2. Diabetes Today: An Epidemic
• In 2018, 34.2 million Americans (10.5% of the population) were diagnosed
with diabetes
• 1.5 million new cases in adults aged 18 years
• ~4100 new diagnoses each day
• Complications of diabetes are a major cause of mortality and morbidity
• 252,806 deaths
• 1 stroke every 2 minutes
• 1 MI ever 80 seconds
• 108,000 lower-limb amputations
• 1 every 5 minutes
• 52,159 begin treatment for ESKD
• 1 patient develops ESKD every 10 minutes
• 24,000 new cases of blindness each year
• Total cost in the United States in 2017: $327 billion
http://www.diabetes.org/diabetes-basics/statistics/
4. Type 1 DM
• 5-10% of all diabetes
• Immune-mediated
• Auto-immune destruction of the Beta cells
• Peak onset below age 30 (75%)
• Typical Characteristics
• Younger
• Normal Body Weight
• Normal BP
• Absolute Insulin Deficiency!!
5. Type 2 DM
• 90-95% of Diabetes
• Insulin Resistance Syndrome
• Association with Obesity
• Typical Characteristics
• BMI >27
• Hypertension
• Lipid Abnormalities
• High/Low Insulin Levels
• Acanthosis Nigricans
10. Diabetes in Hospitalized Patients
• At least 7.2 million patients with history of DM are admitted to
hospitals annually in the US
• Hospitalization and illness-related stress can induce
uncontrolled hyperglycemia
• Hyperglycemia may be related to:
• Medications
• Illness-related insulin resistance
• TPN
• Steroid use
11. Why care?
• It is easy to put DM at the bottom of a hospitalized patient’s
problem list and write it off with a mindless therapeutic plan.
• For Example:
• 70 year old female with MI, Pneumonia & Ankle Fracture
with a history of T2DM
• The Problems:
• MI – caused by CAD -> which was largely caused by DM
• Pneumonia – susceptibility increased by DM/Hyperglycemia
• Fall – caused by
confusion/weakness/dehydration/neuropathy -> all brought
on by Highs or Lows/DM
12. More…
• If her diabetes is not
addressed:
• Her pneumonia will
clear more slowly
• Her outcome from MI
will be worse
• Her fracture will not
heal well
• And worst of all:
• She will be back again,
because the root of
her problems was not
addressed
13. Scope of the Problem
• DM & hyperglycemia in hospitalized
patients leads to:
• Higher morbidity and mortality rates
• Longer Stay
• More Procedures & More Medications
• More infections
• More discharges to some form of long-term care
facility
14. Effect of Hyperglycemia on
Hospital Mortality
0
5
10
15
20
25
30
35
Total Non-ICU ICU
Normoglycemia Known diabetes New hyperglycemia
Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:978-982.
16. Hyperglycemia and Poor Outcomes
Following Myocardial Infarction
0
10
20
30
40
50
Normal Glucose Mild IGT Severe IGT Diabetes
*P<.05 compared with nondiabetic patients. IGT = impaired glucose tolerance.
Bolk J et al. Int J Cardiol. 2001;79:207-214.
*
Mortality
After
1
Year
(%)
Patient Categories Based on Admission Blood Glucose
140 180
17. Acute In-Hospital Complications
Prolonged
Hospital Stay
Disability &
Death
Increased
stress
hormones
Immune
Dysfunction
Increased
Risk of
infection
Impaired
Wound
Healing
Increased
Risk of
Thrombosis
Increased
Inflammation
19. MI = myocardial infarction; DIGAMI = Diabetes Mellitus Insulin-Glucose Infusion in Acute
Myocardial Infarction.
Malmberg K et al. BMJ. 1997;314:1512-1515.
All Subjects
(N=620)
Risk reduction (28%)
P=.011
Standard treatment
0
0.3
0.2
0.4
0.7
0.1
0.5
0.6
0 1
Follow-Up (y)
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
0.3
0.2
0.4
0.7
0.1
0.5
0.6
0 1
Follow-Up (y)
2 3 4 5
Mortality After MI Is Reduced by
Insulin Therapy in DIGAMI-1
20. Benefits of IV InsulinTreatment Following
CoronaryArtery Bypass
• Open-heart surgery
• IV insulin infusion reduced the rate of mortality and deep sternal wound infection
(DSWI) to the incidence observed in patients without diabetes
• Target blood glucose <150 mg/dL
• 3-day postoperative duration of CII
CII = continuous intravenous insulin. Furnary AP et al. Endocr Pract. 2004;10(suppl 2):21-33.
-70
-60
-50
-40
-30
-20
-10
0
Mortality DSWI
Risk
Reduction
(%)
P<.0001
P<.0001
21. Benefits of IV Insulin Treatment in
Critically Ill Hospitalized Patients
-60
-50
-40
-30
-20
-10
0
Total Mortality Blood Infection
Acute Renal
Failure Transfusions Polyneuropathy
Van den Berghe G et al. N Engl J Med. 2001;345:1359-1367.
Reduction
(%)
34%
46%
41%
50%
44%
Intensive Glycemic Control
BG = 80-110 mg/dL in ICU
BG = 180-200 mg/dL after discharge from ICU
22. Effectively Managing the DM
• Allows us to better manage the current problems
• Allows us to prevent recurrent problems
• Improves patient outcomes
• Lowers mortality
25. Limitations of Oral Agents for Managing
In-Hospital Hyperglycemia
• Sulfonylureas
• No rapid dose adjustment or titration due to long duration of action
• Risk of unpredictable hypoglycemia
• Glitinides
• Allow for rapid adjustment and titration
• Risk of hypoglycemia is reduced
• Metformin
• No rapid dose adjustment
• Mostly contraindicated due to relatively increased risk of lactic acidosis in
severely ill hospitalized patients (ie, renal failure, congestive heart failure,
critically ill)
• Thiazolidinediones
• No rapid dose adjustment
• Mostly contraindicated due to increased intravascular volume
Clement S et al. Diabetes Care. 2004;27:553-591.
26. Limitations of Oral Agents for Managing
In-Hospital Hyperglycemia
• DPP-4 Inhibitors
• Dose adjustment needed based on renal function
• Relatively slow onset of action
• SGLT-2 Inhibitors
• Effect independent of insulin action
• Contraindicated if renal function is compromised
• GLP-1 RA’s
• Long acting are impractical as onset may take days to weeks
• Short acting (ie., exenatide, lixisenatide) have been shown to be
useful in the hospital setting
29. Insulin is…
• One of the most important drugs used in
the hospital
• BUT, it is one of the most common sources
of medication-related errors.
30. Insulin: The Most Effective Treatment
• Easy to change dose with increased insulin
requirements during acute illness
• Can be easily changed depending on patient’s
nutrition
• IV Dextrose
• TPN
• Enteral Feeding
• Nutritional Supplements
• NPO
34. Sliding Scales and Their Dangers
• If used alone, they can easily lead to harm:
• T1DM patients
• Never should be treated with ISS alone
• Always require basal insulin
• T2DM patients
• Poor wound healing
• Increased susceptibility to infections
Sliding Scale Insulin = Reactive Approach to DM
• Insulin only given after blood sugar rises (chasing tail)
• Does not prevent high sugars
35. A Better Solution…
• Use Basal Insulin for “background” insulin needs
• Levemir/Lantus/Tresiba
• Use Bolus Insulin to cover the carbs that are
about to be eaten
• NovoLog/Humalog/Apidra
• Use Sliding Scale – only as a supplement to
correct a single glucose value that is out of range
36. Basal-Bolus Therapy:
The Way the Pancreas Does It
Insulin lispro, aspart,
or glulisine
Insulin glargine or
detemir
Breakfast Dinner
Lunch Bedtime
Insulin
Effect
37. Basal-Bolus
• Basal Insulin
• Suppresses glucose production between meals and
overnight
• Maintains nearly constant levels
• Provides ~50% of daily needs
• Pre-Meal/Bolus Insulin
• Limits hyperglycemia after meals
• Provides immediate rise and sharp peak
• Provides ~10-20% of daily requirement at each meal
38. Basal-Bolus Insulin Therapy
• Provides a proactive approach to prevent
hyperglycemia, rather than a reactive “band-aid”
approach.
• Remember: Silding Scale Insulin when used
alone -> guarantees that you never have the
right amount of insulin around when you need it
-> can be harmful or even lethal.
40. Timing is Key!
• Proper timing of glucose testing and insulin
administration can reduce the risk of hypoglycemia and
hyperglycemia
• Administer short-acting Regular insulin 30 min before
meals
• Because the onset is 30-45 minutes
• Administer rapid-acting or bolus insulin analogs
(Humalog/Novolog/Apidra) up to 15 min before meals
• Because the onset is 5-15 minutes
41. Inpatient vs. Outpatient
• What works for a patient at home will not necessarily work for
them in the hospital
• In the hospital patients are:
• Sick
• Stressed
• Sedentary
• Suddenly “Twinkie-Deficient”
• Super-Compliant
• Thus, they may require either more or less therapy than they
did as an outpatient
42. Things NOT to Do With SQ Insulin
Therapy
• Use sliding scales as the sole treatment
• Use basal insulin in combination with premixed insulins
• Use basal insulin as the sole treatment for patients who
can eat
• Hold insulin for normal glucose levels if patients are
eating or receiving enteral feeding
• Hold insulin for patients with type 1 diabetes
44. Indications for IV Insulin Therapy
• Diabetic ketoacidosis
• Nonketotic
hyperosmolar state
• Critical care illness
(surgical, medical)
• Postcardiac surgery
• Myocardial infarction or
cardiogenic shock
• Dose-finding strategy
• NPO status in type 1 or
type 2 diabetes
• Labor and delivery
• Glucose exacerbated by
high-dose glucocorticoid
therapy
• Perioperative period
• After organ transplant
• Total parenteral nutrition
therapy
ACE Task Force on Inpatient Diabetes and Metabolic Control. Endocr Pract. 2004;10:77-82.
44
45. Switching from IV to Subcutaneous
Insulin
• IV insulin has a short half-life (~6 minutes) and should
not be discontinued until subcutaneous medication has
been initiated
• Timing of administration of subcutaneous insulin before
discontinuation of IV insulin
• 1 to 2 hours in advance for short- or rapid-acting insulins
• 2 to 3 hours in advance for intermediate- or long-acting insulins
Clement S et al. Diabetes Care. 2004;27:553-591.
47. What are the Goals?
***If can be achieved without hypoglycemia***
In Critical Patients – can try for 110-140
Patients Pre-Meal Post-Meal
Critical (CCU) 140 <180
Non-Critical <140 <180
49. What is a Low Glucose?
• Blood glucose less than 70with or without symptoms
• Severe Hypoglycemia – requires assistance
• Symptoms of Hypoglycemia:
• Anxiety
• Palpitations
• Tremor
• Sweating
• Hunger
• Paresthesias
• Cognitive dysfunction
• Seizures
• Coma
50. Preventing Hypoglycemia
• Low glucose is the primary limiting factor for achieving
optimal glucose control
• Reduction of insulin dose may be needed if:
• Switched to NPO status
• Reduced PO food intake
• Enteral feeding discontinued
• TPN or IV Dextrose discontinued due to procedures/transport
• Timing of pre-meal insulin & meal time disrupted due to
procedures/transport
• Reduction in steroid dosing
***Glucose monitoring should be increased in the event of
any of the above circumstances ***
51. What to do with Low Glucose?
50-69 and Alert
• 1 tube (15g) Glucose
Gel (if can swallow)
• 4oz of Apple juice or
OJ. DON’T ADD SUGAR
• NPO: 25ml D50 IV
and start D5W
@100ml/h
Level of Conscious
• 50 ml D50 IV &
start IV D5W @
100ml/h
<50 and Alert
Call Physician (Primary/Endo) on patient & Re-check in 15 minutes & Repeat if needed
Glucagon should NOT be repeated
• 2 tubes (30g) Glucose
Gel (if can swallow)
• 8oz of Apple juice or OJ
DON’T ADD SUGAR
• NPO: 50ml D50 IV and
start D5W @100ml/h
IF LESS THAN 70 REPEAT ACCUCHEK. IF STILL BELOW 70 TREAT ASAP.
NO IV ACCESS and NPO: Glucagon 1mg IM/SQ and start IV D5W@100ml/hr
or 50ml D50 Rectally
52. Insulin given too early…
• Patient requires regular
insulin coverage
• Blood glucose checked at
0610
• Insulin is given at 0620
• Breakfast arrives at 0740
• Potential harm: hypoglycemia
• Ideally Regular insulin should
be given 30 min before meal
• If necessary, Regular insulin
may be given with the meal
• Insulin should not be given
more than 30 min before the
meal
53. The Patient is NPO. Now What?
• Patients who are not eating require Basal insulin
to prevent ketosis (T2DM) or ketoacidosis
(T1DM)
• Should be ordered to continue Accu-Cheks Q4
Hours
• Continue the Basal Insulin Analog
(Levemir/Lantus) at the same dose
• Continue the Sliding Scale that is ordered Q4
hours
• ONLY OK to hold the pre-meal insulin boluses
54. Role of Nursing in Inpatient Diabetes Care
• Nurses are essential—and central—to successful
implementation of glucose monitoring and educational
programs to support improved glycemic control.
• Because nurses oversee inpatient care on a 24-hour basis,
nurses have opportunities to coordinate care of patients with
hyperglycemia.
• Nurses are an essential part of the team with physicians,
dieticians, nutritionists that are vital to the patient’s glucose
control.
55. Summary of Glucose Targets
• Treatment threshold: >180 mg/dL
• Goal <140-180 mg/dL for most patients in the ICU
• Lower threshold of 110 mg/dL for selected, low-risk patients
in the ICU
• On the medical floors – Goal is <140
• Both the AACE & ADA all strongly discourage use of sliding
scale insulin, which has been shown to lead to undesirable
lows and highs as compared to basal-bolus insulin approaches.
56. Take Home Messages
• Give insulin as ordered
• Don’t be afraid
• When in doubt -> Call Endo
• If insulin needs to be held -> you need Dr.’s order
