Safe Glycemic Control – A Team SportKristi Kulasa M.D., Assistant Clinical Professor of Medicine ....

Safe Glycemic Control – A Team Sport

Kristi Kulasa M.D., Assistant Clinical Professor of Medicine Director, Inpatient Glycemic Control

Division of Endocrinology, Diabetes, and Metabolism Session 2 of 4: NYSP4P Initiative

Kristi Kulasa- Conflict of Interest Statement

• None

Session I - Feb 12th Dr. Greg Maynard – Why inpatient glycemic control is important – Overview of IV and SC insulin best practices, how to implement – Framework for Improvement

• Session II - Feb 26th Dr. Kristi Kulasa – Inpatient glycemic team structure - – Coordination of meals / insulin / testing – Top things we teach / reinforce – Basal / bolus cases and special situations (TPN, TF, NPO, Steroids,

Transition IV to SC insulin) • Session III - March 12th Dr. Greg Maynard

– Safe use of insulin summary – Hypoglycemia Management and Prevention – Measurement and Monitoring – month to month and day to day – SHM and other resources

• Session IV - March 19th Drs. Kulasa and Maynard – FAQs / Q&A – Transitions – Barriers and How to Overcome Them

Resources • Patient centered approach to achieving optimal glycemic

control is a multidisciplinary process.

UCSD Team Structure • Inpatient Glycemic Consult Team

– 1.5 Endo’s – 3 APN/CDE’s (2 at 400 bed hospital, 1 at 200 bed hospital)

• Multidisciplinary Glycemic Control Steering Committee

– Representatives from Endo, Hospital Medicine, Nursing, Pharmacy, Surgery, Nutrition Services, IT, Nursing Education, POC Lab

– Meets monthly

• Diabetes Initiative Group (Diabetes Nurse Champions) – 1-2 representatives from each unit – Meets monthly

Nursing Education

Patient Education

Coordination of Meals, POC, and Insulin: What’s the problem?

• Separation of ‘duties’ across 3+ disciplines • Lack of communication between all involved parties • Tick sheet mentality • Inconsistent delivery of all components of the process with

frequent interruptions • Separation or delay in POC documentation • Poor documentation and follow up related to food

consumption

American Diabetes Association All correction, supplemental, or adjustment doses of insulin should be based on bedside BG measurements taken immediately prior to insulin administration along with appropriate assessment of nutritional (carbohydrate) intake and prior insulin doses and responses to insulin.

ADA. Diabetes Care 2005; 26 Sup.1:S4–S36; 28 Sup.1:S72–S79; 28:1245–1249.

Top Things We Teach/Reinforce • Purpose/Role of:

– Basal, Nutritional and Correction insulin • Routine NPO • Treatment of Hypoglycemia

– Timely treatment – Rechecks – Why?

• Nutritional Discordance/Interruption in Nutrition – Poor po intake – Interruption in Continuous Nutrition

• Transitions – IV to SC insulin – Inpatient to Outpatient

• Special Situations – Steroids – TPN

Basal Insulin • Long-acting, non-peaking insulin is preferred as it provides

continuous insulin action, even when the patient is fasting

• Purpose: suppress glucose and ketone production • Required in ALL patients with type 1 diabetes

• Most patients with type 2 diabetes will require basal insulin in

the hospital

• Can be estimated to be about 1/2 of the total daily dose of insulin (TDD)

Basal Insulin

Nutritional Insulin • Usually given as rapid-acting analogue (preferred in most

cases) or regular insulin, for those patients who are eating meals

• Purpose: cover food/nutrition • Should not be given to patients who are not receiving

nutrition (e.g. NPO)

• Must be matched to the patient’s nutrition pattern – eating 3 meals vs cont TF or TPN

• Can be estimated to be about ½ of the total daily dose of

insulin (TDD)

Patient eating or receiving bolus TF

Patient eating or receiving bolus TF

Patient receiving continuous TF or TPN

Continuous TF or TPN

Patient NPO or on Carb Limited CLD (0 Carb)

Correctional Insulin • Correctional insulin is extra insulin that is given to correct

hyperglycemia

• Purpose: cover high blood sugar

• Usually rapid-acting or regular insulin (usually the same as the nutritional insulin)

• Can be given when NPO (even if Lispro)

• Often written in a “stepped” format that is used in addition to basal and nutritional insulin, customized to the patient using TDD

• If correctional insulin is required consistently, or in high doses, it suggests a need to modify the basal and/or nutritional insulin doses

Correctional Insulin

Routine NPO • Basal

– Administer even if NPO – Consider 20% reduction if tight control or high risk of

hypoglycemia • Nutritional

– Hold • Correction

– Administer – Consider switching to regular q6hr if prolonged NPO

• IVFs – Consider D5 if tight control or prolonged NPO

Key things to know about SC insulin management in the hospital White font – previous Yellow font – today Green font- future

• Just do it! (when glucose over target) • Basal / Nutritional (prandial) / Correctional • What do I do when the nutrition stops? NPO p MN? • Giving that first dose (how do I do this)? • 50:50 rule – • Perioperative management? • How should we manage at transitions? • How do we manage inpatients in special situations?

– steroids, TPN, etc • Best strategies to reduce iatrogenic hypoglycemia?

Physiologic Insulin Secretion: Basal-Bolus Concept 1. Basal

2. Nutritional 3. Correctional

Calculating Insulin Dosage (Total Daily Dose)

• Calculate from insulin infusion amount – Recent steady state hourly rate x 20, for

example

• Add up insulins taken at home, adjust for glycemic control and other factors

• Calculate from weight, body habitus, other factors

Calculate starting total daily dose (TDD) 0.4 – 0.5 units/kg/day Reduce to 0.3 units/kg/day if hypoglycemia risk increase to 0.5 – 0.6 units/kg/day if overweight / obese

Adjust TDD up or down based on Past response to insulin Presence of hyperglycemia inducing agents, stress

Basal insulin = 50% of TDD Glargine q HS or q AM, detemir in 1 or 2 doses

Starting Basal-Bolus from Scratch

Case 1 • 41 year old male with history of hypertension, DM 2, and

two previous episodes of myositis who presents to the ED with c/o right leg pain and swelling.

• Home regimen: Amaryl 4mg qam and Metformin • A1C: 7.9% • Weight: 81kg

• What are your initial orders for glycemic control?

– Fingersticks? – Orals? – Insulin?

Case 1: Solution • Fingersticks qac and qhs

• Calculate TDD: – No drip

– Home regimen: 2 orals

– Weight: 81kg (0.5) = 40.5 units

• Basal Insulin: Lantus 20 units

• Nutritional Insulin: Lispro 7 units qac

• Correction Insulin: mild-mod w/ Lispro qac/qhs

Case 2 56 year old male admitted with facial contusions after MVA. BG found to be 400s in ED. Pt does endorse polyuria, polydipsia and weight loss of 30 lbs over the last 6mo.

- Weight: 100 kg - Home medical regimen: none - Control: A current HbA1c is 13%, POC glucose in ED is 425

mg/dL

What are your initial orders for glycemic control? fingersticks? orals? insulin?

Case 2: Solution • Bedside glucose testing AC and HS

• Calculate TDD:

– No drip

– Home regimen: none

– Weight: 100kg (0.6) = 60 units • Basal: Lantus 30 units qhs

• Nutritional: Rapid-acting analogue 10 units q ac at the first bite of

each meal

• Correction: Rapid-acting analogue per scale q ac and HS (moderate-high)

Case 2 Continued…

Final read of the CT scan shows a facial fracture and Head and Neck Surgery want to take the patient to the OR the next day. The plan is for surgery first thing in the morning, so the patient will be NPO after midnight. However, he is expected to resume a regular diet at lunch the following day after surgery. What changes would you make to his regimen at this point? fingersticks? IVFs? insulin?

Case 2 Continued: Solution • Bedside glucose testing AC and HS while eating, consider

switching to q 6 hours when NPO for extended period

• Consider IV dextrose infusion while NPO (e.g. D5 at 75-150 cc/hr)

• Basal: continue Glargine 30 units q HS

• Nutritional: Hold because NPO

• Correction: Continue rapid-acting insulin per scale q ac and HS (mod-high dose), consider switching to regular insulin q6hr if NPO for significant period of time

Case 3 • 52 yo male with history of CKD stage IV not on dialysis,

diastolic CHF, DM2 with neuropathy, HLP, HTN admitted with pneumonia

• Home Regimen: Lantus 30 units qhs and Lispro 15/10/13 w/ breakfast, lunch and dinner

• A1C: 5.1% • Weight: 94 kg

• What are your initial orders for glycemic control?

– Fingersticks? – Insulin?

Case 3: Solution • Fingersticks qac and qhs

• TDD calculation – No drip

– Home regimen: 68 units (70-80%) = 47.6-54.4

– Weight: 94 kg (0.3) = 28.2

• Basal insulin: Lantus 14-27 units qday

• Nutritional insulin: 5-9 units qac

• Correction insulin: low-moderate w/ Lispro qac/qhs

Case 4 • 76 year old female with no known past medical Hx (hasn't

seen an MD in years) presents after mechanical fall. Found to be septic w/ PNA, being admitted to ICU.

• Home Regimen: none • A1C: none, BS in ED 453 mg/dL • Weight: 112 kg

• What are your initial orders for glycemic control?

– Fingersticks? – Insulin? – Orals?

Case 4: Solution

• Start insulin gtt

• Fingersticks q1-2hr per protocol

• Adjust insulin q1-2hr per protocol

Case 4: Continued • Pt doing well, improved, off pressors, on NS, ready to eat

and be called out to medicine.

• What orders are you going to write to get patient off drip? – Fingersticks? – Insulin? – Orals?

Total 112.6 units

Insulin Drip Data

Stepwise Approach to Transition from IV to SC Insulin • Calculate how much IV insulin the patient has been requiring

– Use average hourly rate over the last 6hrs (if stable) and multiply by 20 (80%)

• Recognize which component of the physiologic insulin

requirement the IV insulin represents, and translate that to a SC regimen

• Consider any nutritional changes that may be implemented at the time of the transition off of the drip

• Make sure SC insulin is given 2 hrs before discontinuation of the IV insulin

Transition IV to SC Insulin • Diabetic or A1C >6.0%?

– No: correction scale only

– Yes: basal bolus regimen

• Use 80% of the lowest of the following: – the dose administered over the last 12 hours multiplied by 2

– the dose administered over the last 24 hours

• Use average hourly rate over the last 6hrs (if stable) and multiply by 20 (80%)

Case 4: Solution • Fingersticks qac and qhs

• TDD calculation – Home regimen: none

– Weight: 112 kg (0.3 units/kg) = 33.6 units

112 kg (0.4 units/kg) = 44.8 units

– Drip: 1.51 units/hr (avg rate/hr over last 6hrs) x 20 = 30 units x 2 (because pt on no nutrition w/ NS IVFs only) = 60 units

• Basal insulin: Lantus 16-30 units qday

• Nutritional insulin: 5-10 units qac when patient eating

• Correction insulin: low-moderate

• Turn insulin drip off 2hrs after Lantus dose administered

Special Situations

• Typical Ratio 50:50 (basal:bolus)

• Consider Adjusting to 40:60 or 30:70 (basal: bolus) – Steroids – Tube Feeds (super nutrition) – TPN (super nutrition)- sometimes even 20:80 (basal:bolus)

Steroids • Steroids cause general insulin resistance w/ much less

effect on gluconeogenesis

• Glucose elevation is predominantly postprandial hyperglycemia with a relative lack of fasting hyperglycemia

• Treatment large doses of a rapid-acting insulin before meals (often only 2 meals depending on time steroid administered)

• Significant increases in basal insulin should be avoided, as overnight hypoglycemia may be induced.

8am dosed steroid

Steroids

High dose steroids and Insulin Management • For patients without hyperglycemia or prior dx of DM or those well

controlled on oral agents – Always monitor POC glucose, order correction scale insulin – Add scheduled insulin if glucose becomes persistently elevated

• For patients previously on insulin, or elevated A1c and persistent hyperglycemia – Increase TDD by 20-50% with start of steroid therapy – Consider disproportionate increase in nutritional insulin (40:60 instead of

50:50, for example) – Move one step up on correction insulin scale – Adjust as required

• Consider adding NPH to basal/bolus • Low threshold for consultation

Case 5 • 65 yo male with DM2 and COPD admitted with pneumonia

and COPD exacerbation.

• Home Regimen: metformin 1000 mg bid • A1C: 7.2% • Weight: 100 kg

• What are your initial orders for glycemic control?

– Fingersticks? – Orals? – Insulin?

Case 5: Solution • Fingersticks qac and qhs

• TDD calculation

– No drip

– Home regimen: 1 oral

– Weight: 100 kg (0.4 units/kg) = 40 units

100 kg (0.5 units/kg) = 50 units

100 kg (0.6 units/kg) = 60 units

Case 5: Solution • Fingersticks qac and qhs

• TDD calculation – No drip

– Home regimen: 1 oral

– Weight: 100 kg (0.4 units/kg) = 40 units

100 kg (0.5 units/kg) = 50 units

100 kg (0.6 units/kg) = 60 units

• Basal insulin: Lantus 20-25 units qday (50% 0.4-0.5 units/kg TDD)

Lantus 24 units qday (40% of 0.6 units/kg TDD)

• Nutritional insulin: Lispro 6-8 units qac (50% 0.4-0.5 units/kg TDD)

Lispro (36 units total) divided either 12 units qac or 7/14/14 w/ br/lu/di

• Correction insulin: mod-high w/ Lispro qac/qhs

Be careful in Lantus only regimen for BID-q6hr steroids, esp when dec to once daily

Recommend fingersticks and correction scale at a minimum in all patients on steroids (whether h/o DM or not)

Case 6 • 68 yo male with history of DM2 and HTN admitted w/

stroke and AKI (currently on dialysis). Currently NPO on Lantus 8 units qday w/ good glycemic control. Neuro Team calls for recommendations as they are starting continuous tube feeds.

• Home Regimen: metformin 1000 mg bid • A1C: 7.3% • Weight: 61 kg

• What are your recommendations for glycemic control?

– Fingersticks? – Insulin?

Patient receiving continuous TF or TPN

Case 6: Solution • Fingersticks q6hr

• TDD calculation – No drip

– Home regimen: 1 oral

– Weight: 61 kg (0.3 units/kg) = 18 units

• Basal insulin: Lantus 8 units qday

• Nutritional insulin: 2 units q6hr

• Correction insulin: low w/ Regular insulin q6hr

TF rate now increasing and BG are rising, what adjustments to make?

How would you adjust insulin?

Current Regimen: Lantus 8 units qday and Regular 2 units q6hr

Case 6 Continued: Solution • Continue Fingersticks q6hr

• Continue Basal insulin: Lantus 8 units qday

• Increase Nutritional insulin: to 4 units q6hr

• Continue Correction insulin: low w/ Regular insulin q6hr

Session I - Feb 12th Dr. Greg Maynard – Why inpatient glycemic control is important – Overview of IV and SC insulin best practices, how to implement – Framework for Improvement

• Session II - Feb 26th Dr. Kristi Kulasa – Inpatient glycemic team structure - – Coordination of meals / insulin / testing – Top things we teach / reinforce – Basal / bolus cases and special situations (TPN, TF, NPO, Steroids,

Transition IV to SC insulin) • Session III - March 12th Dr. Greg Maynard

– Safe use of insulin summary – Hypoglycemia Management and Prevention – Measurement and Monitoring – month to month and day to day – SHM and other resources

• Session IV - March 19th Drs. Kulasa and Maynard – FAQs / Q&A – Transitions – Barriers and How to Overcome Them

Hypoglycemia Prevention and Management - Measurement that Matters and the Power of Collaboration

Questions and Comments?

Next Session March 12th - Dr. Greg Maynard