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Foundations toManaging InpatientHyperglycemia

Module A

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Learning Objectives

• Develop strategies to identify patients withhyperglycemia or diabetes in the inpatient setting

• Establish glycemic goals to minimize episodes ofhyperglycemia and hypoglycemia in your institution

• Compare and contrast sliding-scale insulin (SSI)therapy with scheduled subcutaneous (SC) insulintherapy

• Outline processes and procedures to ensureappropriate glycemic management in theinpatient setting

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Trends in Glycemic Control Over a 2-year Period in126 US Hospitals; Improvements in Non-ICU Patients

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Point-of-care blood glucose (POC BG) test results at 126 hospitals

Bersoux S et al. J Hosp Med. 2013;8(3):121–125.Journal of Hospital Medicine by John Wiley & Sons. Reproduced with permission of John Wiley & Sons in the formatRepublish in continuing education materials via Copyright Clearance Center.

>180

>200

>250 >300 >350 >400

Patie

nt-d

ays(

%)

25

30

15

20

5

10

0

28.0

25.3

28.0

17.8

10.2

7.25.1

2.9 2.61.2 1.3 0.5

Glucose Level (mg/dL)

20072009

>200

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Glycemic Control in Hospitals in the United States

32.2 32

6.3 5.7

0

5

10

15

20

25

30

35

ICU Non-ICU

Hyperglycemia prevalence(>180 mg/dL)

Hypoglycemia prevalence(<70 mg/dL)

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49,191,313 POC-BG measurements (12,176,299 ICU and 37,015,014 non-ICU values) were obtained from 3,484,795inpatients (653,359 in the ICU and 2,831,436 in non-ICU areas).

Patie

nt-d

ays(

%)

Swanson CM et al. Endocr Pract. 2011;17(6):853–861.

Hyperglycemia During Hospitalization and PoorOutcomes in Numerous Settings: A Few Examples

Citation Patient Population Significant Hyperglycemia-related Outcomes

1 Total parenteral nutrition (TPN) Mortality risk, pneumonia risk, acute renal failure

2 Noncardiac surgery Mortality risk, surgery-specific risk

3 Aneurysmal subarachnoid hemorrhage Mortality risk, impaired prognosis

4 Critically injured trauma patients LOS, mortality risk, ventilator time, infection

5 Chronic obstructive pulmonary disease(COPD) LOS, mortality risk, adverse outcomes

6 Community-acquired pneumonia LOS, mortality risk, complications

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1. Pasquel FJ et al. Diabetes Care. 2010;33(4):739–741. 2. Frisch A et al. Diabetes Care. 2010;33(8):1783–1788.3. Schlenk F et al. Neurocrit Care. 2009;11(1):56–63. 4. Bochicchio GV et al. J Trauma. 2007;63(6):1353–1358.5. Baker EH et al. Thorax. 2006;61(4):284–289. 6. McAllister FA et al. Diabetes Care. 2005;28(4):810–815.

A1C level ≥6.5%A1C level ≥6.5%

Start POC BG monitoringx 24–48 hours

Check A1C level

Start POC BG monitoringx 24–48 hours

Check A1C level

Initiate POC BGmonitoring according to

clinical status

Initiate POC BGmonitoring according to

clinical status

BG monitoringBG monitoring

No history of diabetesBG <140 mg/dL

No history of diabetesBG <140 mg/dL

No history of diabetes butBG >140 mg/dL

No history of diabetes butBG >140 mg/dL

History ofdiabetes

History ofdiabetes

Diagnosis and Recognition of Hyperglycemiaand Diabetes in the Hospital Setting

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POC BG = point-of-care blood glucose testing.Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16–38.

AdmissionAssess all patients for a history of diabetesObtain laboratory BG testing on admission

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Causes of Hospital-related Hyperglycemia

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Known diabetes(uncontrolled, undertreated)

Known diabetes(uncontrolled, undertreated)

Undiagnosed diabetesUndiagnosed diabetes

Stress hyperglycemia(transient physiologic response to the stress of

acute illness or injury)

Stress hyperglycemia(transient physiologic response to the stress of

acute illness or injury)

Iatrogenic (corticosteroids, catecholamines,parenteral and enteral nutrition, reduced exercise)

Iatrogenic (corticosteroids, catecholamines,parenteral and enteral nutrition, reduced exercise)

Patient Example: Severe Hyperglycemiaon Admission in a Patient With Diabetes

• 59-year-old obese male patient with prior historyof T2DM controlled on metformin, glipizide, andsitagliptin; admitted to the critical care unit with sepsis

• On presentation– BG = 329 mg/dL– BP = 108/56 mm Hg– HR = 95 bpm– Respiration = 18 breaths per minute

• Patient weight = 220 lb; height = 5′10″; BMI = 31.6 kg/m2

How would you manage this patient?

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BG = blood glucose; BMI = body mass index; BP = blood pressure; HR = heart rate; T2DM = type 2 diabetes mellitus.

Insulin is the Most Appropriate Agent forCritically Ill Patients

Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353–369.American Diabetes Association. Diabetes Care. 2009;32(suppl 1):S1–S110.

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Rapidly effective

Easily titratable(up or down)

No realcontraindications

IV InsulinCritically IllPatients

Most potentglucose-lowering

agent

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Current Recommendations forHospitalized Patients: Critically Ill Patients

Hyperglycemia

• BG level 140–180 mg/dL• Intravenous insulin preferred

Hypoglycemia

• Reassess the regimen if BG level is <100 mg/dL• Modify the regimen if BG level is <70 mg/dL

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Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353–369.Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16–38.

Admission Orders

• All patients with diabetes admitted to the hospitalshould have their diabetes clearly identified in themedical record

• All patients with diabetes should have an order forblood glucose monitoring, with results available toall members of the health care team

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American Diabetes Association. Diabetes Care. 2014;37(suppl 1):S14–S80.

A1C Testing

Consider obtaining an A1C level in patients with:Consider obtaining an A1C level in patients with:• diabetes admitted to the hospital if the result of testing in the previous

2–3 months is not immediately available• risk factors for undiagnosed diabetes who exhibit hyperglycemia in the

hospital

Examples of when results may be inaccurateExamples of when results may be inaccurate• Recent blood transfusion• Hemoglobinopathy• Certain anemias• Splenectomy• ESRD (especially if on erythropoietin-based therapy)• Pregnancy

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ESRD = end-stage renal disease.American Diabetes Association. Diabetes Care. 2014;37(suppl 1):S14–S80. Schnipper JL et al. Endocr Pract. 2010;16(2):209–218.

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Patient Example: Severe Hyperglycemia onAdmission in a Patient With Diabetes

• A1C ordered– Results are 8.8%

• Admission glucose was 329 mg/dL• Given 3 units of regular insulin IV push• Started on regular insulin 3 units/hour

– Standard drip 100 units/100 mL 0.9% NaCl• BG monitoring every 1 hour until stable, then q 2 hours• Once the patient is stable, will be moved out of the ICU

and will begin scheduled meals

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Insulin Infusion Protocols

Published protocolsvary by• Patient characteristics• Target glucose level• Time to achieve target

glucose level• Incidence of hypoglycemia• Rationale for adjusting the

rates of insulin infusion• Methods of BG measurements

To determine insulininfusion protocolfor an institution,evaluate• Type of patients in critical

care units• Mean baseline glucose

levels• Available resources

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Krikorian A et al. Curr Opin Clin Nutr Metab Care. 2010;13(2):198–204.Nazer LH et al. Endocr Pract. 2007;13(2):137–146.

Successful IV Insulin Protocol

• Reaches and maintains BG successfully within aprespecified target range

• Includes a clear algorithm for making temporary correctivechanges in the IV insulin rate as patient requirements change

• Incorporates the “rate of change” in BG, not just the absolutevalues

• Incorporates the current IV insulin rate• Minimizes hypoglycemia; provides specific directions for

its treatment when it occurs• Provides specific guidelines for timing and selection of doses

for the transition to SC insulin

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Does your institution have an IV insulin protocol in place?Does your institution have an IV insulin protocol in place?

Clement S et al. Diabetes Care. 2004;27(2):553–591.

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Sources of Insulin Protocols

• American Association of Clinical Endocrinologists– http://inpatient.aace.com/protocols-and-order-sets

• Society of Hospital Medicine– http://www.hospitalmedicine.org/resourceroomredes

ign/html/12clinical_tools/04_insulin_ordersiv.Cfm

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Successful Implementation of Protocols

Successful implementation ofprotocols requires:• Buy-in from key stakeholders (critical

care physicians, house staff, nursing,pharmacy, hospital administration,etc)

• Appropriate education throughin-servicing of hospital staff

• Ongoing monitoring of results• Support from endocrinologists for

specific questions or when a patientdoes not respond to the protocolas expected

It is important to keep in mindthat these algorithms have notbeen directly compared inclinical trials.

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Safe Use of IV Insulin Therapy

Insulin infusion concentrations and protocols should bestandardized within a hospital.Insulin infusion concentrations and protocols should bestandardized within a hospital.

All MDs/RNs should be trained with competence and assessedregularly.All MDs/RNs should be trained with competence and assessedregularly.

Accurate bedside BG monitoring done hourly (and if stable,every 2 hours).Accurate bedside BG monitoring done hourly (and if stable,every 2 hours).

Potassium should be monitored and given if necessary.Potassium should be monitored and given if necessary.

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Clement S et al. Diabetes Care. 2004;27(2):553–591.

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TRANSITION FROMIV TO SC INSULIN

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Considerations for Transition From IV to SC Insulin

• Which patients on IV insulin will need a transition toscheduled SC insulin?– T1DM– T2DM on insulin prior to admission– T2DM (or “new hyperglycemia”) requiring

≥2 units/hour of insulin

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T1DM = type 1 diabetes mellitus.Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16–38.

Transition From IV Insulin to SC Insulin

• IV insulin should be transitioned to SC basal-bolusinsulin therapy– When patient begins to eat and BG levels

are stable• Because of short half-life of IV insulin, SC basal

insulin should be administered at least 1–2 hoursprior to discontinuing the drip– If short-acting insulin also administered, IV insulin

may be able to be stopped sooner, eg, after 1 hour

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Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16–38.

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Calculating the SC Insulin Dose

• Establish the 24-hour insulin requirement byextrapolating from the average IV insulin doserequired over the previous 6–8 hours (if stable)

• Take 80% of the total daily dose (TDD) and give onehalf as an intermediate-acting or long-acting insulinfor basal coverage and one half as a short-acting orrapid-acting insulin in divided doses before meal– (If patient is not eating, just give intermediate/long-

acting insulin.)

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Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16–38.

GFR = glomerular filtration rate.Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16–38.

Basal-bolus Insulin Regimen in NoncriticallyIll Patients

Starting insulin—calculate TDD as follows:– 0.2–0.3 U/kg/day in patients >70 years and/or GFR <60 mL/min– 0.4 U/kg/day if BG between 140 and 200 mg/dL and not meeting above criteria– 0.5 U/kg/day if BG between 201 and 400 mg/dL and not meeting above criteria

Distribute 50% of TDD as basal insulin and 50% as nutritional insulin:– Give basal insulin (glargine/detemir) once daily or NPH twice daily at the same

time each day– Give nutritional insulin (rapid-acting insulin analog) in 3 divided doses before

each meal, so long as consistent carbohydrate intake is ensured. Hold if patientis not able to eat

– Provide supplemental (correction) insulin in addition to basal and nutritional– Adjust insulin dose(s) according to results of bedside BG measurements

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Current Recommendations forHospitalized Patients: Noncritically Ill Patients

Hyperglycemia

• Random: <180 mg/dL• Premeal: <140 mg/dL• Scheduled SC insulin preferred• SSI discouraged

Hypoglycemia

• Reassess the regimen if BG level is <100 mg/dL• Modify the regimen if BG level is <70 mg/dL

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Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353–369.Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16–38.

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SC Insulin Administration

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Clement S et al. Diabetes Care. 2004;27:553–591.Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353–369.

Long-actinginsulin Rapid-acting insulin

“Scheduled” (SSI only uses thiscomponent)

BasalBasal Bolus(Nutritional)

Bolus(Nutritional)

CorrectionCorrection

Correction

Basal Nutritional

Total dailyinsulin needs

Basal-bolus Therapy Is Effectivefor the Maintenance of Glycemic Control

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1. Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353–369.2. Bray B. Consult Pharm. 2008;23(suppl B):17–23. 3. Roberts G et al. Med J Aust. 2012;196(4):266–269.4. Umpierrez GE et al. Diabetes Care. 2011;34(2):256–261.

Basal-bolus ismore effective atglycemic controlvs SSI therapy inmedical andsurgical patients.3,4

Effective insulin therapy may contain basal, bolus, andsupplemental doses to achieve target goals.1

Adapted from Bray et al.2

0

25

50

75

0 8:00 12:00 16:00 20:00 24:00 4:00 8:00

Breakfast Lunch Dinner

Bolus (nutritional) insulin

Basal insulin

Plas

ma

Insu

lin (

U/m

L)

Time

Correction insulin

Benefits of Insulin Analogsvs Human Insulin

• Insulin analogs are derivatives of human insulinthat have undergone one or more chemicalmodifications to alter the time-action profile ofthe insulin

• They are produced by recombinant DNA (rDNA)technology

• Time-action profile of SC human insulin does notalways match physiologic demand

• Insulin analogs were designed to more closely mimicnormal physiologic insulin secretion patterns

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Basal Analogs Offer Advantages

FPG = fasting plasma glucose; NPH = neutral protamine Hagedorn.1. Brunton S et al. J Fam Pract. 2005;54(5):445–452. 2. Tanwani LK. Am J Geriatr Pharmacother. 2011;9(11):24–36.

Compared with NPH, basalinsulin analogs provide2:• Reduced rate of hypoglycemia• Once-daily dosing in T2DM• Similar reduction in FPG

Theoretical insulin profile1

NPH

Basal analog

0 24Time (hours)

Seru

m In

sulin

Lev

el

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Advantages of Rapid-acting Insulin Analogs

1. Freeman JS. J Am Osteopath Assoc. 2009;109(1):26–36. 2. Tanwani LK. Am J Geriatr Pharmacother. 2011;9(11):24–36.3. Handelsman Y et al; AACE Task Force for Developing Diabetes Comprehensive Care Plan. Endocr Pract. 2011;17(suppl 2):1–53.

Compared with RHI,rapid-acting insulinanalogs2,3:• Provide a more physiologic

response• Have a more rapid onset

and shorter duration ofaction

• Are associated withless severe episodesof hypoglycemia

* Theoretical representations of insulin levels over time. Adapted from Freeman JS.1

Regular HumanInsulin (RHl)

Rapid-actinginsulin analogs

0 20Time (hours)

Rela

tive

Insu

lin E

ffect

s

Theoretical insulin profile1*

10

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Insulin Analogs

First Generation• Rapid Acting

– Insulin lispro– Insulin aspart– Insulin glulisine

• Long Acting– Insulin glargine– Insulin detemir

Second Generation• Rapid Acting

– FIAsp (NN1218) insulin*aspart with addition ofL-arginine and nicotinamideas an absorption modifier

• Long Acting– Glargine U-300– Insulin degludec*– PEGylated insulin lispro

(LY2605541)*

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*Investigational, not approved by the FDA.

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Hirsch IB. N Engl J Med. 2005;352:174-183. The New England journal of medicine by MASSACHUSETTS MEDICAL SOCIETY Reproducedwith permission of MASSACHUSETTS MEDICAL SOCIETY, in the format reuse in CME materials via Copyright Clearance Center.

0 1 2 53 4 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Regular 6–8 hoursNPH 12–20 hours

Hours

Insulin glargine, insulin detemirup to 24 hours

Insulin aspart, insulin glulisine, insulin lispro 4–6 hours

PlasmaInsulinLevels

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Time-action Profiles of Available Insulin Products

SC Correction Insulin Algorithms

• Does NOT replace scheduled insulin– Rather, it corrects for changing needs

• Based on the insulin sensitivity of the patient– Inferred from total daily insulin requirement, or– Inferred from weight/BMI

• Utilize same rapid-acting analog as that of thenutritional (bolus) insulin– Need rapid onset and short duration of action

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Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16–38.

Supplemental Insulin Scale

BG (mg/dL) Insulin-sensitive Usual Insulin-resistant

>141–180 2 4 6

181–220 4 6 8

221–260 6 8 10

261–300 8 10 12

301–350 10 12 14

351–400 12 14 16

>400 14 16 18

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• If a patient is able and expected to eat all or most of his/her meals, supplemental insulin will beadministered before each meal following the “usual” column dose

• Start at insulin-sensitive column in patients who are not eating, elderly patients, and those withimpaired renal function

• Start at insulin-resistant column in patients receiving corticosteroids and those treated with morethan 80 U/day before admission

Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16–38.

• The numbers in eachcolumn indicate thenumber of units of regularor rapid-acting insulinanalogs per dose.

• “Supplemental” dose is tobe added to the scheduledinsulin dose. Give half ofsupplemental insulin doseat bedtime.

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Sliding-scale Insulin (SSI)

• Definition– Use of a mealtime insulin, typically regular insulin,

as the sole insulin for managing a patient’s diabetes• Potential problems

– Poor control of hyperglycemia (does not addressbasal insulin needs)

– Insulin “stacking”– Hypoglycemia

• Not preferred method of SC insulin delivery

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American Diabetes Association. Diabetes Care. 2014;37(suppl 1):S14–S80.Browning LA, Dumo P. Am J Health Syst Pharm. 2004;61(15):1611–1614.Hirsch IB. JAMA. 2009;301(2):213–214.

Umpierrez G E et al. Diabetes Care. 2011;34(2):256–261. Diabetes care by AMERICAN DIABETES ASSOCIATION Reproduced with permissionof AMERICAN DIABETES ASSOCIATION. in the format Republish in continuing education materials via Copyright Clearance Center.

Glucose Levels During Basal-bolus andSSI Treatment

Changes in BG concentration after thefirst day of treatment with basal-boluswith glargine once daily plus glulisinebefore meals (○) and with SSI 4 times daily(●). *P <0.001, ‡P = 0.02, †P = 0.01.

Glucose levels before meals and bedtime.Premeal and bedtime glucose levels werehigher throughout the day in the SSI group(●) compared with basal-bolus regimen (○).

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Randomization

Bloo

d G

luco

se (m

g/dL

)

120

*

*

‡

Duration of Treatment (days)

1 2 3 4 5 6 7 8 9

‡†

†

A

Breakfast

Bloo

d G

luco

se (m

g/dL

)

220

180

200

140

160

120

*

*

Duration of Treatment (days)

*

B

220

180

200

140

160

*

Lunch Dinner Bedtime

RABBIT-2 Surgery: Composite Hospital Complicationsand Outcomes: SSI vs Basal-bolus Insulin

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Umpierrez G E et al. Diabetes Care. 2011;34(2):256–261.*P = 0.003; **P = 0.050.

26

11

35

11

21

19.6

9

3

01

4

1 1

12.5

0

5

10

15

20

25

30

Number ofpatients with

complications*

Woundinfections**

Pneumonia Acuterespiratory

failure

Acute renalfailure

Bacteremia Mortality Postsurgery ICUadmission

Sliding Scale Insulin

Basal Bolus Insulin

ICU length of stay 3.19 vs 1.23 days; P = 0.003 SSI vs BBICU length of stay 3.19 vs 1.23 days; P = 0.003 SSI vs BB

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Non-insulin Therapies in the Hospital

Sulfonylureas may lead tohypoglycemia if nutrition is

interrupted.

Metformin contraindicated in settingof altered renal function, dehydration,

acidosis, hypoxia, surgery, andfollowing the use of iodinated

contrast dye.

Thiazolidinediones are not rapidlyeffective. They are associated with

edema and congestive heart failure.

Incretin-based therapies (GLP-1receptor agonists, DPP-4 inhibitors)

have a greater effect on postprandialglucose — so would be effective

mainly in eating patients. The formerare associated with nausea.

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DPP-4 = dipeptidyl peptidase-4; GLP-1 = glucagon-like peptide-1.ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care. 2006;29(8):1955–1962.Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353–369.Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16–38.

There is not extensive published experience with non-insulin agents in the hospital.

Case Study Example—Moving to Stepdown Unit

• Patient is stable; will be moved out of the ICUand will begin scheduled meals

• The average dose of IV insulin was1.5 units/hour over the past 8 hours

• TDD is ~40 units– 80% of 40 = 32 units

Basal insulin = 50% of TDD = ~16 units (glargine/detemir)Nutritional = 50% of TDD = ~5 units per meal (x 3 meals)

(lispro/glulisine/aspart)

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Doses are then titrated against actual glucose levels.Doses are then titrated against actual glucose levels.

Medical Nutrition Therapy (MNT)

• MNT should be a component of the glycemicmanagement program for all hospitalized patientswith DM and hyperglycemia

• Consistent amount of carbohydrates at each mealcan be useful in coordinating doses of rapid-actinginsulin to carbohydrate ingestion

• Dietitian to provide carbohydrate content of meals• If amount of carbohydrates vary, fixed insulin doses

will be either too much or too little, resulting influctuations in blood glucose levels

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Striking the Right Balance

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HyperglycemiaHypoglycemia

Essential Part of Any Insulin Use:A Hypoglycemia Protocol

• Clear definition of hypoglycemia– Glucose level (ADA) <70 mg/dL

• Nursing order to treat without delay– Stop insulin infusion (if patient is on one)– Oral glucose (if patient is able to take POs)– IV dextrose or glucagon (if patient is unable to take POs)– Repeat BG monitoring 15 minutes after treatment for hypoglycemia

and repeat treatment if BG not up to target– Directions for when and how to restart insulin

• Documentation!• Look for the cause of hypoglycemia and determine if changes in the

antihyperglycemic treatment strategy are needed

41

ACE/ADA Task Force on Inpatient Diabetes. Endocr Pract. 2006;12(4):458–468.American Diabetes Association. Diabetes Care. 2009;31(suppl 1):S1–S110.Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16–38.

Hypoglycemia Orders

– Nurse treat per protocol, treat if bedside BG level<70 mg/dL; notify resident

• Juice, intravenously administered dextrose, orintramuscularly administered glucagon depending onability to take oral nutrition and intravenous access

• Recheck bedside BG level in 15 minutes and repeatas necessary

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Adapted from Schnipper JL et al. Endocr Pract. 2010;16(2):209–218.

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Causes of Treatment-related Hypoglycemia

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Elliott MB et al. J Diabetes Sci Technol. 2012;6(2):302–309.

Incidence percentage of proximate causes of hypoglycemia

0

Excess insulin

50 60 70

Inadequate monitoring

Diet change

Administration error

Hyperkalemia treatment

Physician computerentry error

20 30 4010

Scenarios Prompting Increased Monitoring andPossible Decreases in Insulin Dose

• Patient is switched to NPO status• Reduction in food intake• Discontinuation of enteral feeding or TPN• Discontinuation or reduction in IV dextrose• Timing of premeal insulin if meal disrupted due to

medical procedures or patient transport• Reduction in corticosteroid administration

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NPO = nothing by mouth; TPN = total parenteral nutrition.

Transition From Hospital to Outpatient Care?

• Preparation for transition to the outpatient settingshould begin at the time of hospital admission

• Multidisciplinary team: bedside nurse,clinical pharmacist, registered dietitian,case manager

• Clear communication with outpatient providers iscritical for ensuring safe and successful transitionto outpatient management

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Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16–38.

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Transition to Discharge

• Does patient have a glucose monitor for home use?• Does patient know how to inject insulin and how to

prevent and to treat hypoglycemia?• Is patient clear about the diabetes therapy

after discharge?• Does patient have appropriate outpatient follow-up

appointment with primary care or specialist?

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Predischarge Checklist

• Diet information• Monitor/strips & Rx• Rx for/supplies of medications, insulin, needles• Treatment goals• Contact phone numbers• “Medi-Alert” bracelet• “Survival Skills” training

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“Survival Skills” to Be Taught Before Discharge

• Basic understanding ofwhat diabetes is

• How and when to takediabetes medications

• Basic knowledge of effectof carbohydrates onglucose levels

• Recognition, treatment,and prevention ofhypoglycemia

• Self-monitoring of BG andimplication of results

• What to do during illness• How to dispose of lancets

and insulin syringes

Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353–369.

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Case Study: Severe Hyperglycemia onAdmission in a Patient with Diabetes

• 59-year-old obese male patient with priorhistory of T2DM controlled on metformin,glipizide, and sitagliptin; admitted to thecritical care unit with sepsis

• On presentation– BG = 329 mg/dL– BP = 108/56 mm Hg– HR = 95 bpm– Respiration = 18 breaths per minute

• Patient weight = 220 lb; height = 5′10″; BMI = 31.6 kg/m2

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BG = blood glucose; BMI = body mass index; BP = blood pressure; HR = heart rate; T2DM = type 2 diabetes mellitus.

Case Study Resolution

• Patient prepares for discharge• A1C level is 8.8%• Patient was on 3 oral agents prior to hospital stay

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How would you manage this patient?

Possibilities for Discharge Hyperglycemia Regimen

• Home regimen• Titration of home regimen• Or new insulin regimen (if last option, simple

regimen with aggressive patient educationand prompt follow-up)

Based on hemoglobin A1C:Based on hemoglobin A1C:

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Case Study Resolution

• Discharge plan– Discuss with the patient the need for basal insulin

in addition to his oral agents– Educator to provide hands-on instruction on

administration techniques– Provide education to caregiver/family if possible– Comprehensive outpatient education should be

scheduled

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Key Learning Points

Insulin remains the most appropriate agent for a majority of hospitalizedpatients.Insulin remains the most appropriate agent for a majority of hospitalizedpatients.

In critically ill patients, insulin is given as a continuous IV infusion.In critically ill patients, insulin is given as a continuous IV infusion.

In noncritically ill inpatients, hyperglycemia is best managed using scheduledSC basal-bolus insulin regimens supplemented with correction doses asneeded and adjusted daily with the guidance of frequent BG monitoring.

In noncritically ill inpatients, hyperglycemia is best managed using scheduledSC basal-bolus insulin regimens supplemented with correction doses asneeded and adjusted daily with the guidance of frequent BG monitoring.

Prevention of hypoglycemia is equally as important to patient outcomes andis an equally necessary part of any effective glucose control program.Prevention of hypoglycemia is equally as important to patient outcomes andis an equally necessary part of any effective glucose control program.

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Key Learning Points

Modern insulin analogs offer advantages over the older human insulins(eg, regular and NPH insulin) because their time-action profiles more closelycorrespond to physiological basal and prandial insulin requirements, andhave a lower propensity for inducing hypoglycemia than human insulinformulations.

Modern insulin analogs offer advantages over the older human insulins(eg, regular and NPH insulin) because their time-action profiles more closelycorrespond to physiological basal and prandial insulin requirements, andhave a lower propensity for inducing hypoglycemia than human insulinformulations.

Long-acting basal insulin analogs (glargine, detemir) are suitable andpreferred for the basal component of therapy; rapid-acting insulin analogs(aspart, lispro, glulisine) are recommended for bolus and correction doses.

Long-acting basal insulin analogs (glargine, detemir) are suitable andpreferred for the basal component of therapy; rapid-acting insulin analogs(aspart, lispro, glulisine) are recommended for bolus and correction doses.

Sliding-scale insulin (SSI) regimens are not recommended, specificallybecause they exclude a basal insulin component from the therapy.Sliding-scale insulin (SSI) regimens are not recommended, specificallybecause they exclude a basal insulin component from the therapy.

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Resources

American Association of Clinical Endocrinologists InpatientGlycemic Resource Center

http://www.aace.com/resources/igcrc/

Institute for Safe Medication Practiceshttp://www.ismp.org/default.asp

American Society of Hospital Pharmacists: Safe Use ofInsulin in Hospitals

hhtp://www.ashop.org/s_ashp/docs/files_Safe_Use_of_Insulin.pdf

Society for Hospital Medicine Resource Centerhttp://www.hospitalmedicine.org/ResourceRoomRedesign/Glyce

micControl.cfm

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