Management of Diabetes and Hyperglycemia at BWH

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Management of Diabetes and Hyperglycemia at BWH
Others!
Nutrition
Physicians
Laboratory
Nursing
Pharmacy
Information Management
Education
Care Coordination
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Goals of this Session

• Purpose

• To review principles of diabetes management on
  the general medicine service

• To discuss cases, issues, challenges related to
  glycemic management

• To discuss the new BICS order set for
  subcutaneous insulin

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SubQ Insulin Protocol

• Based on national guidelines, local studies
• Refined over past year through 2 pilot studies
  and one randomized controlled trial
• Focus of intense MD and nurse education
• Now ready for hospital-wide roll-out of BICS
  order set

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Background

• Diabetes or hyperglycemia is present in gt
  30 of inpatients
• Hyperglycemia is related to poor outcomes
• Length of stay
• Wound infections
• Ability to live independently after discharge
• Inpatient and outpatient mortality

Clement et al. Diabetes Care. 2004. 27 (2) 553-591
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December 2003 ACE Inpatient Diabetes Consensus
Conference
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New AACE Guidelines

• Critically ill patients
• Start insulin at a threshold no higher than 180
• Target range 140-180 mg/dL
• Non critically ill patients
• Pre-meal lt 140 mg/dL, random lt 180 mg/dL
• More stringent if stable, previous tight control
• Less stringent with severe comborbidies

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Approach to Hyperglycemia in Hospitalized Patients

• Inpatient situations are unstable
• Change from home to inpatient regimen
• No single algorithm suitable for all patients
• Review BBG values, clinical condition nutrition
  every day?adjust medications
• Reassess medications at discharge?change back to
  appropriate outpatient (home) regimen

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Options for Glucose Management

• Oral agents
• Insulin drips
• SubQ insulin

should rarely be used
indicated for most ICU patients
indicated for most non-ICU patients
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Limitations of Oral Diabetes Medications in
Inpatients

• Multiple contraindications
• Multiple potential adverse effects
• Little flexibility, opportunity for titration

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Indications for Insulin Drip

• Critical illness
• Acute MI
• Type I, prolonged NPO
• Peri-operative period
• TPN

• Stroke
• Labor and delivery
• Dose-finding strategy
• Any illness requiring prompt glucose control
  (DKA, HHS)

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Most Patients Should Have Three SC Insulin Orders

• Basal (NPH or glargine)
• Nutritional/prandial (aspart or regular)
• Supplemental (correction) AKA sliding scale

Sliding scale should rarely be used alone!
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Basal Insulin NPH or Glargine

• Provides insulin needed to prevent fasting and
  pre-meal hyperglycemia
• MUST always be used if type 1 diabetes!!!
• NPH usually given QAM/QHS or QHS (not BID)
• Glargine (Lantus) can be given any time of day,
  usually QHS

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Nutritional Insulin Aspart, Regular

• Provides insulin needed to cover nutrition
• Aspart (Novolog) preferred if eating because
  rapid onset and very short duration (reduced risk
  for hypoglycemia between meals)

• Must be given at the time the food tray arrives
  (i.e., NOT 8, 12, 5)

• Should be HELD if NPO

• Can even be given immediately after the meal if
  PO intake unpredictable
• Then adjust dose based on amount eaten

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Nutritional Insulin (continued) Aspart, Regular
or NPH/Glargine

• Regular insulin-preferred for tube feeds
• Should be HELD if tube feeds are stopped
• If tube feeds are stopped, hang D10 at TF rate
  until 4-6 hours after last dose
• NPH/glargine-sometimes used if patient is
  reliably tolerating tube feeds
• Should be HELD if tube feeds are stopped
• Hang D10 until 8-10 hours after last dose

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Supplemental Insulin (AKA Sliding Scale)

• Covers unexpected hyperglycemia not controlled by
  basal and/or nutritional insulin
• If eating? add aspart sliding scale to standing
  qac aspart
• If tube feeds?add regular Q6H to standing q6h
  regular
• If NPO?just give regular SS Q6H
• Should vary depending on total insulin
  requirements
• Only give QHS when very hyperglycemic
• Should not be given more frequently than q 4-6 h!!

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Sliding Scale (Alone) Insulin Limitations

• It doesnt work!!
• Reactive, not proactive
• One size doesnt fit all
• Too small doses likely have little or no effect
  on overall glucose control
• Too large doses leads to rollercoaster pattern of
  glycemia
• Increases risk for stacking of insulin and
  hypoglycemia

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Examples of Appropriate,Variable
Supplemental/Correction Scales
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Why arent you worried about hypoglycemia when
using that much insulin?
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As long as you give the patient a dose of insulin
lower than their total insulin requirement, if
the glucose starts to go too low, their
endogenous insulin production will decrease to
compensate!?No Hypoglycemia!
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Sample Order Set Eating

• Check BBG qAC and qHS
• Basal Insulin Give NPH subQ 9 units qam and 9
  units qhs
• Nutritional Insulin Give Aspart 6 units subQ
  0-15 min qac HOLD IF NPO. DO NOT ADMINISTER
  UNLESS MEAL IS PRESENT.

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Sample Orders Eating (Continued)

• Supplemental/Correction Insulin AC Give aspart
  subQ according to the following scale tid ac IN
  ADDITION TO PRANDIAL INSULIN
• 125-199 ? 1 aspart
• 200-249 ? 2 aspart
• 250-299 ? 3 aspart
• 300-349 ? 4 aspart
• gt349 ? 5 aspart call house officer
• Supplemental/Correction Insulin HS
• gt350 ? 5 aspart

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Example Insulin AdministrationNPH 9 AM/HS
Aspart 6 ac Aspart SS

• If the patient with the above orders has a blood
  glucose value before breakfast of 225, you would
  give

9 NPH (Basal) 6 Aspart (Prandial) 2 Aspart
(Supplemental) 17 units total
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Case 1

• Patient with the above orders develops abdominal
  pain, is going to Abd CT next AM, NPO after
  midnight
• What do you do with her insulin orders?

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Case 1 (Continued)

• Give usual QHS NPH insulin (9 units) night before
• Talk to team about dose of NPH to give in AM (do
  not automatically cut it in half!)
• e.g.,give half of AM NPH (4 units) if fasting
  glucose lt140, otherwise give full dose
• Hold prandial Aspart in the morning
• Discuss correctional with H.O.
• Encourage CT to get done early in the day!

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Case 1 (Continued)

• Next day, patient vomits dinner, already given
  Aspart, 1 hour later feels diaphoretic
• Check BS, its 55
• What do you do?

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Hypoglycemia Symptoms

• Shakiness
• Dizziness
• Sweating
• Hunger
• Headache
• Pale skin color
• Sudden moodiness or behavior changes
• Clumsy or jerky movements
• Seizure, difficulty paying attention or confusion
• Tingling sensations around the mouth.
• Some patients may have hypoglycemia unawareness

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Hypoglycemia Treatment

• Goal is get glucose in normal range, but do not
  over-treat
• If symptomatic and can take POs
• 3 glucose tablets, or
• 1/2 cup of fruit juice or regular soda, or
• 1 cup nonfat milk
• Do NOT give OJ plus sugar packets
• Repeat BG in 15 minutes
• Repeat BG lt 60 mg/dL ?repeat
• When BG above 60 mg/dL, give snack or meal

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Hypoglycemia Treatment (Continued)

• If cant take POs
• If IV access
• 25g D50 x 1
• Check blood glucose q 15 minutes and repeat if BG
  below 80 mg/dL
• Do not give POs
• Do not have anything put in their mouths
• Call H.O. to discuss what to do with orders

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Case 1 (Continued)

• Trial of OJ vs. D50, depending on likelihood of
  keeping POs down
• Repeat BBG in 15 minutes, may need to repeat OJ
• Call H.O. to discuss future orders
• In this case, should still get NPH QHS
• Consider giving Aspart immediately after meals
  until PO intake more consistent

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Case 1 (Continued)

• 2 days later, patient is tolerating regular diet,
  taking NPH 10 units QAM/QHS, Aspart 7 units QAC.
  Yesterdays sugars
• 7am 195 ? 71 aspart, 10 NPH
• 12pm 220 ? 72 aspart
• 4pm 260 ? 73 aspart
• 10pm 200 ? 10 NPH
• What should we do now? Its 10am, patient
  already received todays NPH dose (10 U)

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Case 1 (Continued)

• Impression suboptimal control
• Total daily insulin 41 scheduled, 6 extra
• Todays TDD 47 10 for poor control ? 52 units
• Divide into basal and prandial (50/50) ?
• NPH 13 qam, 13 qhs
• Aspart 9 qac
• Change aspart sliding scale to 1,3,5,7,8
• Right now, give an extra 3 units NPH

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Case 1 (Continued)

• Hospital Day 7, shes ready for DC.
• Prednisone 30 mg qd, will taper over 1 week
• Hgb A1c 7.0, sugars mostly lt 180
• On NPH 13 qam/qhs, Aspart 9 ac
• Talk to family, finally find out home regimen
  70/30 20 units BID
• What do you write for DC orders?

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Discharge Orders

• Most patients should resume preadmission regimen
  (unless poor outpatient control)
• If not previously taking insulin and need insulin
  at discharge, discharge insulin regimens should
  be as simple as possible (no more than 1
  injection/day for most patients)
• New insulin orders will require intensive
  education and prompt follow-up

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Case 1 (Continued)

• Glucose control at home good
• Getting less sick, tapering steroids
• Send home on pre-admission regimen

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SummaryReactions to Hyperglycemia

• Supplemental insulin is small part of the answer
• Talk to H.O., discuss reasons (not enough basal
  and/or nutritional, inadequate SS, dietary
  non-adherence, steroids, illness)
• Encourage H.O. to adjust orders
• May need a 1-time dose of regular or NPH

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SummaryReactions to Hypoglycemia

• OJ or D50 is small part of the answer
• Talk to H.O., discuss reasons (too much basal
  and/or nutritional, too much SS, NPO, renal
  failure, improving illness, steroid taper)
• Encourage H.O. to adjust orders
• Do not hold all basal insulin!

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Patients on Tube Feeds or TPN

• Tube feeds Check FSBS Q6H
• If hyperglycemic, basal regular insulin Q6H
  SS
• If tube feeds are held, D/C insulin or hang D10
  at same rate
• TPN Check FSBS Q6H
• If hyperglycemic, regular insulin Q6H SS or
  regular insulin in the bag
• If TPN held, D/C insulin or hang D10

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Addressing Patients ConcernsStarting Insulin
for First Time In the Hospital

• Optimal diabetes care is different in inpatient
  and outpatient settings
• Inpatient glucose control improves outcomes
• Insulin use in hospital doesnt necessarily mean
  they will need insulin as outpatient
• They should discuss outpatient regimen with their
  attending MD and later with their PCP
• Call H.O. or attending if patient still refuses
  SQ insulin or FSBS

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Addressing Patients ConcernsDischarging Patient
on Insulin for First Time

• Hospital documents on patient education
• Pt Ed doesnt all need to be done at once
• Teach as administering insulin, checking blood
  sugars
• Will likely need VNA to review things at home
• Talk to team early about whether will be checking
  FS, administering insulin, using pens or
  needles/syringes at home so can tailor education

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Ideally, Some Patients Should Be Involved In
Their Own Care

• Patient may alert you when the food tray arrives
  so you can obtain BBG and give insulin
• Discuss appetite, likelihood of eating entire
  contents of tray, adjust insulin dose accordingly
• Encourage consistent carbohydrate diet (avoiding
  gifts of food)
• PCAs can help perform some of these roles in
  patients who are cognitively impaired

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Thank you!!