Inpatient Treatment of Diabetes

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1 Inpatient Treatment of Diabetes Alan J. Conrad, MD Medical Director Diabetes Services EVP, Physician Alignment Diabetes Symposium November 12, 2015 Objectives Explain Palomar Health goals for inpatient treatment Provide the basis from the literature for our goals Provide the approach to treatment: basal bolus and correction insulin 1

2 Setting the Stage Uncontrolled hyperglycemia in hospitalized patients with or without a diagnosis of diabetes is associated with adverse outcomes and longer lengths of stay Many patients without pre existing diabetes experience stress related hyperglycemia during hospitalization Setting the Stage An estimated 1/3 of inpatients will experience significant hyperglycemia The costs associated with hospitalization for patients with diabetes accounts for ½ of all costs for this disease (approx. $100 billion) 2

3 Setting the Stage Acute illness, inconsistent caloric intake, changes from home medications and limitations related to the timing of glucose monitoring and insulin administration are all significant obstacles to managing inpatient hyperglycemia Setting the Stage Patients with diabetes or hyperglycemia who are eating should be on a consistent carbohydrate diet, and glucose monitoring should be ordered before each meal and at bedtime Oral agents should be discontinued during acute illness unless it is a very brief hospitalization. If sulfonylureas are continued the patient should have point of care testing. 3

4 Setting the Stage Patients receiving therapies associated with hyperglycemia, such as corticosteroids or octreotide, enteral or parenteral nutrition should be monitored with bedside point of care testing for at least 24 to 48 hours after initiation of these therapies Those with blood glucose measurements greater than 140 mg/dl should have ongoing point of care testing with appropriate therapeutic interventions Goals of Treatment Control hyperglycemia Avoid hypoglycemia Controlling hyperglycemia: Improves wound healing Improves immune system function Avoids infections Avoids dehydration Lowers costs and Length of Stay 4

5 Palomar Health: Goals of Treatment ICU: non ICU: Obstetrics: mg/dl mg/dl Goals of Treatment American Diabetes Association: ICU: non ICU mg/dl <140 mg/dl fasting <180 mg/dl at all times 5

6 Endocrine Society: Goals of Treatment non ICU: <140 mg/dl fasting <180 at all times What the Literature Says ICU Landmark study van den Berghe 2001: Intensive treatment of hyperglycemia in the ICU improves outcomes This study involved surgical ICU patients Goal of treatment was a blood sugar mg/dl No subsequent study could replicate her findings including her own study in the MICU reported in 2006 Subsequent studies resulted in a high rate of hypoglycemia 6

7 What the Literature Says ICU NICE SUGAR Finfer, et al Multi site study Intensive vs conventional glucose control in critically ill patients Conclusion was that controlling sugar mg/dl was as good but with less hypoglycemia Range mg/dl has been generally accepted as the optimal range at this time What the Literature Says Outcomes are improved in: Myocardial infarction Stroke Cardiovascular Surgery Pneumonia CHF 7

8 What the Literature Says Sliding Scale Insulin (SSI) No longer recommended Reactive not proactive Increased risk of hyper and hypoglycemia Has been replaced by the Basal Bolus approach to insulin administration What the Literature Says Umpierrez, et al RABBIT 2 Trial Treatment with insulin glargine and glulisine resulted in significant improvement in glycemic control compared with that achieved with SSI alone Study indicated that a basal bolus insulin regimen is preferred over SSI in the management of non critically ill, hospitalized patients with Type2 diabetes 8

9 What the Literature Says Umpierrez, et al Rabbit 2 Surgery Trial Basal bolus treatment with insulin glargine once daily plus insulin glulisine before meals improved glycemic control and reduced hospital complications compared with SSI in general surgery patients. The study indicated that a basal bolus insulin regimen is preferred over SSI in the hospital management of general surgery patients with Type 2 diabetes 9

10 Basal Bolus approach can be used in patients with Type 2 diabetes naïve to insulin, already on insulin, patients with hyperglycemia or patients transitioning from Intravenous to Subcutaneous insulin There are simple weight based calculations Basal Insulin: Weight multiplied by conversion factor =Total Daily Dose (TDD) Basal equals 50% of the TDD Bolus Insulin: Bolus equals 50% of the TDD divided by 3 to be delivered at each meal (prandial insulin) 10

11 Correction scale insulin: Additional insulin is given to the patient based on the point of care glucose testing If the patient is not eating 100% of their meal the bolus insulin dose can be reduced accordingly Transition from IV to SQ Insulin: Calculate the dosage of IV insulin given in the 6 hours prior to discontinuation of IV insulin Multiply the 6 hour total by 4 to estimate 24 hour IV insulin dose Multiply this number by 80%= TDD 50% TDD is basal, 50% is bolus Correction dose insulin as needed 11

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