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Esta es una clase en power point del doctor Umpierrez sobre el paciente diabético hospitalizado (está en inglés)

Esta es una clase en power point del doctor Umpierrez sobre el paciente diabético hospitalizado (está en inglés)

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  • Using a national database derived from electronic medical records at 39 medical centers, investigators analyzed patterns of blood glucose (BG) control and documented insulin therapy among 16,534 patients hospitalized with acute myocardial infarction from January 2000 to December 2005. Of the 4940 patients (30%) with recognized diabetes mellitus (DM), nearly half (2412 patients, 49%) had mean BG >200 mg/dL during the first 24 hours after hospital admission. When the entire hospitalization was considered, 34% of DM patients had mean BG >200 mg/dL, while 61% had mean BG between 110 and 200 mg/dL, and only 5% maintained mean BG 200 mg/dL during the first 24 hours. When the entire hospitalization was considered, 4% of patients without known DM had mean BG >200 mg/dL, while 65% had mean BG between 110 and 200 mg/dL, and 31% had mean BG <110 mg/dL. Kosiborod M, Inzucchi S, Clark B, et al. National patterns of glucose control among patients hospitalized with acute myocardial infarction. J Am Coll Cardiol. 2007;49(9):1018-183:283A-284A.
  • In a more recent study that involved 2020 consecutive patients admitted to a community hospital in Atlanta, we found that 64% of patients had normal glucose values, 26% had a prior history of diabetes, and that 12% of patients with hyperglycemia, as determined by 2 or more FBG > 126 or RBG > 200, did not had a know history of diabetes prior to admission.
  • Data from Norhammar et al indicate that in 181 consecutive patients hospitalized with MI and no diagnosed diabetes, 66% had undiagnosed glucose abnormalities, including undiagnosed diabetes or IGT. Matz et al found, in 238 consecutive patients hospitalized with stroke, 39% had either IGT or undiagnosed diabetes in addition to 20% with known diabetes. IGT and undiagnosed DM2 are common in acute MI and stroke
  • For the majority of noncritically ill patients treated with insulin, the premeal blood glucose (BG) target should generally be less than 140 mg/dL in conjunction with random BG levels less than 180 mg/dL, provided these targets can be safely achieved. To avoid hypoglycemia, consideration should be given to reassessing the insulin regimen if BG levels decline below 100 mg/dL. Modification of the regimen is necessary when BG values are <40 mg/dL, although this value is lower than the approximate 50 mg/dL level at which cognitive impairment begins in normal persons. Scheduled subcutaneous administration of insulin, with basal, nutritional, and correction components, is the preferred method for achieving and maintaining glucose control. Prolonged treatment with sliding-scale insulin as the sole regimen is discouraged. Noninsulin antihyperglycemic agents are not appropriate in most hospitalized patients who require treatment for hyperglycemia. Moghissi ES, Korytkowski MT, Dinardo M, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control. Endocr Pract. 2009;15(4). http://www.aace.com/pub/pdf/guidelines/InpatientGlycemicControlConsensusStatement.pdf. Accessed May 18, 2009.
  • As a disclosure, I would like to state that was an investigator initiated trial sponsored by SA
  • 09-00953B_CHF_CaseStudy_r16 04/07/11 19:08 RABBIT-2 Trial: Basal-Bolus Insulin Regimen Key point: In the sliding-scale group, 65 patients received regular human insulin (RHI 4 times daily for blood glucose (BG) above 140 mg/dL 1 Eating status 1 : Eating – RHI was given before each meal and at bedtime according to the “usual” column of the sliding-scale protocol. Not eating – RHI was given every 6 hours according to the “insulin sensitive” column of the sliding-scale protocol. Persistent hyperglycemia 1 : If fasting and premeal plasma glucose levels remained persistently >140 mg/dL (without hypoglycemia), the insulin dosing was progressively increased (from “insulin sensitive” to “usual” or from “usual” to “insulin resistant”) If the mean daily BG level was >240 mg/dL, or if 3 consecutive BG levels were >240 mg/dL on the maximal dose allowed by the protocol, patients were switched to the basal-bolus insulin regimen Hypoglycemia 1 : If hypoglycemia developed, the insulin dosing was decreased (from “insulin resistant” to “usual” or from “usual” to “insulin sensitive”) [1/Umpierrez. DiabetesCare.Sept. 2007/p2183/Table 1] ___________________________________________________________________________________________ Umpierrez GE, Palacio A, Smiley D, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care. 2007;30:2181-2186. [Umpierrez. DiabetesCare.Sept. 2007/p2183/Table 1]
  • Key Point: Patients randomized to basal-bolus therapy achieved better glycemic control compared with those receiving sliding-scale insulin delivery in a hospitalized, non – ICU setting. This multicenter, prospective, open-label, randomized study enrolled 130 nonsurgical, insulin-naïve patients with a known history of diabetes for >3 months, admitted to medical general services with a blood glucose level between 140 and 400 mg/dL. Patients were randomly assigned to receive either sliding-scale regular insulin (SSRI; n=65) 4 times daily or a basal-bolus regimen with insulins glargine and glulisine (n=65). The goal of insulin therapy was to maintain fasting and premeal blood glucose levels < .01), mean random glucose (189 ± 42 vs 164 ± 35 mg/dL, respectively, P < .001), and mean glucose (193 ± 54 vs 166 ± 32 mg/dL, respectively, P < .001) during the hospital stay. The overall BG difference between treatment groups was 27 mg/dL ( P < .01), with a mean daily BG difference ranging from 23 to 58 mg/dL during days 2 through 6 of therapy ( P < .01). Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care. 2007;30(9):2181-2186.
  • Key Point: A significant number of patients in the basal-bolus group reached the BG target of 240 mg/dL, despite dose maximization. Glycemic control improved in these patients once they were switched to the basal-bolus regimen. Two patients in each group had hypoglycemia (defined as BG <40 mg/dL) were reported. Umpierrez GE, Smiley D, Zisman A, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial). Diabetes Care. 2007;30(9):2181-2186.
  • Since there was no a priori data to better direct the starting dose of in the inpatient setting, we arbitrarily used the working algorithm currently used at Grady Memorial/Emory hospital for those with inpatient hyperglycemia
  • Since there was no a priori data to better direct the starting dose of in the inpatient setting, we arbitrarily used the working algorithm currently used at Grady Memorial/Emory hospital for those with inpatient hyperglycemia
  • In the DEAN (Detemir plus Aspart vs NPH Plus Regular in Medical Patients with T2DM) trial, investigators randomized 130 nonsurgical patients with a blood glucose (BG) between 140 and 400 mg/dL to receive detemir once daily and aspart before meals (n=67) or neutral protamine Hagedorn (NPH) and regular insulin twice daily (n=63). Patients treated with detemir/aspart received half of the total daily dose (TDD) as detemir and half as aspart insulin. Detemir was given once daily at the same time of the day. Aspart was given in 3 equally divided doses with each meal. To prevent hypoglycemia, if a patient was not able to eat a given meal, the dose of aspart was held. Insulin dosage was adjusted daily according to BG values. Patients treated with NPH/regular insulin received two thirds of TDD before breakfast and one third before dinner. The insulin dose was given as two thirds NPH and one third regular insulin in the morning with breakfast, and two thirds NPH and one third regular insulin in the evening with dinner. The slide shows the changes in mean daily BG concentration. The BG target of less than 140 mg/dL before meals was achieved in 45% of the detemir/aspart group and in 48% of the NPH/regular group ( P =NS). Umpierrez GE, Hor T, Smiley D, et al. Comparison of inpatient insulin regimens with detemir plus aspart versus neutral protamine hagedorn plus regular in medical patients with type 2 diabetes. J Clin Endocrinol Metab. 2009;94(2):564-569.
  • Patient self-management of diabetes in the hospital should be facilitated when appropriate. Staff understanding of new treatment modalities and the actions of new antihyperglycemic agents should be ensured through in-service training. Orally administered antihyperglycemic agents should be prescribed with caution and with observance of changing organ function, potential drug interactions, and contraindications that might arise in the hospital. Caregivers, fearing hypoglycemia, may hope to prevent hypoglycemic episodes by substituting sliding-scale management for anticipatory insulin therapy. This strategy is ineffective or even harmful if used alone. The preferred approach is to use measures for prevention of hypoglycemia that do not promote hyperglycemia. Braithwaite SS, Buie MM, Thompson CL, et al. Hospital hypoglycemia: not only treatment but also prevention. Endocr Pract. 2004;10(suppl 2):89-99.

Umpierrez%20 inpatient non_icu%20guidelines_7_2010[1][1] Umpierrez%20 inpatient non_icu%20guidelines_7_2010[1][1] Presentation Transcript

  • Clinical Guidelines for the Management of Hyperglycemia in Hospitalized Patients in a Non-Critical Care Setting Work in Progress The Endocrine Society, European Endo Society, American Heart Association, American Diabetes Association, Society of Hospitalist Medicine, American Association of Diabetes Educators
  • Inpatient Hyperglycemia in non-critical care setting
    • What is the frequency of hyperglycemia and diabetes?
    • What diagnosis criteria should we use?
    • What is the association between hyperglycemia and outcomes?
    • How should we manage hyperglycemia in non-ICU setting?
  • Hyperglycemia: Scope of the Problem Kosiborod M, et al. J Am Coll Cardiol. 2007;49(9):1018-183:283A-284A. No Diabetes 26% Diabetes 50 40 30 20 10 0 <110 110-140 50 40 30 20 10 0 <110 110-140 140-170 170-200 >200 78% 140-170 170-200 >200 Mean BG, mg/dL Patients, %
  • Hyperglycemia*: A Common Comorbidity in Medical-Surgical Patients in a Community Hospital 62% 12% 26% Normoglycemia Known Diabetes New Hyperglycemia Umpierrez G et al, J Clin Endocrinol Metabol 87:978, 2002 n = 2,020 * Hyperglycemia: Fasting BG  126 mg/dl or Random BG  200 mg/dl X 2
  • New and Stress hyperglycemia
    • Patients with hyperglycemia without a previous history of diabetes should be tested with a hemoglobin A1C during the hospital stay or with an oral glucose tolerance test after discharge to confirm the diagnosis of diabetes.
    • Less than 35% of patients had normal glucose tolerance after 3 to 12 months of follow-up.
    Norhammar et al. Lancet 2002; 359(9324): 2140-4. Arora et al. Endocr Pract 2009; 15(5): 425-30. Greci et al. Diabetes Care 2003; 26(4): 1064-8.
  • IGT and Undiagnosed T2DM are Common in Acute MI and Stroke Norhammar A, et al. Lancet 2002;359:2140−4. Matz K, et al. Diabetes Care 2006;792−7. 2-hour OGTT 70 60 50 40 30 20 10 0 Norhammar (n=181) Matz (n=238) Patients (%) 66 39 Myocardial infarction Stroke IGT Undiagnosed T2DM 35 23 31 16
  • Epidemiology of Inpatient Hyperglycemia in non-critical care setting
    • What is the frequency of hyperglycemia and diabetes?
    • What diagnosis criteria should we use?
    • What is the association between hyperglycemia and outcomes?
    • How should we manage hyperglycemia in non-ICU setting?
  • ADA 2010 - Categories of Increased Risk for Diabetes* ADA Clinical Practice Recommendations, January 2019 NORMAL IFG or IGT PREDIABETES DIABETES FPG < 100 mg/dl FPG > 100 - 125 mg/dl (IFG) FPG > 126 mg/dl 2-h PG < 140 mg/dl 2-h PG > 140 - 199 mg/dl (IGT) 2-h PG > 200 mg Random PG > 200 + symptoms A1C 5.7% to 6.4% ≥ 6.5%
  • A1C for Diagnosis of Diabetes in the Hospital
    • Inhospital hyperglycemia is defined as an admission or inhospital BG > greater 140 mg/dl.
    • HbA1c > 6.5% can be identified as having diabetes, and patients with A1C 5.7%-6.4% can be considered as being at risk for diabetes.
    • Implementation of A1C testing can be useful:
      • assess glycemic control prior to admission
      • assist with differentiation of newly diagnosed diabetes from stress hyperglycemia
      • designing an optimal regimen at the time of discharge
  • Comparison of sensitivity and specificity achieved for the diagnosis of diabetes based on FPG, at various levels of HbA1c, from NHANES III and 1999–2004 NHANES J Clin Endocrinol Metab, July 2008, 93(7):2447–2453
  • Factors influencing A1c
  • Epidemiology of Inpatient Hyperglycemia in non-critical care setting
    • What is the frequency of hyperglycemia and diabetes?
    • What diagnosis criteria should we use?
    • What is the association between hyperglycemia and outcomes?
    • How should we manage hyperglycemia in non-ICU setting?
  • Hyperglycemia and Pneumonia Outcomes BG (mg/dl) < 110 110 - <198 198 - <250 ≥ 250 * * * * * p: < 0.05 vs BG < 198 mg/dl (11 mmol/L) Admission glucose (mg/dl) % McAllister et al, Diabetes Crae 28:810-815, 2005 N= 2,471 patients with CAP
  • Community Acquired Pneumonia Outcomes in Patients with Diabetes % Hospitalization Mortality Pleural Effusion Concomitant Illnesses P: < 0.001 N= 660 (DM: 106 & non-DM: 554) No differences in microorganisms and bacteremia rates Falguera et al, Chest 128:3233-3239, 2005 * * * * 93 8 17 78 31 18 53 40 * Diabetes No Diabetes
    • A case control study of 108,593 patients who underwent noncardiac surgery.
    • *Odds ratio for perioperative mortality is 1.19 (95% CI 1.1–1.3) per mmol/l increase of glucose level
  • Thirty Day Mortality and Inhospital Complications in diabetic and non-diabetic subjects † p = 0.1 * p= 0.001 #p=0.017 † * * * * # * % A Frisch et al. Diabetes Care, May 2010
  • Hyperglycemia and mortality Mean POSTSURGERY blood glucose and ODDS RATIOS for 30 day mortality in diabetic and non diabetic patients A Frisch et al. Diabetes 58 (suppl 1) A27, 2009
  • Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes Total In-patient Mortality Normoglycemia Known New Diabetes Hyperglycemia 1.7% 3.0% 16.0% * Mortality (%) * P < 0.01 Umpierrez GE et al, J Clin Endocrinol Metabol 87:978, 2002
  • AACE/ADA Target Glucose Levels in Non – ICU Patients
    • Glucose Target in non – ICU setting:
      • Premeal glucose targets <140 mg/dL
      • Random BG <180 mg/dL
      • To avoid hypoglycemia, reassess insulin regimen if BG levels fall below 100 mg/dL
      • Occasional patients may be maintained with a glucose range below and/or above these cut-points
    Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4). http://www.aace.com/pub/pdf/guidelines/InpatientGlycemicControlConsensusStatement.pdf
  • Epidemiology of Inpatient Hyperglycemia in non-critical care setting
    • What is the frequency of hyperglycemia and diabetes?
    • What diagnosis criteria should we use?
    • What is the association between hyperglycemia and outcomes?
    • How should we manage hyperglycemia in non-ICU setting?
    • ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care. 2006 & 2009
    • Diabetes Care. 2009;31(suppl 1):S1-S110..
    Antihyperglycemic Therapy Insulin Recommended OADs Not Generally Recommended IV Insulin Critically ill patients in the ICU SC Insulin Non-critically ill patients Recommendations for Managing Patients With Diabetes in the Hospital Setting
  • AACE/ADA Consensus Statement Non-insulin therapies in the hospital?
    • Sulfonylureas are a major cause of hypoglycemia
    • Metformin contraindicated in setting of decrease renal blood flow and with use of iodinated contrast dye
    • Thiazolidinediones associated with edema and CHF
    • α glucosidase inhibitors are weak glucose lowering agents
    • Pramlintide and GLP1-directed therapies can cause nausea and have a greater effect on postprandial glucose
    Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009
  • Management of Hyperglycemia and Diabetes in non-ICU Setting
    • Non-ICU
      • Sliding Scale Short-Acting Insulin
      • Basal/bolus therapy (MDI)
        • NPH and Regular insulin
        • Long-acting and rapid-acting insulin
      • Premix insulin
  • Study Type: Prospective, multicenter, randomized, open-label trial Patient Population : 130 subjects with DM2 Diet and/or oral hypoglycemic agents Umpierrez et al, Diabetes Care 30:2181–2186, 2007
    • D/C oral antidiabetic drugs on admission
    • Starting total daily dose (TDD):
      • 0.4 U/kg/d x BG between 140-200 mg/dL
      • 0.5 U/kg/d x BG between 201-400 mg/dL
    • Half of TDD as insulin glargine and half as rapid-acting insulin (lispro, aspart, glulisine)
      • Insulin glargine - once daily, at the same time/day.
      • Rapid-acting insulin- three equally divided doses (AC)
    Ra ndomized B asal B olus versus Sliding Scale Regular I nsulin in patients with t ype 2 Diabetes Mellitus (RABBIT-2 Trial) Umpierrez et al, Diabetes Care 30:2181–2186, 2007
  • Umpierrez GE et al. Diabetes Care . 2007;30:2181-2186.
    • Before meal: Supplemental Sliding Scale Insulin (number of units)
      • Add to scheduled insulin dose
    • Bedtime: Give half of Supplemental Sliding Scale Insulin
    Sliding Scale Insulin Regimen Blood Glucose (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
  • Rabbit 2 Trial: Changes in Glucose Levels With Basal-Bolus vs. Sliding Scale Insulin Umpierrez GE, et al. Diabetes Care . 2007;30(9):2181-2186. Days of Therapy BG, mg/dL 100 120 140 160 180 200 220 240 Admit 1 Sliding-scale Basal-bolus b P< .05. a a a b b b b 2 3 4 5 6 7 8 9 10 a P< .05.
    • Sliding scale regular insulin (SSRI) was given 4 times daily
    • Basal-bolus regimen: glargine was given once daily; glulisine was given before meals.
    • 0.4 U/kg/d x BG between 140-200 mg/dL
    • 0.5 U/kg/d x BG between 201-400 mg/dL
    • Persistent hyperglycemia (BG>240 mg/dl) is common (15%) during SSI therapy
    Hypoglycemia rate: Days of Therapy BG, mg/dL 100 120 140 160 180 200 220 240 Admit 1 Sliding-scale Basal-bolus 260 280 300 3 3 4 5 6 7 2 4 2 1 Rabbit 2 Trial: Treatment Success With Basal-Bolus vs. Sliding Scale Insulin
    • Basal Bolus Group:
      • BG < 60 mg/dL: 3%
      • BG < 40 mg/dL: none
    • SSRI:
      • BG < 60 mg/dL: 3%
      • BG < 40 mg/dL: none
    Umpierrez GE, et al. Diabetes Care . 2007;30(9):2181-2186.
  • Study Type: Prospective, randomized, open-label trial Patient Population : 130 subjects with DM2 Oral hypoglycemic agents or insulin therapy Study Sites : Grady Memorial Hospital, Atlanta, GA Rush University Medical Center , Chicago, IL Umpierrez et al, J Clin Endocrinol Metab 94: 564–569, 2009
  • Detemir–Aspart Insulin Regimen
    • D/C oral antidiabetic drugs on admission
    • Starting total daily dose (TDD):
      • 0.4 U/kg/d x BG between 140-200 mg/dL
      • 0.5 U/kg/d x BG between 201-400 mg/dL
    • Half of TDD as insulin detemir and half as aspart
      • Insulin detemir - once daily, at the same time of the day.
      • Insulin aspart - three equally divided doses (AC)
    Umpierrez et al, J Clin Endocrinol Metab 94: 564–569, 2009
  • NPH–Regular Split-Mixed Regimen
    • D/C oral antidiabetic drugs on admission
    • Starting total daily dose (TDD):
      • 0.4 U/kg/d x BG between 140-200 mg/dL
      • 0.5 U/kg/d x BG between 201-400 mg/dL
    • Three-fifth of TDD as insulin NPH and two-fifth as regular
      • NPH insulin– twice daily, 2/3 before breakfast, 1/3 before dinner
      • Regular insulin- twice daily, 2/3 before breakfast, 1/3 before dinner
    Umpierrez et al, J Clin Endocrinol Metab 94: 564–569, 2009
  • DEAN Trial: Changes in Mean Daily Blood Glucose Concentration BG, mg/dL Duration of Therapy, d Data are means  SEM. Detemir + aspart NPH + regular Basal-bolus regimen: detemir was given once daily; aspart was given before meals. NPH/regular regimen: NPH and regular insulin were given twice daily, two thirds in AM, one third in PM. Umpierrez GE, et al. J Clin Endocrinol Metab . 2009;94(2):564-569. P =NS 100 120 140 160 180 200 220 240 Pre-Rx BG 0 1 2 3 4 5 6-10
  • Blood glucose (mg/dL) Detemir + Novolog NPH + Regular DEAN-Trial
    • NPH/Regular
      • BG < 40 mg/dl: 1.6%
      • BG < 60 mg/dl: 25.4%
    • Detemir/Aspart
      • BG < 40 mg/dl: 4.5%
      • BG < 40 mg/dl: 32.8%
    Umpierrez et al, J Clin Endocrinol Metab 94: 564–569, 2009 DEAN Trial: Hypoglycemia To determine risk factors for hypoglycemic events during SC insulin therapy
  • *p-values are from Wilcoxon Two-Sample Test Summary of Univariate Analyses Umpierrez et al, ADA Scientific Meeting, Poster #516, 2009   p-value * variable BG < 60 mg/dl BG < 70 mg/dl AGE 0.036 0.001 wt 0.027 0.001 A1C 0.521 0.658 Creatinine 0.011 0.002 Enrollment BG 0.166 0.319 Previous treatment 0.005 <.001 Previous insulin Rx  <0.001 <.001 Treatment group <0.001 <.001
  • RAndomized Study of Basal Bolus Insulin Therapy in the Inpatient Management of Patients with Type 2 Diabetes Undergoing General Surgery: RABBIT Surgery Trial Guillermo E Umpierrez, Dawn Smiley, Sol Jacobs, Limin Peng, Angel Temponi, Christopher Newton, Denise Umpierrez, Patrick Mulligan, Darin Olson, Jana MacLeod, Monica Rizzo. Umpierrez et al, Preliminary data- ADA Scientific Session 2010
  • Research Design and Methods
    • Study Type: Multi-center, prospective, open-label randomized clinical trial
    • Patient Population: Patients with type 2 DM admitted to general surgery services
    • Study Sites: Grady Memorial Hospital, Veterans Affairs Medical Center and Emory University Hospital, Atlanta, GA
    • Treatment Groups:
      • Group 1: basal/bolus regimen with glargine once daily and glulisine before meals
      • Group 2: sliding scale regular insulin (SSRI) four times daily
    Umpierrez et al, Preliminary data- Abstract submitted to ADA Scientific Session 2010
    • Primary outcome:
      • Differences between groups in mean daily BG concentration
      • Composite of hospital complications including: postoperative wound infection, pneumonia, respiratory failure, acute renal failure, and bacteremia.
    • Secondary outcome:
    • Differences between groups in any of the following measures:
    • Mean fasting and pre-meal BG, number of hypoglycemic (BG < 70 mg/dL and < 40 mg/dL) and hyperglycemic (BG > 200 mg/dL) events , length of hospital stay, need for ICU care, and rate of complications including wound infection, pneumonia, acute renal failure, and mortality.
  • RABBIT SURGERY TRIAL 211 Patients with type 2 DM that underwent general surgery Glargine + Glulisine (Gla+Glu) N= 104 Group 1: 0.5 U/kg Half as glargine once daily Half as glulisine before meals Sliding scale insulin (SSRI) N= 107 OPEN - LABELED RANDOMIZATION Group 2: 4 times/day for BG >140 mg/dl
  • RABBIT 2 SURGERY Umpierrez et al, Preliminary data- Abstract to be submitted_ADA Scientific Session 2010
  • Rabbit Surgery Trial Glucose levels during Basal Bolus and SSRI Therapy * p<0.001 † p: 0.01 ŧ p: 0.02 SSI GLA+GLU
  • Glucose levels Before meals and Bedtime SSI Basal Bolus
  • Differences in BG Concentration Within Target During Hospital Stay and After 24 Hours of Treatment
  • Hospital Complications: Primary outcome
  • Umpierrez et al, Preliminary data- Abstract to be submitted_ADA Scientific Session 2010 Hypoglycemic Events
  • Treatment with glargine once daily plus glulisine before meals improved glycemic control and reduced hospital complications compared to SSRI in general surgery patients with T2DM. Our study indicates that basal/bolus insulin regimen is the preferred insulin regimen in the hospital management of general surgery patients with type 2 diabetes. Summary & Conclusion RABBIT 2 SURGERY
  • Management Recommendations
    • All patients with T1DM must receive insulin treatment with basal bolus, multi-dose insulin combination of NPH plus regular insulin or continuous insulin pump.
    • Patients treated with insulin at home should be continued with insulin therapy in the hospital.
    • Scheduled subcutaneous basal bolus insulin regimen is preferred for the majority of non-critically ill patients with hyperglycemia.
    • The practice of using sliding scale insulin (SSI) as a single form of therapy is undesirable.
  • Strategies for Preventing Hypoglycemia
    • In-service training on new treatment modalities and the actions of new antihyperglycemic agents
    Braithwaite SS, et al. Endocr Pract. 2004;10(suppl 2):89-99.
    • Reducing outpatient insulin dose in patients treated with insulin prior to admission
    • Basal Bolus is preferred over SSRI and NPH/regular combination
    • D/C oral antidiabetic drugs on admission
    • Starting total daily dose (TDD):
      • 0.3 U/kg/d in elderly and renal failure (lean?)
      • 0.4 U/kg/d x BG between 140-200 mg/dL
      • 0.5 U/kg/d x BG between 201-400 mg/dL
    • Half of TDD as insulin glargine and half as rapid-acting insulin (lispro, aspart, glulisine)
    • Decrease outpatient insulin dose by 20-25%
    Basal Bolus Insulin Regimen in T2DM: Summary Umpierrez et al, Diabetes Care 2007; JCEM 2009; Diabetes 2010
  • Rabbit Surgery Trial Glucose levels during Basal Bolus and SSRI Therapy * p<0.001 † p: 0.01 ŧ p: 0.02 Mainly Basal (Glargine) Insulin
  • 4:00 16:00 20:00 24:00 4:00 8:00 12:00 8:00 Time Glargine once daily 0.25 U/kg Basal-PLUS Insulin Regimen Insulin Action Leahy J. In: Leahy J, Cefalu W, eds. Insulin Therapy . New York: Marcel Dekker; 2002:87; Nathan DM. N Engl J Med. 2002;347:1342 Aspart, Lispro or Apidra before meals per sliding scale
  • A1C < 7% Re-start outpatient treatment regimen (OAD and/or insulin) A1C 7%-9% Re-start outpatient oral agents and D/C on glargine once daily at 50-80% of hospital dose A1C >9% D/C on basal bolus at same hospital dose. Alternative: re-start oral agents and D/C on glargine once daily at 50-80% of hospital dose Discharge insulin Algorithm Discharge Treatment
  • Needed Research Studies
    • What is the role of medical nutrition therapy in non-critical care setting?
    • How should glycemia be monitored in non-critical care setting?
    • How should hyperglycemia be managed across transitions in care?
    • What are the best predictors of hypoglycemia?
    • What is the financial impact of glycemic control in non-critical care areas?