Management of Inpatient Hyperglycemia

Feb 2014

Case Vignette

45 year old obese female with DM type II is admitted for acute nausea, vomiting, and epigastric pain. CT Abdomen with IV contrast demonstrates acute pancreatitis. Her diabetes is usually controlled on metformin 1000mg BID and glyburide 10mg BID. Admission BMP shows a random glucose of 240. How do you manage her hyperglycemia?

A. Continue home regimen

B. Continue home glyburide and discontinue metformin

C. Start sliding scale insulin

D. Start correction insulin

Learning Objectives

• Appreciate difference between sliding scale insulin vs correction insulin

• Understand optimal glycemic control goals in ICU vs non ICU settings

• Review the pharmacokinetics of different insulin preparations

• Learn how to use correction insulin and initiate insulin therapy on UCI wards

The problem with sliding scale insulin

Time 0700

Break-

fast

0800 1200

Lunch

1300 1700

Dinner

1800 2100

Blood Glucose

275 350 400 250

Sliding scale

6

units

10 units 12 units 6 units

•Sliding Scale Insulin - Treats hyperglycemia with only short/rapid acting insulin without long-acting basal insulin- Reactive therapy -Treats current hyperglycemia, does not prevent future hyperglycemia- Can cause large swings in glucose levels throughout day

Typical day battling hyperglycemia

Correction Insulin

• Correctional Insulin

– Results in physiologic subcutaneous insulin administration

– Treats current hyperglycemia with the goal of preventing further hyperglycemic events during the hospital course

– Includes initiation of three components:1. basal insulin (long acting)2. nutritional insulin (rapid acting, pre-meal)3. correctional insulin (rapid acting, for real time adjustment)

– Administer correction scale insulin BEFORE the meal using a rapid or short acting insulin

A better day when using correction insulin

Time 700 EAT 0800 1200 EAT 1300 1700 EAT 1800 2100

Blood Glucose

170 275 210 350 250 400 250

Sliding Scale

6 10 12 6

Correction Scale

2units

4 units

6 units

6 units

Sliding scale: 34 units of rapid/short acting insulin administeredCorrection scale: 18 units of rapid/short acting insulin

Remember, it is the concept of correction insulin we want to practice. If this patient remains hyperglycemic, adjust basal/nutritional insulin therapy

AACE/ADA Consensus Statement on Management of Inpatient Hyperglycemia

BG goals Avoid Tips

MICU •140-180 <110 •If >180, initiate IV short acting insulin

General Wards

•Pre-meal <140

•Random <180

<100 •In glucocorticoid therapy, initiate accuchecks for 48 hours and then initiate insulin therapy as appropriate

•Avoid routine use of corrective insulin at bedtime unless continuous nutrition/TPN

Rapid (Prandial,Bolus)Short (Prandial,Bolus)

Intermediate(Basal)

Long(Basal)

Correction Insulin Tips

Start with If uncontrolled add

On insulin at home

(DM I, some DM II)

NPO *Home basal insulin *Correctional scale insulin

Eating *Home basal insulin (reduce 50%)

*Home prandial insulin (reduce doses by 25-50%)

*Correctional scale insulin

Not on insulin

(pre-DM, DM II)

NPO Stop all oral anti-hyperglycemics.

Start correctional scale

*Basal insulin

Eating Cautiously use oral anti-hyperglycemics

OR

Start *basal, *prandial, AND *correctional scale insulin

*Basal insulin

*Prandial insulin

*Correctional scale

Current UCI Glycemic Monitoring Protocol

UCI is aggressively pursuing the concept of correction insulin and preventing hyperglycemia. Many more patients will be initiated on insulin therapy

When to pursue insulin therapy

• All DM I

• Most DM II receiving medication treatment

• Uncontrolled hyperglycemia > 180 (2 episodes in 24 hours)

• If unsure, then monitor qAC/qHS glucose monitoring for 24 hours and then continue if BG > 180

How to Initiate Insulin Therapy (if not already on insulin OR if uncontrolled diabetes)

Regimen Tracts

Dose Low

(DM I,

Lean DM II)

Standard

(Normal weight DM)

Moderate

(Overweight DM)

Aggressive

(Obese DM)

Total Daily Dose (TDD)

0.3 units/kg/day

0.4 units/kg/d 0.5unit/kg/d 0.6unit/kg/d

Basal ½ TDD

Prandial ½ TDD divided into 3 meals

Correction Scale

Yup, they will also receive this too

It should be the same rapid/short acting insulin as used for prandial insulin

See next page

Correction Scale with Meals

Regimen Tracts

Dose Low

(DM I,

Lean DM II)

Standard

(Normal weight DM)

Moderate

(Overweight DM)

Aggressive

(Obese DM)

Total Daily Dose (TDD)

0.3 units/kg/d 0.4 units/kg/d 0.5unit/kg/d 0.6unit/kg/d

161-200 1 units 2 units 3 units 4 units

201-250 2 units 4 units 5 units 6 units

251-300 3 units 6 units 7 units 8 units

Insulin Dose Adjustment for CKD

• No dose adjustment if GFR >50

• Use 75% of baseline insulin dose if GFR 10-50

• Use 50% of baseline insulin dose if GFR <10

Example: At home takes 40 units of glargine qHS

If GFR 30: give 30 units of glargine qHS

If GFR <10: give 20 units of glargine qHS

Long Beach VA Guidelines on Adjustment of Insulin

• If glucose above target, increase insulin doses by 10-20% (2-5 units) every 1-2 days

• Once patient clinically stable on insulin regimen, d/c correctional insulin and check glucose 2 hours after meals (target BS <150 two hours after a meal)

How to Adjust:

Patient on NPH/Regular insulin regimen

• If fasting glucoses elevated, increase evening NPH

• If pre-lunch or 2 hr post breakfast elevated, increase AM pre-breakfast regular

• If pre-dinner or 2 hr post lunch elevated, increase AM NPH

• If bedtime or 2 hr post-dinner elevated, increase pre-dinner regular

• May need bedtime snack once glucoses are well controlled

Long Beach VA Guidelines on Adjustment of Insulin

Patient on Lantus with Regular/Aspart insulin:

• If fasting elevated, increase Lantus

• If pre-lunch or 2 hr post breakfast elevated, increase pre-breakfast regular/Aspart

• If pre-dinner or 2 hr post lunch elevated, increase pre-lunch regular/Aspart

• If bedtime or 2 hr post-dinner elevated, increase pre-dinner regular/Aspart

• If all glucoses elevated, may need to increase all insulins

Case Vignette

45 year old obese female with DM type II is admitted for acute nausea, vomiting, and epigastric pain. CT Abdomen with IV contrast demonstrates acute pancreatitis. Her diabetes is usually controlled on metformin 1000mg BID and glyburide 10mg BID. Admission BMP shows a random glucose of 240. How do you manage her hyperglycemia?

A. Continue home regimen

B. Continue home glyburide and discontinue metformin

C. Start sliding scale insulin

D. Start correctional insulin

Case Vignette Answer: D

•Answers A and B incorrect because patient likely to be NPO

•Answer C, sliding scale insulin is no longer in favor.

CORRECT ANSWER(S)Option 1:Initiate insulin therapy (basal, prandial, corrective scale) on admission

Option 2:Start q6 accuchecks with correction scale (regular insulin is commonly used). Correct BS per Aggressive Regimen since is obese DM type IIBS 160-200 – 4 units BS 201-250 – 6 units, etc.

If BS is still >180 after 1-2 days, then initiate longer insulin therapy (basal, prandial, corrective scale).

Note Option 2 less preferable because random BS>180 and requires high doses of PO meds already so odds are she will have uncontrolled hyperglycemia

Last Question

55 year old male with DM I comes from with cough and fevers. Admitted for treatment of pneumonia. He normally takes 20 units glargine qHS and 6 units aspart with each meal. How would you manage his blood sugar?

A. Continue home regimen

B. Give 10 units glargine qHS and 2 units aspart qAC

C. Give home glargine dose only

D. Give home aspart doses only

Correct Answer is B

Patient likely can eat, albeit he may eat less in setting of illness and restrictive hospital diets. He is DM type I so he needs continuous insulin coverage. The safest option is to decrease his insulin doses by 25-50% and monitor.

His goal BS is a FBG <140 and random BS <180. If he continues to experience hyperglycemia, then do the following.

•Basal insulin: uptitrate the glargine or redose based on a TDD of 0.3units/kg/day•Prandial insulin: uptitrate the aspart or re-dose based on a TDD of 0.3 units/kg/day•Initiate correction scale: Give additional aspart for BS >160.

Take Home Points

• Correction insulin is a concept to prevent hyperglycemia. It may include the initiation of insulin therapy (basal insulin, prandial insulin, AND correction scale)

• Avoid hypoglycemia. A safe inpatient BS goal is no lower than 100

• Avoid severe hyperglycemia. A good target is a random BS <180

• Reassess insulin needs after any change in nutritional status (NPO, PO, tube feeds)

• Readjust basal and nutritional insulin if still requiring additional correctional scale insulin or hyperglycemia persists every 1-2 days

Easy self-directed learning materials

• American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Diabetes Care June 2009 32(6) 1119

• Intensive insulin therapy in critically ill patients. NEJM 2001; 345(19): 1359

• Management of Hyperglycemia in the Hospital Setting. Inzucci et al. NEJM 2006; 355: 1903-1911

• The Nice-Sugar study investigators: Normoglycemia in Intensive Care Evaluation Survival Using Glucose Algorithm Regulation Intensive vs conventional glucose control in critically ill patients. NEJM 2009; 360:1283

• UpToDate “Management of DM in hospitalized patients” and “General Principals in Insulin Management.” Accessed on June 11, 2012.

• UCI Inpatient Glycemic Monitoring and Treatment Guidelines. 2012