Management of Special Situations in Inpatient Hyperglycemia: Case Studies in Action Module B 1
Learning Objectives Assess the impact of special situations on glucose control, eg, an increased risk for either hyperglycemia or hypoglycemia Identify potential risks for insulin errors to implement risk reduction strategies that improve patient safety Develop treatment strategies to manage special situations affecting glucose control in the inpatient setting 2
Current Recommendations for Hospitalized Patients: Critically Ill and Noncritically Ill Patients ICU BG level 140 180 mg/dl IV insulin preferred Non Critical Care Settings Premeal BG level <140 mg/dl All BG levels <180 mg/dl Reassess the regimen if BG level is <100 mg/dl Modify the regimen if BG level is <70 mg/dl BG = blood glucose; IV = intravenous. Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353 369. Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16 38. 4
Causes of Hospital related Hyperglycemia Known diabetes (uncontrolled, undertreated) Undiagnosed diabetes Stress hyperglycemia (transient physiologic response to the stress of acute illness or injury) New Hyperglycemia Iatrogenic (corticosteroids, catecholamines, parenteral and enteral nutrition, reduced exercise) 5
Hospitalization: Multiple Transitions, Shifting Clinical Situations Rehabilitation Facility Perioperative Management Primary Care Provider U 500 Insulin Steroid Therapy Ward Hospital Surgery ICU Insulin Pump Enteral Nutrition Skilled Nursing Facility Parenteral Nutrition Adapted from Low Wang CC, Draznin B. Hosp Pract (1995). 2013;41(2):45 53. 7
Basic Paradigm for Management of Inpatient Hyperglycemia in Patients With Pre existing Diabetes Evaluation of patient s preadmission glycemic control with a quick review of glucose patterns Discontinuation of non insulin glucose lowering medications (in most cases) Ordering scheduled point of care monitoring and scheduled insulin dosing while keeping the patient s inpatient glucose goals in mind Outlining clear parameters for the management of hypoglycemia Evaluation of the daily BG patterns or the daily adjustments of insulin dose and type as needed Adequate planning for discharge Low Wang CC, Draznin B. Hosp Pract (1995). 2013;41(2):45 53. 8
Special Hospitalized Populations with Altered Insulin Sensitivity as Compared to the General Population Decreased insulin sensitivity Infected Acute organ injury (AMI, stroke) Postsurgical Glucocorticoid therapy Pressor therapy (esp. epinephrine) Transplant patients TPN/PPN Enteral (tube) feeding ESRD, pre dialysis* Severe burns Hyperglycemia (glucotoxicity) Increased insulin sensitivity Hypoadrenal Hypopituitary Malnourished ESRD, post dialysis Post hyperglycemia correction (reversal of glucotoxicity) AMI = acute myocardial infarction; ESRD = end stage renal disease; PPN = peripheral parenteral nutrition; TPN = total parenteral nutrition. Adapted from Low Wang CC, Draznin B. Hosp Pract (1995). 2013;41(2):45 53. 9 * may still be hypoglycemia prone
Transition From IV to SC insulin 10
Use of IV Insulin in the Inpatient Setting In the intensive care unit Patients with DKA Patients with HHS During/ after major surgery DKA = Diabetic ketoacidosis; HHS = hyperglycemic hyperosmolar state. Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353 369. 11
Transition From IV Insulin to SC Insulin IV insulin should be transitioned to SC basal bolus insulin therapy When patient begins to eat and BG levels are stable Because of short half life of IV insulin, SC basal insulin should be administered at least 2 3 hours prior to discontinuing the drip If short acting insulin also administered, IV insulin may be able to be stopped sooner, eg, after 1 hour SC = subcutaneous. Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16 38. 12
Rationale for Starting SC Insulin Prior to Discontinuation of IV Insulin SC insulin prior to d/c of IV insulin keeps BG levels within target range IV insulin infusion Failing to give SC insulin prior to d/c of IV insulin leads to rebound hyperglycemia IV insulin infusion Blood Glucose SC insulin dose Blood Glucose No SC insulin 5 4 3 2 1 0 +1 + Time (hours) 2 +3 +4 5 4 3 2 1 0 +1 + Time (hours) 2 +3 +4 Low Wang CC, Draznin B. Hosp Pract (1995). 2013;41(2):45 53. 13
SC Insulin Administration Scheduled (Sliding-scale insulin only uses this component) Basal Nutritional Correction Correction Total daily insulin needs Basal Nutritional Longacting insulin Rapid acting insulin Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353 369. Clement S et al. Diabetes Care. 2004;27(2):553 591. 14
Basal bolus Therapy Is Effective for the Maintenance of Glycemic Control Effective insulin therapy may contain basal, bolus, and supplemental doses to achieve target goals. 1 Plasma Insulin ( U/mL) 75 Breakfast Lunch Dinner Bolus insulin 50 Basal insulin 25 0 0 8:00 12:00 16:00 20:00 24:00 4:00 8:00 Time Adapted from Bray. 2 Correction insulin Basal bolus is more effective at glycemic control vs sliding scale therapy in medical and surgical patients. 3,4 1. Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353 369. 2. Bray B. Consult Pharm. 2008;23(suppl B):17 23. 3. Roberts G et al. Med J Aust. 2012;196(4):266269. 4. Umpierrez GE et al. Diabetes Care. 2011;34(2):256 261. 15
Sliding scale Insulin Definition Use of a mealtime insulin, typically regular insulin, as the sole insulin for managing a patient s diabetes i.e., no scheduled basal insulin or prandial insulin Potential problems Poor control of hyperglycemia (does not address basal insulin needs); also does not address premeal needs Insulin stacking Hypoglycemia Not preferred method of SC insulin delivery American Diabetes Association. Diabetes Care. 2014;37(suppl 1):S14 S80. Browning LA, Dumo P. Am J Health Syst Pharm. 2004;61(15):1611 1614. Hirsch IB. JAMA. 2009;301(2):213 214. 16
Converting From IV to SC Insulin Endocrine Society guidelines conservatively recommend the following: Establishing the 24 hour insulin requirement by averaging the IV insulin dose required over the previous 6 8 hours Using a fraction of that (ie, 75% 80%) as the total daily dose (TDD) of SC insulin Giving half of that as basal and dividing the other half among rapid acting insulin before meals Clinical trial support using 80% of the TDD to achieve 80 140 mg/dl Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16 38. Schmeltz LR et al. Endocr Pract. 2006;12(6):641 650. 17
Case Study Example: Moving to Step down Unit Patient is stable, will be moved out of the CCU and will begin scheduled meals The average dose of IV insulin was 1.5 units/hour over the past 8 hours TDD: ~40 units 80% of 40 = 32 units Basal insulin = 50% of TDD = ~16 units (glargine/detemir) or 8 units NPH bid Nutritional = 50% of TDD = ~5 units per meal (x 3 meals) (lispro/glulisine/aspart; = 15 units) Doses are then titrated against actual glucose levels. 18
Mean Glucose and In hospital Mortality in Patients With AMI: Hypoglycemia and Hyperglycemia Both Associated with Increased Mortality, Especially in Patients with No Diabetes 20 15 No diabetes All patients Diabetes (Reference: Mean BG 100 110 mg/dl) Odds Ratio 10 5 1 0 Mean BG Level (mg/dl) Kosiborod M et al. Circulation. 2008:117(8):1018 1027. 19
Tight Glycemic Control in Critically Ill Adults: Risk of Severe Hypoglycemia A Meta analysis of 26 Randomized Controlled Trials (13,567 patients) 20 Severe Hypoglycemia ( 40 mg/dl) Overall Severe Hypoglycemia RR 5.99 (4.47 8.03) CI = confidence interval. Griesdale D et al. CMAJ. 2009;180(8):821 827. Study Van den Berghe et al. 8 Henderson et al. 31 Bland et al. 25 Van den Berghe et al. 9 Mitchell et al. 35 Azevedo et al. 22 De La Rosa et al. 12 Devos et al. 13 Oksanen et al. 36 Brunkhorst et al. 11 Iapichino et al. 32 Arabi et al. 10 Mackenzie et al. 33 NICE-SUGAR 18 Overall Favors IIT Favors conventional control 0.1 1 10 Risk Ratio (95% CI)
MANAGING HYPOGLYCEMIA IN THE HOSPITAL 21
Hypoglycemia and Mortality in AMI Patients, Stratified by Insulin Therapy 60 P <0.001 18.4 Hypoglycemia No hypoglycemia Hypoglycemia was a predictor of higher mortality in patients not treated with insulin, but not in patients treated with insulin. Mortality (%) 10 9.2 P <0.92 10.4 10.2 N = 7338 no hypo 0 No Insulin Treatment Insulin Treatment N = 482 hypo (BG <60 mg/dl) Kosiborod M et al. JAMA. 2009;301(5):1556 1564. Hypoglycemia was a predictor of higher mortality in patients not treated with insulin, but not in patients treated with insulin. 22
Hypoglycemia and Risk of Death in Critically Ill Patients: NICE SUGAR Study Subgroup Median Time From Hypoglycemia to Deaths Population Death (IQR) no. days Hazard Ratio (95% Cl) P Value No hypoglycemia Moderate hypoglycemia Insulin No insulin Severe hypoglycemia Insulin No insulin 726 545 136 57 22 3089 2066 378 186 37 9 (3 23) 5 (1 22) 10 (4 15) 1 (0 9) 1.00 1.22 (1.03 1.44) 1.64 (1.34 2.01) 1.68 (1.23 2.29) 3.84 (2.37 6.23) 0.007 0.003 0.12 1.00 8.00 Decreased Risk of Death Increased Risk of Death NICE SUGAR Study Investigators. N Engl J Med. 2012;367(12):1108 1118. 23
Deleterious Impact of Hypoglycemia Sympathoadrenal response Cardiac dysrythmias Neuroglycopenia Altered sensorium and vision Falls Aspiration? Pro inflammatory state? Procoagulant state? Endothelial dysfunction Seaquist ER et al. Diabetes Care. 2013;36(5):1384 1395. Cryer PE. N Engl J Med. 2013;369(4):362 372. Goto A et al. BMJ. 2013;347:f4533. Rubin DJ, Golden SH. Hosp Pract. 2013;41(1):109 116. Hanefeld M et al. Cardiovasc Diabetol 2013;12:135. 24
The Hidden Costs of Inpatient Hypoglycemia Prolonged length of stay Malpractice suits CMS and never events CMS = Centers for Medicare and Medicaid Services 25
CMS and Never Events In 2008, the Centers for Medicare and Medicaid Services (CMS) implemented a provision that denies Medicare payment for hospital acquired conditions (HACs) This provision brings attention to the quality of patient care and the financial impact associated with "never events" occurring during a patient's hospitalization Examples include: Stages III and IV pressure ulcers Catheter associated urinary tract infection Vascular catheter associated infection Falls resulting in fractures, dislocations, and/or intracranial injuries Manifestations of poor glycemic control Complications associated with hypoglycemia (death/disability) Sand H et al. Neurohospitalist. 2012;2(1):18 27. 26
Causes of Treatment related Hypoglycemia Incidence percentage of proximate causes of hypoglycemia Excess insulin Inadequate monitoring Diet change Administration error Hyperkalemia treatment Physician computer entry error 0 10 20 30 40 50 60 70 Elliott MB et al. J Diabetes Sci Technol. 2012;6(2):302 309. 27
Scenarios Prompting Increased Monitoring and Possible Decreases in Insulin Dose Patient is switched to NPO status Reduction in food intake Discontinuation of enteral feeding or TPN Discontinuation or reduction in IV dextrose Timing of premeal insulin if meal disrupted due to medical procedures or patient transport Reduction in corticosteroid administration NPO = nothing by mouth. 28
Special Situations Hypoglycemia <70 mg/dl <40 mg/dl (severe) Can take PO Give 15 g carb (4 oz. orange juice) NPO Give 12.5 g carb IV (1/2 amp D50) MS changes Give 25 g carb IV (1 amp D50) Rule of thumb: 25 g carb will BG 25 50 mg/dl Document in chart Assess reason for hypoglycemia (food, insulin dose, sepsis, renal failure, hepatic failure) Re evaluated regimen; usually decrease insulin 29
Patients Receiving Enteral or Parenteral Nutrition 30
Case Study: Total Parenteral Nutrition 55 year old obese male is admitted with enterocutaneous fistula, no prior history of diabetes On admission, his BG level = 200 mg/dl A1C level: 7.5% (previously unrecognized DM) Patient is not eating, and it is anticipated that he will not be able to eat for 1 week TPN is started DM = diabetes mellitus. 31
Prevalence of Hyperglycemia in Patients Receiving Specialized Nutritional Support Prevalence of hyperglycemia in patients receiving enteral nutrition is up to 30% May be >50% in patients receiving parental nutrition Gosmanov AR, Umpierrez GE. Curr Diab Rep. 2013;13(1):155 162. Pleva M et al. Nutr Clin Pract. 2009;24(5):626 634. Arinzon Z et al. Arch Gerontol Geriatr. 2008;47(3):383 393. Pancorbo Hidalgo PL et al. J Clin Nurs. 2001;10(4):482 490. 32
Hyperglycemia During TPN: Marker of Poor Outcomes and Mortality in the Hospital 60 Admission Pre TPN Max within 24 hrs During TPN 10 days 50 p = 0.038 p = 0.0007 p = 0.010 p = 0.038 Mortality (%) 40 30 20 10 20 33 26 25 46 35 28 12 13 12 19 43 42 31 18 17 0 <120 121 150 150 180 >180 <120 121 150 150 180 >180 <120 121 150 BG Level (mg/dl) 150 180 >180 <120 121 150 150 180 >180 Pasquel FJ et al. Diabetes Care. 2010;33(4):739 741. 33
Adverse Outcomes Significantly Associated With Hyperglycemia in Patients Receiving TPN N BG Level (mg/dl) Odds Ratio P <0.05 Death Any Infection Renal Failure Cheung et al. 111 <125 vs >164 10.9 3.9 10.9 Lin et al. 457 <114 vs 137 180 2.3 2.7 NS Pasquel et al. 276 120 vs >180 2.8 3.6* 2.2 Sarkisian et al. 100 180 vs >180 7.22 NS NS Olveira et al. 605 >180 vs <140 5.6 NR NR *Data reported for pneumonia only. Cheung NW et al. Diabetes Care. 2005;28(10):2367 2371. Lin LY et al. Am J Med Sci. 2007;333(5):261 265. Pasquel FJ et al. Diabetes Care. 2010;33(4):739 741. Sarkisian S et al. Can J Gastroenterol. 2010;24(7):453 457. Olveira G et al. I. 2013;36(5):1061 1066. 34
Case Study: Total Parenteral Nutrition What is the insulin treatment you would recommend for a DM patient on TPN? 1. IV insulin, separate from TPN 2. Insulin added to TPN 3. Basal bolus insulin 35
Approach to the Management of Hyperglycemia in Patients Receiving Enteral or Parenteral Nutrition Enteral Nurition (EN) or Parenteral Nutrition (PN) is initiated EN = enteral nutrition; PN = parenteral nutrition; POC = point of care. Gosmanov AR, Umpierrez GE. Curr Diab Rep. 2013;13(1):155 162. 36 Start (no diabetes) or continue (known diabetes) POC BG monitoring q4 6h BG >180 mg/dl x1 or BG = 140 180 mg/dl x2 Patient on EN Use diabetes specific formula. Start insulin therapy: basal insulin 0.15 0.25 U/kg (NPH q8h, glargine qd, detemir qd, bid). Supplemental shortacting insulin q4 6h Patient on PN Consider limiting load in TPN to 150 200 g/dl/day. Start insulin therapy. Mix regular insulin with PN or use supplemental short acting insulin q4 6h. Titrate daily insulin therapy per glycemic. Request notifications if nutrition support regimen is changed. Initiate appropriate discharge planning.
General Recommendations: Hyperglycemia Associated With Parenteral Nutrition (PN) For patients receiving PN, regular insulin administered as part of the PN formulation can be both safe and effective. A BG level >120 mg/dl before PN predicts the need for insulin SC correction dose insulin is often used, in addition to insulin that is mixed with the IV nutrition. When starting PN, the initial use of a separate insulin infusion can help in estimating the TDD of insulin that will be required Separate IV insulin infusions may be needed to treat marked hyperglycemia during PN Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16 38. Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353 369. Roehl KA et al. JPEN J Parenter Enteral Nutr. 2013;37(6):755 762. 37
Case Study: Insulin Needs and Enteral Nutrition 70 year old woman admitted with a stroke She has a prior history of T2DM, controlled on oral agents BG level on admission = 150 mg/dl, A1C level = 7% Currently she is unable to swallow Continuous EN is started on hospital day 2 T2DM = type 2 diabetes mellitus. 38
Case Study: Insulin Needs and Enteral Nutrition What insulin treatment would you recommend for a DM patient on enteral tube feedings? (BG >200 mg/dl) 1. Sliding scale only with rapid acting insulin 2. IV insulin, variable rate infusion 3. NPH and regular insulin every 8 hours 4. Glargine qd or detimir qd/bid 5. Supplemental short acting insulin every 4 6 hours 39
Glycemic Management of the Patient Receiving Enteral Nutrition (EN) Continuous EN Basal insulin: 40% 50% of TDD as long or intermediate acting insulin given once or twice a day Short acting insulin: 50% 60% of TDD given q6h Cycled EN Intermediate acting insulin given together with a rapid or short acting insulin with start of TF Rapid or short acting insulin administered q4 6h for duration of EN administration Correctional insulin given for BG level above goal range Bolus EN Rapid or short acting insulin given prior to each bolus Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16 38. 40
Limited Clinical Trial Data Comparing Insulin Therapy During Enteral Nutrition (EN) One prospective RCT has evaluated different insulin regimens in hospitalized patients receiving EN support 50 patients with and without history of DM with BG levels >140 mg/dl randomized to sliding scale with regular insulin (SSRI) alone vs with long acting insulin glargine once daily Results No difference in glucose control but 48% of SSRI group required rescue with NPH due to persistent hyperglycemia RCT = randomized controlled trial. Korytkowski MT et al. Diabetes Care. 2009;32(4):594 596. 41
Cautions With Insulin and Enteral Feedings Unexpected interruptions in enteral feeding occur frequently! Administration of long acting insulin independent of enteral feeding may increase the risk of hypoglycemia Consider ordering D10 infusion (to provide calories) to be administered if tube feeding is discontinued or interrupted to prevent hypoglycemia Some data suggest that the use of biphasic analogs (premixed 70/30, 70/25) may be less likely to cause hypoglycemia because of their shorter durations of action Low Wang CC, Draznin B. Hosp Pract (1995). 2013;41(2):45 53. Hsia E et al. Nutr Clin Pract. 2011;26(6):714 717. 42
Preventing Hypoglycemia in Patients Receiving Enteral and Parenteral Nutrition If tube feeding is interrupted: Start IV 10% dextrose infusion 50 ml/hour Consider reducing next dose of long or intermediate acting insulin, and Increase frequency of bedside glucose monitoring If parenteral nutrition is interrupted: Consider reducing next dose of long or intermediate acting insulin (if used) Reduce dose of scheduled insulin if: Renal insufficiency Discontinuation or reduction in steroids Discontinuation of vasopressors Decrease in carbohydrate intake Gosmanov AR, Umpierrez GE. Curr Diab Rep. 2013;13(1):155 162. 43
Limited Clinical Trial Studying Insulin Protocols for Total Parenteral Nutrition (TPN) An insulin protocol for management of hyperglycemia in patients receiving TPN was superior to ad hoc management Initiation of insulin at rate of 1 unit:20 g of dextrose with further up titration to ratio of 1 unit:15 g if BG >140 mg/dl was effective in nondiabetic patients in ICU (or average total daily insulin dose of 0.3 ±0.2 u/kg) Jakoby MG, Nannapaneni N. JPEN J Parenter Enteral Nutr. 2012;36(2):183 188. 44
Managing Hypoglycemia (BG <70 mg/dl) in Patients Receiving Enteral or Parenteral Nutrition Administer IV dextrose 50% 25 50 ml If repeat BG is <70 mg/dl in 15 minutes, repeat dextrose IV push and start IV 10% dextrose infusion 50 ml/hour If repeat BG is 70 mg/dl in 15 minutes, measure BG in 1 hour and repeat treatment until BG is >100 mg/dl Administer intramuscular 1 mg glucagon if there is no IV access Reduce or hold next dose of long or intermediate acting insulin (if used) Gosmanov AR, Umpierrez GE. Curr Diab Rep. 2013;13(1):155 162. 45
46 Perioperative Glucose Control
Examples of Perioperative Hyperglycemia and Poor Outcomes Independent of diabetes status, increases the risk of perioperative morbidity and mortality. 1 Preoperative BG >200 mg/dl is associated with deep sternal wound infections among patients undergoing CABG. 2 Preadmission hyperglycemia independent risk factor for inpatient symptomatic pulmonary embolism after major orthopedic surgery. 3 Hyperglycemia before carotid endarterctomy is associated with increased perioperative stroke, transient ischemic attack, myocardial infarction, and death. 4 CABG = coronary artery bypass grafting. 1. Lipshutz AK, Gropper MA. Anesthesiology. 2009;110(2):408 421. 2. Trick WE et al. J Thorac Cardiovasc Surg. 2000;119(1):108 114. 3. Mraovic B et al. J Arthroplasty. 2010;25(1):64 70. 4. McGirt MJ et al. Neurosurgery. 2006;58(6):1066 1073. 47
Importance of Perioperative Glycemic Control in General Surgery Study evaluated relationship of perioperative hyperglycemia (>180 mg/dl) and insulin administration on mortality, preoperative interventions, and infections for patients undergoing elective colorectal and bariatric surgery at 47 participating hospitals between 4th quarter of 2005 and 4th quarter of 2010 If preoperative hyperglycemia was corrected with insulin, outcomes were better NO significant increase in infections preoperative interventions or death Worst outcomes: BG >180 mg/dl Best outcomes: BG <130 mg/dl Kwon S et al. Ann Surg. 2013;257(1):8 14. 48
Glycemic Control (<180 mg/dl) in Patients With Diabetes During Cardiac Surgery Reduces mortality Reduces morbidity Lowers the incidence of wound infections Reduces hospital LOS Enhances longterm survival Lazar HL et al; Society of Thoracic Surgeons Blood Glucose Guideline Task Force. Ann Thorac Surg. 2009;87(2):663 669. 49
IV Insulin Infusions: A Treatment Consideration During Surgery for Patients With T1DM In the critically ill, glycemic control is best achieved with continuous insulin infusions rather than intermittent SC insulin injections or intermittent IV insulin boluses All patients with diabetes undergoing cardiac surgical procedures should receive an insulin infusion postoperatively for at least 24 hours to keep BG <180 mg/dl In patients with T1DM and labile T2DM patients on insulin, it is advisable to begin insulin infusion preoperatively or intraoperatively to facilitate better postoperative control Lazar HL et al; Society of Thoracic Surgeons Blood Glucose Guideline Task Force. Ann Thorac Surg. 2009;87(2):663 669. 50
Preoperative Management and Assessment for Patients With Diabetes Obtain A1C level prior to surgery in patients with DM or those at risk for postoperative hyperglycemia to characterize level of glycemic control Initiate scheduled insulin therapy, using a combination of long and short acting SC insulin, to achieve glycemic control for in hospital patients awaiting surgery Consider insulin infusion protocol in selected T1DM patients or T2DM patients with labile control Hold nutritional insulin after dinner the evening prior to surgery; consider modest 10% 20% reduction in evening long acting insulin Lazar HL et al; Society of Thoracic Surgeons Blood Glucose Guideline Task Force. Ann Thorac Surg. 2009;87(2):663 669. 51
Oral Agents All oral hypoglycemic agents and non insulin diabetes medications should be held starting the night before surgery Especially those that stimulate insulin secretion, such as sulfonylureas and meglitinides, because of their potential for producing hypoglycemia during fasting prior to surgery Potential for decreased renal function and metformin considerations but stopping antidiabetic therapy too early may compromise glucose control perioperatively 52
Early Postoperative Period If an IV insulin infusion is initiated in the preoperative period, it should be continued throughout the intraoperative and early postoperative period according to institutional protocols to maintain serum glucose levels 180 mg/dl. Lazar HL et al; Society of Thoracic Surgeons Blood Glucose Guideline Task Force. Ann Thorac Surg. 2009;87(2):663 669. 53
54 Glucocorticoid induced Diabetes
Steroid Case Study 65 year old patient with T2DM is admitted for severe COPD exacerbation. His outpatient medications include insulin glargine 32 units SC at bedtime and insulin aspart 9 units SC before meals. He is started on prednisone 60 mg orally every morning as part of his treatment regimen. What do you expect the impact will be on his BG level, How might you adjust his Inpatient regimen? COPD = chronic obstructive pulmonary disease. 55
Steroid Case Study: Which of the following is most likely to occur? 1. All insulin requirements are likely to increase; therefore, his insulin glargine and insulin aspart doses should be increased by approximately 30% 2. His fasting BG level is likely to increase significantly; will need to increase his insulin glargine dose by approximately 30% 3. His postprandial glucoses are likely to increase significantly; will need to increase his premeal insulin aspart by approximately 30% 56
Glucocorticoids and Glycemic Control Administration of glucocorticoids Glucose elevation is predominantly postprandial with relative lack of fasting hyperglycemia Treatment often requires large doses of rapidacting insulin before meals (usually before lunch and dinner) Significant increase in basal insulin should be avoided as overnight hypoglycemia may be induced Low Wang CC, Draznin B. Hosp Pract (1995). 2013;41(2):45 53. 57
Prandial vs Fasting Glycemia Plasma Glucose Concentration (mg/dl) 400 300 200 100 0 Before Breakfast 2 Hours After Breakfast Before Lunch 2 Hours After Lunch Prednisolone administered Prednisolone not administered Before Dinner 2 Hours After Dinner Iwamoto T. Pharmacotherapy. 2004:24(4):508 514. 58
High Incidence of Steroid induced Hyperglycemia in the Hospital 80 nondiabetic patients treated with high dose steroids At least one BG level Percentage of Patients 100.0% 90.0% 86.0% 80.0% 70% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% >144 mg/dl >180 mg/dl Percentage of patients 60 50 40 30 20 10 0 Mean BG levels 48 14 144 mg/dl 180 mg/dl Fong AC, Cheung NW. Diabetes Res Clin Pract. 2013;99(3):277 280. 59
Frequency of Hyperglycemia in Patients Receiving High dose Corticosteroids Percent High dose defined as a dose equivalent of at least 40 mg/day of prednisone. Donihi AC et al. Endocr Pract. 2006;12(4):358 362. Episodes 60
General Recommendations: Hyperglycemia Associated With Steroids Initiate SC basal bolus insulin therapy is recommended Starting insulin dose and timing of administration individualized depending on severity of hyperglycemia and duration/dosage of steroid therapy Suggested starting dosage of 0.3 0.5 U/kg day For patients receiving high dose glucocorticoids and in those with severe hyperglycemia that is difficult to control, the use of continuous insulin infusion may be appropriate Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16 38. Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353 369. 61
Basal bolus Therapy with Emphasis on Nutritional Insulin Medium dose glucocorticoids (40 60 mg/day) tend to cause minimal increase in FPG and marked elevation in PPG. Basal Insulin drip NPH Long-acting insulin analog (glargine, detemir) Scheduled Nutritional* Emphasis on regular or rapid-acting insulin analog Supplemental/ Correction* Regular or rapidacting insulin analog q4 6h *Rapid analog preferred. FPG = fasting plasma glucose; PPG = postprandial glucose. Clement S et al. Diabetes Care. 2004;27(2):553 591. Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353 369. 62 Analog Mixes
Hyperglycemia and Glucocorticoid Therapy: Summary Institute glucose monitoring for at least 48 hours in all patients Prescribe insulin therapy as needed according to results of bedside BG monitoring During initiation and taper of steroid therapy, proactive adjustment of insulin therapy can help avoid uncontrolled hyperglycemia and hypoglycemia. Umpierrez GE et al; Endocrine Society. J Clin Endocrinol Metab. 2012;97(1):16 38. Moghissi ES et al; American Association of Clinical Endocrinologists; American Diabetes Association. Endocr Pract. 2009;15(4):353 369. 63
Concentrated Forms of Insulin: The Example of U 500 64
U 500 Case Study 58 year old male complaining of right toe pain and foot infection admitted to rule osteomyelitis Height = 5 11 ; weight = 257 lb; BMI = 36 kg/m 2 A1C level = 10.9% Patient states that he is on insulin human injection U 500 (concentrated) insulin 30 units before breakfast and dinner at home Started on vancomycin 1g IV q12h 65
Essential Prescribing Information Insulin human injection U 500 contains 500 units of insulin in each milliliter (5 times more concentrated than traditional insulin human injection U 100) Extreme caution must be observed in the measurement of dosage because inadvertent overdose may result in serious adverse reaction or life threatening hypoglycemia To reduce the risk of dosing errors, the actual dose in units, corresponding unit marking on U 100 insulin syringe or ml markings on volumetric (TB or allergy) syringe with accompanying conversion chart 66
When a U 500 Insulin Patient Is Admitted to the Hospital, Several Safety Issues Arise U 500 insulin syringes do not exist, so patients use regular U 100 insulin syringes to draw up their insulin at home. As the corresponding units on a regular insulin syringe are not comparable, there is misrepresentation of actual dose given. Dosed in tenths of milliliters. Pharmacy should interview the patient on admission to verify correct dose by having the patient demonstrate drawing up actual home dose. Samaan KH et al. Am J Health Syst Pharmacy. 2011;68(1):63 68. 67
U 500 Case Study When Pharmacy interviews the patient, he demonstrates that he draws the insulin to the 30 mark on the U 100 syringe. What is the actual dose the patient is receiving at home? 1. 30 units of R U 500 insulin before meals 2. 150 units of R U 500 insulin before meals 3. 6 units of R U 500 insulin before meals 68
Comparison of U 100 ml Syringe With Insulin Human Recombinant U 100 and Insulin Human Recombinant U 500 Dose U 500 Regular U 100 Regular Although both are drawn to the 5 unit mark, the syringe with U 500 contains 25 units, whereas the syringe with U 100 contains 5 units of insulin. 69
Safety Measures Required to Reduce the Risk of Dosing Errors Standardized CPOE, with alerts to Pharmacist and Diabetes Educator Pharmacy home dose verification of R U 500 insulin on admission Patient s R U 500 sent home or stored in Pharmacy Pharmacy dispenses prefilled volumetric syringe to the unit U 500 insulin dose and volume documented in the MAR 70
Continuous Subcutaneous Insulin Infusions (CSII), Also Known as Insulin Pump Therapy, in the Hospital Setting 71
Insulin Pumps Electronic devices that deliver insulin through a subcutaneously inserted catheter: basal rate (variable) + bolus delivery for meals Used predominantly in T1DM Pump patients are fastidious about their BG control and reluctant to yield control to the inpatient medical team Hospital personnel tend to be unfamiliar with pumps Hospitals do not stock pump supplies Need policies to allow pump patients to manage their own diabetes during hospitalizations (many ethical/ medicolegal considerations!) 72
Insulin Pumps 73
74
Physiological Insulin Delivery From an Insulin Pump Mealtime boluses 8 U 10 U Insulin Level 5 U 2 U 0.8 U/h 0.7 U/h 0.9 U/h 0.6 U/h 1.1 U/h Basal rates 0 2 4 6 8 10 12 14 16 18 20 22 24 Hours 75
Inpatient CSII Protocol Patients who have been well controlled with CSII at home can self manage their pumps during hospitalization Patients should confirm in writing their willingness and ability to use insulin pumps Nurses should verify and document all administered basal rates and bolus doses If pump is interrupted for >1 hour, another source of insulin (either IV or SC) MUST be given 30 minutes prior to discontinuation eg, Insulin pumps must be discontinued for an MRI Patient Attestation I confirm that I have been fully trained on the use of my insulin pump prior to this hospitalization and that I am capable and willing to manage it independently during my hospital stay. If at any time I feel that I am unable to manage the pump, I will alert my medical team. Patient Witness CSII = continuous SC insulin infusion; MRI = magnetic resonance imaging. Noschese ML et al. Endocr Pract. 2009;15(5):415 424; EL3, review of medical records; EL4, expert opinion. 76
Transitioning Insulin Pump Therapy From the Outpatient to the Inpatient Setting: A Review of 6 Years' Experience With 253 Cases Data show that adherence to core process measures improved over time 100% of cases had an endocrinology consultation 100% had insulin pump order set completed 94% had documentation of signed agreement specifying patient responsibilities for continued use of pump technology while hospitalized 64% had documentation of insulin pump flow sheet Clinical outcomes Episodes of severe hyperglycemia (>300 mg/dl) and hypoglycemia (<40 mg/dl) were significantly less common among pump users No pump site infections, mechanical pump failures, or episodes of diabetic ketoacidosis were observed among patients remaining on therapy Cook CB et al. J Diabetes Sci Technol. 2012;6(5):995 1002. 77
Resources American Association of Clinical Endocrinologists Inpatient Glycemic Resource Center http://www.aace.com/resources/igcrc/ Institute for Safe Medication Practices http://www.ismp.org/default.asp American Society of Hospital Pharmacists: Safe Use of Insulin in Hospitals hhtp://www.ashop.org/s_ashp/docs/files_safe_use_of_insulin.pdf Society for Hospital Medicine Resource Center http://www.hospitalmedicine.org/resourceroomredesign/glycemiccont rol.cfm Samaan KH et al. Addressing safety concerns about U 500 insulin in a hospital setting. Am J Health Syst Pharmacy. 2011 Jan 1;68(1):63 68. 78