glulisine (Apidra™)
• Insulin lispro (Humalog®)
• Insulin lispro U200 (Humalog® 200 units/mL)
10 - 15 min
10 - 15 min
10 - 15 min
10 - 15 min
1 - 1.5 h
1 - 1.5 h
1 - 2 h
1 - 2 h
3 - 5 h
3 - 5 h
3.5 - 4.75 h
3.5 - 4.75 h
Short-acting insulins (clear):
• Insulin regular (Humulin®-R)
• Insulin regular (Novolin®geToronto)
30 min 2 - 3 h 6.5 h
Basal Insulins
Intermediate-acting insulins (cloudy):
• Insulin NPH (Humulin®-N)
• Insulin NPH (Novolin®ge NPH)
1 - 3 h 5 - 8 h Up to 18 h
Long-acting basal insulin analogues (clear)
• Insulin detemir (Levemir®)
• Insulin glargine (Lantus®)
• Insulin glargine U300 (Toujeo®)
• Insulin glargine (BasaglarTM)
90 min
90 min
Up to 6 h
90 min
Not applicable
Up to 24 h (detemir 16-24 h)
Up to 24 h (glargine 24 h)
Up to 30 h
Up to 24 h (glargine 24 h)
2016
Insulin Type (trade name) Time action profile
Premixed Insulins
Premixed regular insulin – NPH (cloudy):
• 30% insulin regular/ 70% insulin NPH
(Humulin® 30/70)
• 30% insulin regular/ 70% insulin NPH
(Novolin®ge 30/70)
• 40% insulin regular/ 60% insulin NPH
(Novolin®ge 40/60)
• 50% insulin regular/ 50% insulin NPH
(Novolin®ge 50/50)
A single vial or cartridge contains a
fixed ratio of insulin
(% of rapid-acting or short-acting
insulin to % of intermediate-acting
insulin)
Premixed insulin analogues (cloudy):
• 30% Insulin aspart/70% insulin aspart protamine
crystals (NovoMix® 30)
• 25% insulin lispro / 75% insulin lispro protamine
(Humalog® Mix25®)
• 50% insulin lispro / 50% insulin lispro protamine
(Humalog® Mix50®)
Types of Insulin (continued) 2016
Renal Failure
Diabetic patients at risk, even if not
previously known RF
Common complication of acute medical
illnesses
Increases risk of hypoglycemia
Closely monitor renal function, reassess
management (diabetes meds, other
nephrotoxic medications, etc)
Liver Disease
Metformin and lactic acidosis
Risk of hypoglycemia (hepatic
gluconeogenesis)
Concomitant pancreatic dysfunction
(exocrine and endocrine)
Approach to Management
Complete Hx, including dietary history, home values
(if available), medications, diabetic complications
(RF)
Labs, including Urea, Cr, K+, and HgB A1C
Determine goals of glycemic control ("tight" vs
relaxed, short term vs long term)
Evaluate and anticipate impact of acute illness(es)
on glucose control and choice of medication
Management (cont’d)
Diabetic diet
Accuchecks (frequency and duration individualized)
Preference is to continue usual medications when
possible (including insulin)
Reassess management as clinical situation changes
”Judicious” use of sliding scale
Above all, avoid hypoglycemia (ensure protocol exists)
Insulin Sliding Scales Indications
On home insulin
NPO or variable PO intake
Artificial feeding (parenteral or enteral)
Acutely ill
Peri-operative
Co-morbities, especially liver disease, renal failure
Use of steroids
Sliding Scales
Short-acting insulin
Often QiD, but increased risk of hypoglycemia
overnight
Alternatively TiD AC meals +/- ½ dose at HS
Both CDA and ADA recommend against using
sliding scale alone (Reactive rather than proactive)
Total daily dosing used to covert to basal/bolus
4.0
10.0
Breakfast Lunch Dinner Bedtime
BG (mmol/L) Bolus insulin (U)
< 4 Call MD
4.1 – 10.0 0
10.1 – 13.0 2
13.1 – 16.0 4
16.1 – 19.0 6
> 19.0 Call MD
6.0
Bolus insulin QID
14.0
6.0
16.5
3.0
Sliding Scale alone
What do you do?
What do you do?
What do you do?
What do you do?
+4 U
0 U 0 U
+6 U
QID: four times daily; SSI: sliding-scale insulin; BG: blood glucose
Sliding Scale Insulin Alone Results
in Variable Glucose ControlBG (mmol/L)
BASAL + BOLUS + CORRECTION Results in
Smoother Glycemic Control
4.0
10.0
Breakfast Lunch Dinner Bedtime
BG (mmol/L) Bolus insulin (U)
< 4 Call MD
4.1 – 10.0 0
10.1 – 13.0 2
13.1 – 16.0 4
16.1 – 19.0 6
> 19.0 Call MD
6.0
12.0
6.0
Correctional Insulin AC meals
What do
you do?
What do you do?
What do
you do?
6+2 U
6+0 U
6U 6U
What do you do?
6+0 U
6.0
ROUTINE Bolus insulin
Basal
insulin6U
18 U
Routine Basal
Sliding Scales
I begin with basic sliding scale, and review the glycemic readings
Adjust the scale according to readings:
if glu 10.1-13 4 units
13.1-16 6 units
16.1-18 8 units
18.1-22 10 units
22.1-26 12 units
> 26 14 units
Next step(s) depend on anticipated duration of the need for thesliding scale
I don’t necessarily include “call MD”
Steroids
Variable effect on glycemic control
Can cause hyperglycemia in non-diabetics
Particular risk with Prednisone (effect can begin
to wear off after 12 hours)
Avoid HS insulin if taking qD steroids
Caution when changing from IV to PO
Can use qD N in AM
Helpful Tips
Ensure you know what the patient is actually taking, not
just what they were prescribed
Review accuchecks early in the day BEFORE long acting
insulins
Include in your orders fixed time(s) to reassess sliding scales,
accuchecks etc as a “forced” reminder
Err on the side of higher glucose values, especially if you
anticipate a short term admission (minimize risk of
hypoglycemia, improve patient comfort)
Unexpectedly high sugars may indicate occult infection
Pitfalls
Not reviewing the actual glucose readings
Continuing accuchecks qid despite being in target range
Forgetting about IVs that continue unnecessarily
Not reassessing sliding scales if NPO, vomiting etc
Using metformin with IV contrast, especially cardiac caths
Complications associated with Acute Kidney Injury
Giving extra doses of short-acting insulin in between sliding scale
Discharge Planning
In most situations, resume medications as prescribed at
home
Dietary counselling/Pt education
Consider modifying treatment if clear evidence of sub-
optimal baseline control (ideally in consultation with pt’s
primary care provider)
May need to modify based on sequelae of hospitalization
(e.g., new renal failure, new medications)
Ensure safe and effective transition to pt’s health care
provider(s)
Key Messages
Determine goals of therapy
Be aware of co-morbities
Safe and effective use of
sliding scales
References
Clinical Practice Guidelines from the
Canadian Diabetes Association
http://guidelines.diabetes.ca
American Diabetes Association: Standards
of Medical care in Diabetes 2016
http://care.diabetesjournals.org/content/s
uppl/2015/12/21/39.Supplement_1.DC2/20
16-Standards-of-Care.pdf
QUESTIONS?
•
•
•
•
•
•
•
•
31
•
•
•
•
•
•
32
Recommended