Diabetes Management in Hospital Orlando, May 31, 2003 Paul C. Davidson, MD, FACE Atlanta Diabetes...

Diabetes Management in Hospital

Orlando, May 31, 2003

Paul C. Davidson, MD, FACE

Atlanta Diabetes Associates

Atlanta, Georgia

Diabetes in Hospitalized Patients

• 6 Million US Hospitalizations

15% of Admissions

• 24 Million Hospital Days

20% of All Hospital Days

• 36% First Diagnosed in Hospital 66% No Documentation by Physician 27% Labeled Hyperglycemia

2% Diagnosis on Face Sheet

Diabetes in Hospitalized Patients1997 Costs

•$$23,500 Each Diabetes Patient vs.23,500 Each Diabetes Patient vs. $12,200 for Non-Diabetes Patient$12,200 for Non-Diabetes Patient

•60% of All Diabetes-Related Costs60% of All Diabetes-Related Costs

•Only 5% DKA, HHNKCOnly 5% DKA, HHNKC

•48% Diabetes Complications48% Diabetes Complications

•52% Other Conditions52% Other Conditions

Impairment of Phagocytic Function Bybee, 1964

Short, Transient Hyperglycemia

Abnormalities in granulocyte

adherence, chemotaxis, phagocytosis,

bacterocidal function. Bybee, 1964; Hill, 1974;

Chase, 1981; Rosenberg, 1990

Effects of HyperglycemiaInfectious Disease

Global PerspectivesEffect of Underlying DiabetesImpact of Acute Diabetic State

Stress ResponseCounter Regulatory Hormones

Epinephrine, Glucagon, Cortisol, GH Glucose Toxicity

Increased Glucose, FFA, KetonesAcidosis: Lactic or KetosisMechanism of Progressive Insulin Resistance

Diabetes in Hospitalized Patients Diabetes in Hospitalized Patients ..

PathophysiologyPathophysiology

Role of Insulin and Glucose in Acute MI

Insulin Anti-inflammatory

– Acute Reduction CRP Anti-thrombotic

– Profibrinolytic

• Suppresses PAI-1 Suppresses FFA

– Preserve Endothlium Suppresses MMPs

– Prevents Rupture

Glucose

Pro-inflammatory

Pro-thrombotic

Induces MMPs (Matrix Matalloproteinases)

– Mediates Plaque Rupture

Dandona Diab Care 2003

Detriments:Decreased AppetiteMeals Held or DelayedDecreased ActivityOral Agents StoppedInsulin HeldSliding Scale Insulin

Only for Extreme BGs Benefit: Detecting Hyperglycemia

Effects of Hospitalization

on Diabetes Management

Missed Opportunities:

To Reduce Hospital Morbidity and

Mortality

To Initiate Interventions to Delay

Long-term Complications

Diabetes in Hospitalized Patients Diabetes in Hospitalized Patients ..

Failure to Treat Hyperglycemia

Diabetes in Hospitalized Diabetes in Hospitalized

Patients .Patients . Psychology Psychology

Patients expect good glycemic control as part of Patients expect good glycemic control as part of

hospital carehospital care

They strive for recommended goals at homeThey strive for recommended goals at home

Difficult to understand staff’s casual approach to Difficult to understand staff’s casual approach to

BG’s >150BG’s >150

Diabetes in Hospitalized Diabetes in Hospitalized Patients . Patients .

Clinical RisksClinical Risks

• High-risk for Bacterial Infection– Surgery– Catheters– Intravenous Access– Anesthesia

• Problems with wound healing

• Problems with tissue and organ perfusion

Infections in Diabetes

One BG >220 mg/dl results in 5.8 times increase in nosocomial infection rate

Two hours hyperglycemia results in impaired WBC function for weeks

Pomposelli, New England Deaconess, J Parenteral and Enteral Nutrition 22:77-81,1998

Side Effects of BG >200 mg/dl Side Effects of BG >200 mg/dl

Reduced Intravascular VolumeReduced Intravascular Volume

DehydrationDehydration

Electrolyte FluxesElectrolyte Fluxes

Impaired WBC FunctionImpaired WBC Function

Immunoglobulin InactivationImmunoglobulin Inactivation

Complement DisablingComplement Disabling

Increased Collagenase, Decreased Wound Increased Collagenase, Decreased Wound CollagenCollagen

Evidence for Immediate Benefit of Evidence for Immediate Benefit of Normoglycemia in Hospitalized PatientsNormoglycemia in Hospitalized Patients

Numerous Publications on in Vitro EvidenceNumerous Publications on in Vitro Evidence

– Neutrophil DysfunctionNeutrophil Dysfunction

– Complement InhibitionComplement Inhibition

– Altered Redox State (Pseudohypoxia)Altered Redox State (Pseudohypoxia)

– Glucose Rich Edema as Culture MediaGlucose Rich Edema as Culture Media

Recent Outcome Studies Supporting Good Glucose Control in Hospital Recent Outcome Studies Supporting Good Glucose Control in Hospital SettingSetting

Reduction in CRPReduction in CRP

Open Heart Surgery in DiabetesPortland St. Vincent Medical Center

Control Group

N=968

1987-1991

SubQ Insulin q 4 h

Goal 200 mg/dl

Standard Deviation 36

All Mean BG’s <200 47%

Study Group

N=1499

1991-1997

IV Insulin

Goal 150-200 mg/dl

Standard Deviation 26

All Mean BG’s <200 84%

Furnary et al, The 34th Meeting of The Society of Thoracic Surgeons New Orleans, LA January 26, 1998

170180190200210220230240250

DOS POD 1 POD 2 POD 3

SQI

CII

Open Heart Surgery in DiabetesPortland St. Vincent Medical Center Perioperative Blood Glucose

Furnary et al, The 34th Meeting of The Society of Thoracic Surgeons New Orleans, LA January 26, 1998

Incidence of DSWI: 1987-1997

0.0%

1.0%

2.0%

3.0%

4.0%

87 88 89 90 91 92 93 94 95 96 97

Year

DS

WI DM Pts.

Non-DM

CII

Furnary, et al, The 34th Meeting of The Society of Thoracic Surgeons New Orleans, LA January 26, 1998

Open Heart Surgery in DiabetesOpen Heart Surgery in DiabetesPortland CII ProtocolPortland CII Protocol

MortalityMortality AllAll (99/2467) 4.0%(99/2467) 4.0%

SQI SQI 6.1% 6.1%

CIICII 3.0% 3.0%

DSWIDSWI 19.0% 19.0%

No DSWI 3.8%No DSWI 3.8%

Recent ExperienceRecent Experience

1994-1997 DSWI as in non-diabetics1994-1997 DSWI as in non-diabetics

1996-7 No DSWI in last 15 mo.1996-7 No DSWI in last 15 mo.

Open Heart Surgery in DiabetesJohn Hopkins

24.3% with infections

BG divided into quartiles Relative Odds

Q1 121-206 20.1%

Q2 207-229 21.6% 1.17

Q3 230-252 29.8% 1.86*

Q4 252-352 25.7% 1.72*

Golden SH Diabetes Care 22: 1408, 1999 * P < 0.01

Admission glucose values >108 mg/dl

IV Insulin with Bypass Surgery

Hospital mortality identical

Diabetics and Non-diabetics (1.75%

vs. 1.71%)

Usual Diabetic Mortality 50% Higher

CABG in DiabetesKalin 1998

DIGAMI StudyDiabetes, Insulin Glucose Infusion in Acute Myocardial Infarction

Acute MI With BG > 200 mg/dl Intensive Insulin Treatment IV Insulin For > 24 Hours Four Insulin Injections/Day For > 3 Months Reduced Risk of Mortality By:

28% Over 3.4 Years

51% in Those Not Previous Diagnosed

Malmberg BMJ 1997;314:1512Malmberg BMJ 1997;314:1512

Cardiovascular RiskMortality After MI Reduced by Insulin Therapy in the DIGAMI Study

Malmberg, et al. BMJ. 1997;314:1512-1515.

All Subjects

(N = 620)Risk reduction (28%)

P = .011

Standard treatment

0

.3

.2

.4

.7

.1

.5

.6

0 1Years of Follow-up

2 3 4 5

Low-risk and Not Previously on Insulin

(N = 272)Risk reduction (51%)

P = .0004

IV Insulin 48 hours, then 4 injections daily

0

.3

.2

.4

.7

.1

.5

.6

0 1Years of Follow-up

2 3 4 5

6-11

623 Hyperglycemic Patients

Mortality and Stroke Severity

Increase Linearly with BG

BG >144 mg/dl in First 24 Hours

Double Mortality Risk

Stroke in Diabetes

Weir

Diabetes with Steroid TherapyPiedmont Hospital

1998

Problem Noted by DRC Case Managers

– Frequency of Hyperglycemia in “Non-Diabetic” Patients

– Prevalence Among Steroid Treated

– No Systematic Plan of Response

– Frequency of Discharge “Out-of-Control”

The Dark Side of CorticosteroidsThe Dark Side of Corticosteroids

Diabetes with Steroid TherapyPiedmont Hospital1998

N ot Tes ted0 %

N ot Trea ted0 %

U n con tro lled B G6 3 %

1 2 % o f To ta l

C on tro lled B G3 7 %

Trea ted1 0 0 %

B G > 2 0 01 0 0 %

C on tro lled B G0 %

B G Tes ted1 0 0 %

K n ow n D iab e tes1 9 %

N ot Tes ted2 6 %

2 1 % o f To ta l

N o t Trea ted2 3 %

7 % o f To ta l

U n con tro lled B G8 0 %

1 9 % o f To ta l


Trea ted7 7 %

B G > 2 0 05 2 %


B G Tes ted7 4 %

N o R ecord ed D iab e tes8 1 %

P atien ts R ece ivin g > 5 0 m g m P red n ison e E q u iva len t in O n e D ay6 6 3 1 ou t o f 2 5 ,3 0 9 A d m iss ion s

Chart Review by Terry Kaplan RNChart Review by Terry Kaplan RN

Diabetes with Steroid TherapyPiedmont Hospital1998

Controlled41%

Not Tested21%

Not Treated7%

Uncontrolled31%

Opportunity for Improvement 59%

Classical Diabetes ManagementTypical A1c 9%

The daily dosage of insulin is divided

– 2/3 in the morning and 1/3 in the evening.

– Two thirds NPH and 1/3 Regular.

Results

– 70/30 Insulin

• (The insulin for the retarded)

– No Patients to Goal!

Sliding Scale Insulin

Five Units for Each Plus on bid Urine TestingTable of BG Ranges and R DosesCorrection Bolus Formula

–(BG-Target BG) / CF

No Benefit When Used Without Basal InsulinThree Times More Hyperglycemia Compared to Standing Dose NPHQueale, 1997

ICU Survival

1548 Patients (mostly OHS pts.)

All with BG >200 mg/dl

Randomized into two groups

– Maintained on IV insulin

– Conventional group (BG 180-200)

– Intensive group (BG 80-110)

Conventional Group had 1.74 X mortality

Van den Berghe et al, NEJM 2001;345(19):1359

ICU Survival

Conventional Intensive

Mean AM BG 153 103

% Receiving Insulin 39% 100%

BG < 40 mg/dl 6 39


No serious hypoglycemic events

ICU Survival

Intensive Therapy (80 to 110 mg/dL) resulted in:

34% reduction in mortality

46% reduction in sepsis

41% reduction in dialysis

50% reduction in blood transfusion

44% reduction in polyneuropathy


ICU IV Insulin Protocol

Arterial BG q 1-2 hrs

If > 100 mg/dl, 2 U/h If > 200 mg/dl, 4 U/h

If > 140 mg/dl, increase by 1 – 2 U/h

If 121 to 140 mg/dl, increase by 0.5 – 1 U/h

If 111 to 120 mg/dl, increase by 0.1 – 0.5 U/h

If 81 to 110 mg/dl, no change

If 61 to 80 mg/dl, change back to prior rate


Methods For Managing Hospitalized Persons with Diabetes

Continuous Variable Rate IV Insulin Drip

Major Surgery, NPO, Unstable, MI, DKA, Hyperglycemia, Steroids, Gastroparesis, Delivery, etc

Basal / Bolus Therapy (MDI)

Continuous Variable Rate IV Insulin Davidson 1982

Mix Drip with 125 units Regular Insulin in 250 cc NS

Starting Rate: Units / hour = (BG – 60) x 0.02

Check glucose hourly and adjust

Change Multiplier to keep in desired range

– 100 to 140 mg/dl

Continuous Variable Rate IV Insulin

Adjust Multiplier to obtain glucose in target range

If BG not decreasing > 50 mg/dL and > 140 mg/dL, increase by 0.01

If BG < 100 mg/dL, decrease by 0.01

If BG 100 to 140 mg/dL, no change in Multiplier If BG is < 80 mg/dL, Give D50 cc = (100 – BG) x 0.4 Give continuous rate of Glucose in IVF’s Once eating, continue drip till 2 hour post SQ

insulin

Glucommander

Invented in 1984 Davidson and Steed

Based on 17 Year Experience with a Computer Based Algorithm for the Administration of IV Insulin

Developed for Marketing by MiniMed and Roche

GMS System

Shelved Pending FDA Approval of IV Use of Insulin

Useful and Safe for Any Application of IV Insulin

Glucommander

Computer Based Algorithm for IV Insulin

Invented by Davidson and Steed in 1984

17 Year Experience

Developed for Marketing by MiniMed and Roche

GMS System

Shelved Pending FDA Approval of IV Insulin

Useful and Safe for Any Application of IV Insulin

Glucose Management System

Glucommander .

Summary of PerformanceGlucose Averages for 3404 Patients

Glu

cose

mg

m/d

l

Hours

50

Pe

rce

nti

les

90

10

Glucommander . Effectiveness

Initial blood glucose

– Median 292 mg/dl

– Range 181-1,568 Time to achieve glucose < 180 mg/dl

– Median 3 hours

– Range 0.3 - 19.7 Time to achieve first of three consecutive glucose results between 60 -

180 mg/dL

– Median 3. 1 hours

– Range 0.3 - 22.5

GlucommanderPrinciples

0123456789

10

0 100 200 300 400 500

Insu

lin

Un

its

/ H

ou

r

Glucosemgm / dl

GlucommanderComparsion to Other Systems

0123456789

10

0 100 200 300 400 500

Insu

lin

Un

its

/ H

ou

r

Glucosemgm / dl

Glucommander

ADA

MARKS

FURNEY

METCHICK

VAN DEN BERGHE

IV DRIP

Hospital Diabetes PlanHospital Diabetes Plan

NPO Pathway For All Diabetes PatientsNPO Pathway For All Diabetes Patients

Finger Stick BG ac qid on ALL AdmissionsFinger Stick BG ac qid on ALL Admissions

Check All Steroid Treated PatientsCheck All Steroid Treated Patients

Diagnose DiabetesDiagnose Diabetes

FBG >126 mg/dlFBG >126 mg/dl

Any BG >200 mg/dlAny BG >200 mg/dl

Paul Davidson MDPaul Davidson MDAtlanta Diabetes AssociatesAtlanta Diabetes Associates


Document Diagnosis in ChartDocument Diagnosis in Chart

Hyperglycemia Is Diabetes Until Proven OtherwiseHyperglycemia Is Diabetes Until Proven Otherwise

Bring to All Physician’s AttentionBring to All Physician’s Attention

Note on Problem List and Face SheetNote on Problem List and Face Sheet

Check Hemoglobin A1CCheck Hemoglobin A1C

Hold Metformin; Hold TZD with CHF, Liver DysfunctionHold Metformin; Hold TZD with CHF, Liver Dysfunction

Use Insulin in All Hospitalized Persons with Diabetes Use Insulin in All Hospitalized Persons with Diabetes Continue for Course of Hospitalization

Paul Davidson MDAtlanta Diabetes Associates


Get Diabetes Education ConsultGet Diabetes Education Consult

Instruct Patient in Monitoring and RecordingInstruct Patient in Monitoring and Recording

See That Patient Has Meter on DischargeSee That Patient Has Meter on Discharge

Decide on Case Specific Program for DischargeDecide on Case Specific Program for Discharge

Arrange Early F/U with PCPArrange Early F/U with PCP

Paul Davidson MDAtlanta Diabetes Associates


Follow National Guidelines For Endocrinology Consults

– Any Type 1

– Any Hypoglycemia Requiring Intervention

– DKA or HHNC

– Patient on Insulin Pump

– Pregnant Diabetic

– Glucocorticoid Therapy in Diabetes

– Progressive Diabetic Complications

– HbA1c >8%, Microalbuminuria >30 mg,LDL >130, HDL <35, TG >400 mg/dl

Treat Any Patient With BG > 150 With InsulinTreat Any Patient With BG > 150 With Insulin

– Treat Any BG >150 with Rapid-acting Insulin Treat Any BG >150 with Rapid-acting Insulin (BG-100) / (7000 / wt #) (BG-100) / (7000 / wt #)

– Treat Any Recurrent BG >200 with IV InsulinTreat Any Recurrent BG >200 with IV Insulin

If More than 0.5 u/hr IV Insulin Required with Normal If More than 0.5 u/hr IV Insulin Required with Normal BG Start Long Acting InsulinBG Start Long Acting Insulin

Protocol for Insulin in Hospitalized PatientProtocol for Insulin in Hospitalized Patient

• Prescription for insulin therapy includes:

• Basal Insulin (BI)

• Carbohydrate-to-Insulin Ratio (CIR)

• Correction Factor (CF)

•1600 Records from Pump Patients Studied

•Data from 182 best-controlled pump patients

• Analyzed for optimum parameters

•Resulting formulae used as model for others

• The Accurate Insulin Management (AIM) formulae

The Accurate Insulin Management (AIM) Formulae

RESULTS

Accurate Insulin Management

(AIM) formulaeCarbohydrate-to-Insulin Ratio:

CIR=2.8*BW#/TDDCorrection Factor:

CF=1700/TDDBasal Insulin:

Basal=0.48*TDD

0

50

100

150

200

250

300

0 50 100 150 200

Total Daily Dose of Insulin (TDD)

Bo

dy

We

igh

t in

lbs

125

100

75

50

25

Co

r rection

Facto

r

25 20 15 12 10 9 8 7 6 5

Carbohydrate to Insulin Ratio

CF Curve

AIM Nomogram

Davidson et al Diab Tech Ther 2003 Vol 5 No 2

( CIR = 2.8 Wt / TDD )( C

F =

17

00

/ TD

D )

Intial Dosing: Plot BW and 25 CIR for BI Plot BW and 12 CIR for TDD

Plot BW and TDDfor CIRPlot TDD and CF curve for CFFollow-up Dosing: Change CF as above Change CIR by 20% toward CIRAIM

4

3

2


Daily Total: Pre-Admission or Weight (#) x 0.24 uDaily Total: Pre-Admission or Weight (#) x 0.24 u

– 50 % as Glargine (Basal) 50 % as Glargine (Basal)

• Split as q 12 DosesSplit as q 12 Doses

– 50% as Rapid-acting Insulin (Bolus)50% as Rapid-acting Insulin (Bolus)

• Give in Proportion to CHO Eaten, CIR 12Give in Proportion to CHO Eaten, CIR 12 BG >150: (BG-100) / CFBG >150: (BG-100) / CF

– CF = 7000 / Wt(#) CF = 7000 / Wt(#) Do Not Use Sliding Scale As Only InsulinDo Not Use Sliding Scale As Only Insulin Do Not Hold Insulin When BG Normal


Treatment of HypoglycemiaTreatment of Hypoglycemia

Any BG <80 mg/dl: D50 = (100-BG) x 0.4 ml IVAny BG <80 mg/dl: D50 = (100-BG) x 0.4 ml IV

Do Not Hold Insulin When BG NormalDo Not Hold Insulin When BG Normal

20

40

60

80

100

120

140

160

Glu

cose

Correction of Hypoglycemia with Glucose100-BG X 0.2 Grams

Before After

Richardson Diabetes 1999 50:A200

100-BG X 0.15 Grams

Hospital Diabetes PlanHospital Diabetes PlanConclusionsConclusions

Any BG >200 mg/dl Is Diabetes (Fasting >126 mg/dl)Any BG >200 mg/dl Is Diabetes (Fasting >126 mg/dl)

Most Diabetes Is Type 2Most Diabetes Is Type 2

All DM patients Must Self-Monitor BG’s and RecordAll DM patients Must Self-Monitor BG’s and Record

No BG >150 mg/dl Should Go UntreatedNo BG >150 mg/dl Should Go Untreated

Most Hospitalized DM Patients Should Be on InsulinMost Hospitalized DM Patients Should Be on Insulin

IV Insulin is Most Effective, Efficient, Safest Rx in Acute Illness IV Insulin is Most Effective, Efficient, Safest Rx in Acute Illness (Glucommander)(Glucommander)

Hospital Diabetes PlanHospital Diabetes Plan Conclusions 2

Switch to Basal Insulin Glargine– IV Hourly Dose X 24 / 2

DC IV Glucose Feed and Give Rapid Acting Insulin p.c.

– One Unit Per 12 Grams CHO BG ac tid, hs, 3 am

– Correct with Rapid Insulin• (BG - 100) / 7000 / BW#

Type 2 Diabetics Are Resistant to Insulin Reactions

Treat Insulin Reactions in Hospital With IV Glucose

Do Not Be Hold Insulin for Normal BG, i.e. 80-120

HbA1c Values >7% Indicates Sub-optimal Care

Hospital Diabetes PlanHospital Diabetes Plan Conclusions 3

Discharge Plan For BG Control

The Physician of Record Is the Link Between the Best

Diabetes Care and the Patient

Use Available Diabetes Resources

Diabetes Educators

Dietiticians

Endocrinologists

The Paradigm for the MilleniumThe Paradigm for the MilleniumHyperglycemia: A “Mortal” SinHyperglycemia: A “Mortal” Sin

A blood glucose over 200 in a hospitalized patient A blood glucose over 200 in a hospitalized patient causes increased morbidity and mortality.causes increased morbidity and mortality.

In the 21st Century In the 21st Century

Neglecting BG >200 Neglecting BG >200

Is MalpracticeIs Malpractice

Conclusion

All hospital patients should have normal glucose

Insulin

The agent we have

to control glucose

only

most powerfulpowerful

QUESTIONS

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