Treatment of diabetes mellitus in hospitals Done by: Fatimah Al-Shehri Pharm.D Candidate King...
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Treatment of diabetes mellitus in hospitals Done by: Fatimah Al-Shehri Pharm.D Candidate King Abdulaziz university Supervised by: Dr.Hani Hassan Clinical
Treatment of diabetes mellitus in hospitals Done by: Fatimah
Al-Shehri Pharm.D Candidate King Abdulaziz university Supervised
by: Dr.Hani Hassan Clinical pharmacist/internal medicine.
Slide 2
Outline -Introduction. -Goals in the hospital settings.
-Prevention of hyperglycemia and hypoglycemia. -Treatment.
Slide 3
Introduction: Glycemic control is unstable in hospitalized
patients because of : - Stress of the illness or procedure. -
Concomitant changes in dietary intake - Physical activity.
-Frequent interruption of the patient's usual antihyperglycemic
regimen.
Slide 4
Goals in hospitals : - Avoid hypoglycemia. -Avoid severe
hyperglycemia. -Avoid volume depletion --Avoid electrolyte
abnormalities. -Ensure adequate nutrition.
Slide 5
Avoidance of hypoglycemia: Hypoglycemia (ie, serum glucose
conc
Slide 6
Avoidance of hyperglycemia: It is a long-standing clinical
observation when blood glucose sugar is above 110mg/dl.
Hyperglycemia consequences : - Volume and electrolyte disturbances
mediated by osmotic diuresis. - caloric and protein loss in
under-insulinized patients. -Immune and neutrophil function is
impaired.
Slide 7
Glycemic targets in hospitals: Target of the blood sugar
deepens on the severity of the illness. A-Critically ill patients.
B-Non-critically ill patients.
Slide 8
:Non-critically ill Glycemic goals in non-critically ill
patients :
Slide 9
Treatment
Slide 10
Treatment of hyperglycemia in hospital: 1- The type of
diabetes. 2-The patient's current BG concentrations. 3-Prior
treatment. 4-The severity of illness. 5- The expected caloric
intake during the acute episode..
1-Insulin : Types of insulin: 1-long-acting insulin: such as
glargine or detemir. 2-Intermediate-acting insulin:such as NPH. 3-
Premeal rapid or short-acting insulin such as :regular insulin,
aspart, lispro.
1-Basal bolus insulin regimen : 1-Basal bolus regimen: Basal
Insulin: Prevents between meal and overnight hyperglycemia Bolus
insulin: Limits hyperglycemia after meals.
Slide 20
1-Basal bolus insulin regimen: Proactive Approach: Anticipate
major change in blood glucose levels and prevent them from
occurring Insulin therapies that mimic physiological release of
insulin. Individualized basal-bolus insulin therapies (BBI)
Slide 21
:2-Sliding-scale insulin SSI: involves use of regular insulin
or a rapid-acting insulin analogue provided without any other
scheduled short-acting or long-acting insulin.
Slide 22
2-Sliding scale insulin: Urine glucose monitoring. Boil urine
sample with solution containing copper sulfate. 1934 Sliding Scale
by Elliot Joslin.
Slide 23
3-Todays Insulin Sliding Scale: Blood glucose monitoring, Use
of glucometer. Regimens for rapid-acting or short-acting insulin.
Schedule:TID-QID. Units :Blood glucose level : 0 Unit.20
Slide 24
Which sliding scale :
Slide 25
Advantages & Disadvantages of ISS: AdvantagesDisadvantages
Not individualized Creates a roller coaster effect Reactive
Approach Not evidence based practice Can initiate right away
SimpleConvenient Umpierrez GE, Palacio A, Smiley D. Sliding scale
insulin use: myth or insanity? Am J Med 2007; 120: 563 567
Slide 26
2-Insulin sliding scale :
Slide 27
SSI - Traditional Insulin Sliding Scales: No basal insulin. -
Supplemental Scale or Correction Scale: ISS + (basal insulin +/-
bolus insulin) Primarily used AS: dose-finding strategy (bolus
insulin dosage) -As a supplement when rapid changes in insulin
requirements (i.e. stress or illness)
Slide 28
ISS vs. BBI?
Slide 29
Evidence against SSI:
Slide 30
Rabbit trial 2:
Slide 31
Evidence against the SSI :
Slide 32
Although sliding scale insulin regimens are prescribed for the
majority of inpatients with diabetes, they appear to provide no
Benefit.. in fact, when used without a standing dose of
intermediate- acting insulin, they are associated with an increased
rate of hyperglycemic episodes.
Slide 33
Evidence against SSI: MJA 2012; 196: 266269 doi:
10.5694/mja11.10853
Slide 34
Mean change in BGL from baseline in the two insulin therapy
groups. MJA 2012; 196: 266269 doi: 10.5694/mja11.10853
Slide 35
Conclusion : under routine clinical conditions, implementation
of a BBI protocol to manage hyperglycaemia in hospitalised patients
resulted in a lower mean daily BGL than did SSI. BBI is associated
with an increase in mild, but not severe, hypoglycaemia. We
recommend that protocols for inpatient glycaemic control based
around BBI be widely implemented.
Slide 36
Time to stop SSI: 1-Unaware of problems associated with ISS 2-
Unwilling to make changes to therapies initiated by another
physician 3- Lack of evidence Long-term care (LTC) setting
Slide 37
Slide 38
QUESTION: AS clinical pharmacist, When making your
recommendation to the physician, what information might you want to
include about SSI and BBI ? A-Basal-bolus is a proactive approach
to management, preventing hyperglycemia without increasing the risk
of hypoglycemia. B-The use of insulin sliding scale is not
evidence-based practice. C-Insulin sliding scale is most likely the
medication causing the patient to fall and affecting patients
ability to focus. D- All of the above.
Slide 39
:3- Correction insulin The dose of correction insulin should be
individualized based upon relevant patient characteristics such as
: - Previous level of glucose control. - Previous insulin
requirements. - The carbohydrate content of meals. Correctional
insulin needs : - 1800 rule: 1800/TDI=number of mg/dl of glucose
lowering per 1 unit of rapid acting insulin. ((1 unit of rapid
actin insukin will reduce the BG concentration by x mg/dl. - 1500
rule :1500/TDI.
Slide 40
:3- Correction insulin Correction insulin alone may also be
used : - As initial insulin therapy in patients with type 2
diabetes previously treated at home with diet or an oral agent, who
will not be eating regularly during hospitalization. It is
typically administered every six hours as regular insulin. However,
if the patient is eating and finger stick glucoses are consistently
elevated (>180mg/dL [10.0 mmol/L]) : (basal-bolus regimen).
Slide 41
Insulin requirements: 50 % of the total daily dose can be given
as BI. The remaining 50% can be given in equally divided doses
prior to meals (1/3 prior to each meal). 2-Regular insulin:1-Basal
bolus regimen: 70%(2/3) of the dose given in the morning. 30%(1/3)
of the dose given in the evening. 50% basal insulin. 50% bolus
insulin. e.g: 25 units/day (NPH). - 16 units in the morning. - 9
units in the evening. e.g: 25 units/day. - Glargin:12.5 unit as
basal -Lispro: 12.5 ( 4.4.4 ) as bolus.
4-Insulin infusion: Insulin infusions are typically used in
critically ill ICU patients, rather than in patients on the general
medical wards of the hospital.