glycemic_control_in_the_hospitalized_patient_august_2019.ppt

R OD MAR IAN N E AR C EO - MEN D OZA, MD .
A S S I S T A N T P R O F E S S O R
D E P A R T M E N T O F M E D I C I N E
D I V I S I O N O F E N D O C R I N O L O G Y , D I A B E T E S A N D M E T A B O L I S M
L O Y O L A U N I V E R S I T Y M E D I C A L C E N T E R
9 A U G U S T 2 0 1 9
GLYCEMIC CONTROL IN THE
HOSPITALIZED PATIENT
INPATIENT MANAGEMENT OF HYPERGLYCEMIA : A REVIEW

OBJECTIVES
• Definition of Diabetes
• Prevalence
• Inpatient Glycemic Management
• Insulin Therapy
• Non-insulin Therapy
• Goals of Treatment
• Treatment Strategies and Common Pitfalls
• Discharge Planning and Transition of Care

DIABETES MELLITUS
• The term diabetes mellitus describes several diseases of
abnormal carbohydrate metabolism that are
characterized by hyperglycemia.
• It is associated with a relative or absolute impairment in
insulin secretion, along with varying degrees of
peripheral resistance to the action of insulin.

CLASSIFICATION OF DIABETES
• TYPE 1 DIABETES (beta cell destruction, usually leading to absolute insulin deficiency)
• Immune-mediated
• Idiopathic
• Latent autoimmune diabetes in adults (LADA)
• TYPE 2 DIABETES (insulin resistance with relative insulin deficiency)
• GESTATIONAL DIABETES MELLITUS
OTHER TYPES:
• GENETIC DEFECTS
• Maturity onset diabetes of the young (MODY)
• DISEASES OF THE EXOCRINE PANCREAS
• Cystic fibrosis, Hereditary hemochromatosis, Chronic pancreatitis, Fibrocalculous pancreatic
diabetes
• ENDOCRINOPATHIES/ DRUG-INDUCED DIABETES

2014
Diabetes is a huge and growing problem…
2035

Diabetes is a huge and growing problem…

… and the costs to society are high and escalating
Diabetes is a human and economic burden
4.9 million deaths per
year
50% of deaths under 60
years of age
Intersects with all
dimensions of
development
US$612 billion
11% of worldwide healthcare
expenditure

HEALTHCARE IMPACT
• People with diabetes are more likely to be hospitalized
and to have longer durations of hospital stay than those
without diabetes
• 22% of all hospital inpatient days were incurred by
people with diabetes
• Hospital inpatient care accounted for half of the $174
billion total US medical expenditures for this disease
Clement et al. Management of Diabetes and Hyperglycemia in Hospital. Diabetes Care 27(2): 553- 591, 2004

CONSIDERATIONS ON ADMISSION
• Initial orders should state that the patient has type 1 diabetes
or type 2 diabetes or no previous history of diabetes.
• If the patient has diabetes, an order for an A1C should be
placed if none is available within the prior 3 months.
• In addition, diabetes self-management education should be
ordered and should include appropriate skills needed after
discharge, such as taking glycemic medication, glucose
monitoring, and coping with hypoglycemia.

GLYCEMIC TARGETS IN HOSPITALIZED
PATIENTS
Standard Definition of Glucose Abnormalities:
• Hyperglycemia in hospitalized patients has been defined
as blood glucose > 140 mg/dL
• An admission A1C value >/ 6.5% suggests that diabetes
preceded hospitalization.

HYPOGLYCEMIA
• ADA now defines clinically significant hypoglycemia as
glucose values <54 mg/dL, while severe hypoglycemia is
defined as that associated with severe cognitive
impairment regardless of blood glucose level.
• A blood glucose level of <70 mg/dL is considered an
alert value and may be used as a threshold for further
titration of insulin regimens.

HYPOGLYCEMIA
• Hypoglycemia is associated with increased mortality.
• Iatrogenic hypoglycemia triggers:
• reduction of corticosteroid dose
• reduced oral intake
• emesis
• new NPO status
• inappropriate timing of short-acting insulin in relation to meals
• unexpected interruption of oral, enteral, or parenteral feedings
• altered ability of the patient to report symptoms.
Predictors of Hypoglycemia
• In one study (Ulmer et al 2015), 84% of patients with an episode of
severe hypoglycemia (<40 mg/dL) had a prior episode of
hypoglycemia during the same admission.

HYPOGLYCEMIA
• In another study of hypoglycemic episodes(Dandy et al
2014), 78% of patients were using basal insulin, with the
incidence of hypoglycemia peaking between midnight
and 6 A.M.
• Despite recognition of hypoglycemia, 75% of patients did
not have their dose of basal insulin changed before the
next insulin administration.

MODERATE VERSUS TIGHT GLYCEMIC
CONTROL
• Glycemic goals within the hospital setting have changed in the last
15 years.
• The initial target of 80–110 mg/dL was based on a 42% relative reduction in
intensive care unit mortality in critically ill surgical patients.
• However, a meta-analysis of over 26 studies, including the largest,
Normoglycemia in Intensive Care Evaluation–Survival Using
Glucose Algorithm Regulation (NICE-SUGAR), showed increased
rates of severe hypoglycemia and mortality in tightly versus
moderately controlled cohorts.
• This evidence established new standards: initiate insulin therapy for
persistent hyperglycemia greater than 180 mg/dL

INPATIENT GLYCEMIC TARGET
• Once insulin therapy is initiated, a glucose target of 140–180
mg/dL is recommended for most critically ill patients.
• More stringent goals, such as 110–140 mg/dL may be appropriate for
select patients, such as cardiac surgery patients, and patients with
acute ischemic cardiac or neurological events provided the targets
can be achieved without significant hypoglycemia.
• American Heart Association (AHA) recommends the use of an insulin
infusion when glucose values are >180 mg/dL (10 mmol/L) in
patients with an MI and a complicated course
• A glucose target between 140 and 180 mg/dL is
recommended for most patients in non- critical care units.

BEDSIDE BLOOD GLUCOSE
MONITORING
• In a patient who is eating meals, glucose monitoring
should be performed before meals.
• In a patient who is not eating, glucose monitoring is
advised every 4–6 h.
• More frequent blood glucose testing ranging from every
60 min to every 2 h is required for patients receiving
intravenous insulin.

TREATMENT OPTIONS
Hospital setting: Insulin therapy is preferred.
Orally administered agents have a limited role in the
inpatient setting.
• ICU setting: IV infusion is the preferred route of insulin
administration in patients with labile sugars
• allows rapid dosing adjustments to address alterations in the
status of patients, given its short half life
• Non ICU setting: subcutaneous administration of insulin

SUBCUTANEOUS INSULIN THERAPY IN
HOSPITALIZED PATIENTS
Three components to a basal/bolus regimen:
• Basal insulin
• Meal/prandial or nutritional bolus insulin
• Correction scale insulin

PHYSIOLOGICAL INSULIN COMPONENTS
• Basal: Targets fasting hyperglycemia
• Nutritional:
• Targets IV dextrose, TPN, enteral feeds,
• nutritional supplements or meals (prandial)
• Correction:
• “supplemental” insulin for hyperglycemia

Basal (background) insulin needs
NORMAL INSULIN SECRETION
0
10
20
30
40
50
0 2 4 6 8 10 12 14 16 18 20 22 24
Serum
insulin
(µU/mL)
Time
Meal Meal Meal
Bolus (meal)
insulin needs
60

Rapid (lispro, aspart, glulisine)
Hours
Long (glargine)
Short (regular)
Intermediate (NPH)
Long (detemir)
Insulin
Level
0 2 4 6 8 10 12 14 16 18 20 22 24
PHARMACOKINETICS OF INSULIN
PRODUCTS
Adapted from Hirsch I. N Engl J Med. 2005;352:174-183.

BASAL INSULIN
• Provides a constant 24-hour peakless level of insulin to
suppress the liver's release of glucose during the fasting
state and between meals
• Glargine: Provides relatively peakless basal insulin
• Basal insulin, when dosed correctly, should not cause
hypoglycemia when patients are restricted from oral
nutritional intake (NPO)

BOLUS INSULIN /
CARBOHYDRATE COVERAGE
• Designed to prevent predicted postprandial rise in glucose
• Best provided with one of the rapid-acting analogs (lispro,
aspart, or glulisine) with each meal
• Have a rapid onset of action and usually reach peak levels
within 60 minutes
• Should be given 0–15 minutes before a meal
• Insulin to carbohydrate ratio allows flexibility with carbohydrates
at meals while maintaining glycemic control

CORRECTION INSULIN
• Intended to lower hyperglycemic glucose levels, not to
cover nutritional hyperglycemia
• The mealtime bolus insulin dose + correction insulin dose
can be added and administered simultaneously before
each meal

LUMC CORRECTION FACTOR
ALGORITHM
• Correction Factor - Algorithm A (low dose)
For patients requiring a TOTAL of 40 units or less per day:
• 1 unit if pre-meal glucose 180-210 mg/dL
• 2 units if pre-meal glucose 211-260 mg/dL
• 5 units if pre-meal glucose is greater than 360 mg/dL
• Correction Factor - Algorithm B (moderate dose)
For patients requiring a TOTAL of 41-80 units per day:

LUMC CORRECTION FACTOR
ALGORITHM
Correction Factor - Algorithm "C" (high dose)
Correction Factor - Algorithm "D"

SUBCUTANEOUS INSULIN THERAPY IN INSULIN NAÏVE
• Estimating patients' total daily insulin requirement, or
total daily dose (TDD), is the first step in ordering
insulin
• Optimal glycemic control:
• 50% of TDD is provided as basal insulin and 50% is
provided as bolus insulin.

CARBOHYDRATE COVERAGE
 Method for setting carbohydrate ratio
1. The 500 rule and Total daily dose (TDD) of insulin
• Divide 500 by the person’s TDD (all the insulin a patient uses in a day –basal and
bolus)
 Example: The patient is on Lantus 20 units, and Novolog 4 units before each meal
• This patient’s TDD is then 32 units ( 20 + 12)
• 500/TDD
• 500/32 = 15.6
• This patients initial ICR would then be set at 1/15 or one unit of insulin for every 15
grams of carbohydrate consumed

CORRECTION SCALE: INSULIN
SENSITIVITY FACTOR
• Sensitivity factor (also referred to as the correction
factor) is the drop in blood glucose level, measured
in milligrams per deciliter (mg/dl), caused by each
unit of insulin taken

INSULIN SENSITIVITY FACTOR
• Two most common methods for figuring the sensitivity factor
• 1500 and 1800 rules
• 1500 rule: sensitivity factor for regular insulin
• 1800 rule: sensitivity factor for rapid acting insulin
 To figure the sensitivity factor:
• Figure the person’s total daily dose of insulin (TDD)
• Divide 1800 by the TDD : This is the person’s sensitivity factor.

INSULIN SENSITIVITY FACTOR
 Example: The patient takes 20 units of Lantus at night and 5 units of Novolog before
each meal
• TDD of insulin is 35
• 1800/35= 51 (Round to 50)
• This person’s sensitivity factor is 50
• 1 unit of rapid acting insulin will drop this person’s blood glucose levels about 50
mg/dl.
• Using the sensitivity factor:
• Patient’s blood glucose level is 300 mg/dl with their goal blood glucose set at 150
mg/dl.
• This patient’s blood glucose is 150 mg/dl above goal.
• Take 150 and divide by 50 (sensitivity factor).
• 150/50=3 This patient would need to take 3 units of rapid acting insulin to bring their
blood glucose level down to their goal of 12=50mg/dl

ADJUSTING INPATIENT INSULIN
THERAPY
• Fasting glucose is the best indicator of adequacy of the
basal insulin dose
• Glargine can be adjusted every 24–48 hours until fasting
glucose is < 140 mg/dl.
• Glucose levels during the rest of the day: appropriateness
of mealtime bolus insulin doses (rapid-acting insulin)
• Prelunch glucose: breakfast dose
• Predinner glucose: lunchtime dose
• Bedtime glucose: dinnertime dose

WHEN SHOULD WE ADMINISTER INSULIN AND
CHECK POC GLUCOSE LEVELS?
• If the patient is eating, insulin injections should align with
meals.
• In such instances, POC glucose testing should be performed
immediately before meals.
• If oral intake is poor, a safer procedure is to administer
the rapid-acting insulin immediately after the patient eats
or to count the carbohydrates and cover the amount
ingested.

RABBIT 2 TRIAL
• RABBIT 2 Trial:
(Randomized Study of Basal-Bolus Insulin Therapy in the
Inpatient Management of Patients with Type 2 Diabetes)
• Prospective, multicenter, randomized trial
• Insulin-naive type 2 diabetic patients on general medicine
floor
• Compared basal-bolus vs. SSI
• Primary end point: mean daily blood glucoses
• Secondary outcomes: hypoglycemic events, severe
hyperglycemia, LOS & mortality rate
Umpierrez et al. Diabetes Care 30(9): 2181-2186, 2007.

RABBIT 2 TRIAL
• Glycemic control rapidly improved after switching to
basal-bolus regimen after persistent severe
hyperglycemia
• Basal/bolus insulin regimen is preferred over SSI in the
management of noncritically-ill, hospitalized patients with
type 2 diabetes

SELF MANAGEMENT IN THE HOSPITAL: CONTINUOUS
SUBCUTANEOUS INSULIN INFUSION (CSII) PUMP
THERAPY
• Candidates:
• patients who successfully conduct self-management of diabetes
at home
• have the cognitive and physical skills needed to successfully self-
administer insulin
• have adequate oral intake
• be proficient in carbohydrate estimation
• have stable insulin requirements

CRITERIA FOR SELF MANAGEMENT OF
INSULIN PUMP
• Mentally alert and oriented x 3
• Has no physical/dexterity limitations
• Alternatively, if patient unable to self-manage, a non-health system caregiver (i.e. family
member/guardian) is available to provide support/assistance to manage insulin pump 24
hours/day
• Medically stable
• No identified reasons for pump discontinuation
• Criteria for pump discontinuation:
• Cognitive or psychological limitations:
• Altered, deteriorating or fluctuating changes to state of consciousness and/or cognitive status,
including use of medications that may interfere with cognition or may be sedating (e.g. narcotics)
• Psychiatric illness that interferes with the patient’s ability to self-manage (at risk of selfharm/suicide)
• Medical conditions:
• DKA, or persistent unexplained hyperglycemia
• Persistent/recurrent severe hypoglycemia
• Critically ill (sepsis, trauma) and needs intensive care
• Other inter-current illnesses where use of the insulin pump is risky or non-effective, as determined by
the medical staff

CRITERIA FOR SELF MANAGEMENT OF
INSULIN PUMP
• Pump functionality or performance limitations:
• Pump not functioning
• Hyperglycemia fails to respond to appropriate action (bolus
insulin)
• Insufficient pump supplies (hospital will not provide)
• Physical limitations to using the insulin pump
• Refusal or unwillingness to participate in self-care or to agree
to self-management terms
• Non-health system guardian or caregiver support/assistance
(for patients under 18), required to manage insulin pump, is
not available 24 hours/day

ORAL ANTIHYPERGLYCEMIC AGENTS IN
• In most instances in the hospital setting, insulin is the
preferred treatment for glycemic control.
• However, in certain circumstances, it may be appropriate
to continue home regimens including oral
antihyperglycemic medications.

DM TYPE 2: DIET TREATED
• Minor surgery/imaging procedure/non-critical acute illness: no
specific anti-hyperglycemic therapy
• Continue Blood glucose monitoring
• Insulin therapy should be instituted if the preprandial
blood glucose concentration exceeds 180 mg/dL
• Insulin may not be necessary after the episode is over
• On NPO: correction insulin can be administered every six
hours
• if the patient is eating with BG >180 mg/dL: basal-bolus
insulin regimen should be initiated

SPECIFIC CLINICAL SITUATIONS
 Patients Receiving Glucocorticoid Therapy
• Hyperglycemia is a common complication of corticosteroid
therapy (post prandial glucose)
• Institute glucose monitoring for at least 24 hours in all patients
receiving high-dose glucocorticoid therapy
• During corticosteroid tapers, insulin dosing should be
proactively adjusted to avoid hypoglycemia
• Glucocorticoid type and duration of action must be considered
in determining insulin treatment regimens.
• Once-a- day, short-acting glucocorticoids such as prednisone
peak in about 4 to 8 h so coverage with intermediate- acting
• For long-acting glucocorticoids such as dexamethasone or multidose
or continuous glucocorticoid use, long-acting insulin may be used.

Situation Basal/Nutritional Correctional
Continuous enteral feedings Continue prior basal
If no known basal: calculate from
TDD or consider 10 units glargine
daily
Nutritional: rapid-acting insulin
every 4-6 hour
Rapid-acting insulin every 4-6h for
hyperglycemia
Bolus enteral feedings Continue prior basal or, if none,
calculate from TDD or consider
10 units glargine daily
Nutritional: rapid-acting insulin
SQ before each feeding
Rapid-acting insulin every 4-6 h for
hyperglycemia
Parenteral feedings Add regular insulin to TPN IV
solution
Rapid-acting insulin every 4 h for
hyperglycemia

COMMON TREATMENT PITFALLS
• Using order set as “SS” Bolus + correction factor
• Not using basal Rabbit 2 trial
• Uptitrating basal w/o bolus Basal and Bolus= 50:50
• Holding basal when NPO not required if dosed
properly
• Adjusting insulin w/o discussing w/ nurse Team Work

DISCHARGE PLANNING
• Preparation for transition to the outpatient setting should
begin at the time of hospital admission
• Discharge planning, patient education, and clear
communication with outpatient providers are critical for
ensuring a safe and successful transition to outpatient
glycemic management.
• Appointment-keeping behavior is enhanced when the
inpatient team schedules outpatient medical follow- up
prior to discharge.

DISCHARGE PLANNING
• Following areas of knowledge be reviewed and addressed prior
to hospital discharge:
• Identify the health care provider who will provide diabetes care
after discharge.
• Level of understanding related to the diabetes diagnosis, self-
monitoring of blood glucose, explanation of home blood glucose
goals, and when to call the provider.
• Definition, recognition, treatment, and prevention of
hyperglycemia and hypoglycemia.
• Information on consistent nutrition habits.
• It is important that patients be provided with appropriate durable
medical equipment, medications, supplies (e.g., insulin pens),
and prescriptions along with appropriate education at the time
of discharge in order to avoid a potentially dangerous gap in
care.

TRANSITION FROM THE ACUTE CARE
SETTING
• An outpatient follow-up visit with the primary care
provider, endocrinologist, or diabetes educator within 1
month of discharge is advised for all patients having
hyperglycemia in the hospital.
• If glycemic medications are changed or glucose control
is not optimal at discharge, an earlier appointment (in 1–
2 weeks) is preferred, and frequent contact may be
needed to avoid hyperglycemia and hypoglycemia.

PREVENTING ADMISSIONS AND
READMISSIONS
Preventing Hypoglycemic Admissions in Older Adults
• Insulin-treated patients 80 years of age or older are more than
twice as likely to visit the emergency department and nearly
five times as likely to be admitted for insulin-related
hypoglycemia than those 45–64 years of age.
• To further lower the risk of hypoglycemia- related admissions
in older adults, providers may, on an individual basis, relax
A1C targets to <8% or <8.5% in patients with shortened life
expectancies and significant comorbidities

SUMMARY
• Managing diabetes and hyperglycemia during
hospitalization : vital for optimal clinical outcomes
• Insulin: best treatment for inpatient management but can
be very challenging given the stress of illness, changing
caloric intake throughout the hospital stay and limitations
to care provided by hospital personnel
• Understanding of physiological insulin administration and
the use of the three components of subcutaneous insulin
therapy (basal, mealtime bolus, and correctional insulin)

SUMMARY
• Perform an A1C for all patients with diabetes or hyperglycemia
admitted to the hospital if not performed in the prior 3 months.
• Insulin therapy should be initiated for treatment of persistent
hyperglycemia starting at a threshold ≥180 mg/dL.
• Once insulin therapy is started, a target glucose range of 140–180
mg/dL is recommended for the majority of critically ill patients and
noncritically ill patients.
• Sole use of sliding scale insulin in the inpatient hospital setting is
strongly discouraged.
• Early and thoughtful discharge planning: helps to ensure
continued glucose control in the outpatient setting

GLYCEMIC CONTROL IN THE
HOSPITALIZED PATIENT
INPATIENT MANAGEMENT OF HYPERGLYCEMIA : A REVIEW
T H A N K Y O U !

glycemic_control_in_the_hospitalized_patient_august_2019.ppt

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to glycemic_control_in_the_hospitalized_patient_august_2019.ppt

Similar to glycemic_control_in_the_hospitalized_patient_august_2019.ppt (20)

Recently uploaded

Recently uploaded (20)

glycemic_control_in_the_hospitalized_patient_august_2019.ppt

Editor's Notes