master template

1
Diabetes Management in Hospital November 16,
2003 Endocrine Fellows Conference
Paul C. Davidson, MD, FACE Atlanta Diabetes
Associates Atlanta, Georgia
2
Diabetes in Hospitalized Patients

• 6 Million US Hospitalizations
• 15 of Admissions
• 24 Million Hospital Days
• 20 of All Hospital Days
• 36 First Diagnosed in Hospital
  66 No Documentation by Physician
  27 Labeled Hyperglycemia
  2 Diagnosis on Face Sheet

3
Diabetes in Hospitalized Patients1997 Costs

• 23,500 Each Diabetes Patient vs.
• 12,200 for Non-Diabetes Patient
• 60 of All Diabetes-Related Costs
• Only 5 DKA, HHNKC
• 48 Diabetes Complications
• 52 Other Conditions

4
Impairment of Phagocytic Function Bybee,
1964Short, Transient Hyperglycemia
Abnormalities in granulocyte adherence,
chemotaxis, phagocytosis, bacterocidal
function. Bybee, 1964 Hill, 1974 Chase,
1981 Rosenberg, 1990
Effects of Hyperglycemia Infectious Disease
5
Global Perspectives Effect of Underlying
Diabetes Impact of Acute Diabetic StateStress
Response Counter Regulatory Hormones Epinephrin
e, Glucagon, Cortisol, GHGlucose Toxicity
Increased Glucose, FFA, KetonesAcidosis
Lactic or KetosisMechanism of Progressive
Insulin Resistance
Diabetes in Hospitalized Patients
.Pathophysiology
6
Role of Insulin and Glucose in Acute MI

• Insulin
• Anti-inflammatory
• Acute Reduction CRP
• Anti-thrombotic
• Profibrinolytic
• Suppresses PAI-1
• Suppresses FFA
• Preserve Endothlium
• Suppresses MMPs
• Prevents Rupture

• Glucose
• Pro-inflammatory
• Pro-thrombotic
• Induces MMPs (Matrix Matalloproteinases)
• Mediates Plaque Rupture

Dandona Diab Care 2003
7
Detriments Decreased Appetite Meals Held or
Delayed Decreased Activity Oral Agents
Stopped Insulin Held Sliding Scale
Insulin Only for Extreme BGs Benefit
Detecting Hyperglycemia
Effects of Hospitalization on Diabetes Management
8
Missed Opportunities To Reduce Hospital
Morbidity and Mortality To Initiate
Interventions to Delay Long-term
Complications
Diabetes in Hospitalized Patients
.Failure to
Treat Hyperglycemia
9
Diabetes in Hospitalized Patients
.

Psychology

• Patients expect good glycemic control as part of
  hospital care
• They strive for recommended goals at home
• Difficult to understand staffs casual approach
  to BGs gt150

10
Diabetes in Hospitalized Patients
.

Clinical Risks

• High-risk for Bacterial Infection
• Surgery
• Catheters
• Intravenous Access
• Anesthesia

• Problems with wound healing

• Problems with tissue and organ perfusion

11
Infections in Diabetes

• One BG gt220 mg/dl results in 5.8 times increase
  in nosocomial infection rate
• Two hours hyperglycemia results in impaired WBC
  function for weeks

Pomposelli, New England Deaconess, J Parenteral
and Enteral Nutrition 2277-81,1998
12
Side Effects of BG gt200 mg/dl

• Reduced Intravascular Volume
• Dehydration
• Electrolyte Fluxes
• Impaired WBC Function
• Immunoglobulin Inactivation
• Complement Disabling
• Increased Collagenase, Decreased Wound Collagen

13
Evidence for Immediate Benefit of Normoglycemia
in Hospitalized Patients

• Numerous Publications on in Vitro Evidence
• Neutrophil Dysfunction
• Complement Inhibition
• Altered Redox State (Pseudohypoxia)
• Glucose Rich Edema as Culture Media
• Recent Outcome Studies Supporting Good Glucose
  Control in Hospital Setting
• Reduction in CRP

14
Open Heart Surgery in DiabetesJohn Hopkins

• 24.3 with infections
• BG divided into quartiles Relative
  Odds
• Q1 121-206 20.1
• Q2 207-229 21.6
  1.17
• Q3 230-252 29.8
  1.86
• Q4 252-352 25.7
  1.72

P lt 0.01
Golden SH Diabetes Care 22 1408, 1999
15
Admission glucose values gt108 mg/dl IV Insulin
with Bypass Surgery Hospital mortality identical
Diabetics and Non-diabetics (1.75 vs.
1.71) Usual Diabetic Mortality 50 Higher
CABG in Diabetes Kalin 1998
16
623 Hyperglycemic Patients Mortality and Stroke
Severity Increase Linearly with BG BG gt144
mg/dl in First 24 Hours Double Mortality Risk
Stroke in Diabetes
Weir
17
Diabetes with Steroid TherapyPiedmont
Hospital1998

• Problem Noted by DRC Case Managers
• Frequency of Hyperglycemia in Non-Diabetic
  Patients
• Prevalence Among Steroid Treated
• No Systematic Plan of Response
• Frequency of Discharge Out-of-Control

The Dark Side of Corticosteroids
18
Diabetes with Steroid TherapyPiedmont
Hospital1998
Chart Review by Terry Kaplan RN
19
Diabetes with Steroid TherapyPiedmont
Hospital1998
Opportunity for Improvement 59
20
Classical Diabetes ManagementTypical A1c 9
Mis

• The daily dosage of insulin is divided
• 2/3 in the morning and 1/3 in the evening.
• Two thirds NPH and 1/3 Regular.
• Results
• 70/30 Insulin
• (The insulin for the retarded)
• No Patients to Goal!

21
Sliding Scale Insulin

• Five Units for Each Plus on bid Urine Testing
• Table of BG Ranges and R Doses
• Correction Bolus Formula
• (BG-Target BG) / CF

• No Benefit When Used Without Basal Insulin
• Three Times More Hyperglycemia Compared to
  Standing Dose NPH

Queale, 1997
22
Methods For Managing Hospitalized Persons with
Diabetes

• Continuous Variable Rate IV Insulin Drip
• Major Surgery, NPO, Unstable, MI, DKA,
  Hyperglycemia, Steroids, Gastroparesis, Delivery,
  etc
• Basal / Bolus Therapy (MDI)

23
Continuous Variable Rate IV Insulin Davidson 1982

• Give continuous rate of Glucose in IVFs
• Mix Drip with 125 units Regular Insulin in 250
  cc NS
• Starting Rate Units / hour (BG 60) x 0.02
• Check glucose hourly and adjust
• Change Multiplier to keep in desired range
• 100 to 140 mg/dl

24
Continuous Variable Rate IV Insulin

• Adjust Multiplier to obtain glucose in target
  range
• If BG not decreasing gt 50 mg/dL and gt 140
  mg/dL, increase by 0.01
• If BG lt 100 mg/dL, decrease by 0.01
• If BG 100 to 140 mg/dL, no change in
  Multiplier
• If BG is lt 80 mg/dL, Give D50 cc (100 BG) x
  0.4
• Once eating, continue drip till 2 hour post SQ
  insulin

25
Glucommander AN ADAPTIVE, COMPUTER-DIRECTED
SYSTEM FOR IV INSULIN, SHOWN TO BE SAFE, SIMPLE,
AND EFFECTIVE IN 120,618 HOURS OF OPERATION

• Invented in 1984 Davidson and Steed
• Based on 17 Year Experience with a Computer Based
  Algorithm for the Administration of IV Insulin
• Developed for Marketing by MiniMed and Roche
• GMS System
• Shelved Pending FDA Approval of IV Use of Insulin
• Useful and Safe for Any Application of IV Insulin

26
Glucose Management System
27
Intravenous Insulin with Severe Illness

• Three major recent studies
• DIGAMI Prospective Randomized Study of
  Intensive Insulin Treatment
  on Long
  Term Survival After Acute Myocardial Infarction
  in Patients with Diabetes Mellitus
• Malmberg, et al. BMJ. 19973141512-1515.
• Portland Continuous Insulin Infusion Reduces
  Mortality in Patients with Diabetes Undergoing
  Coronary Artery Bypass Grafting
• Fumary et al J Thorac Cardiovasc Surg
  20031231007-21
• Leuven Intensive Insulin Therapy in Critically
  Ill Patients
• Van den Berghe et al N Engl J Med 2001 345
  1359-67

28
DIGAMI StudyDiabetes, Insulin Glucose Infusion
in Acute Myocardial Infarction

• Acute MI With BG gt 200 mg/dl
• Intensive Insulin Treatment
• IV Insulin For gt 24 Hours
• Four Insulin Injections/Day For gt 3 Months
• Reduced Risk of Mortality By
• 28 Over 3.4 Years
• 51 in Those Not Previous Diagnosed

Malmberg BMJ 19973141512
29
Cardiovascular RiskMortality After MI Reduced
by Insulin Therapy in the DIGAMI Study
IV Insulin 48 hours, then 4 injections daily
All Subjects
Low-risk and Not Previously on Insulin
.7
.7
(N 620)
(N 272)
.6
.6
Risk reduction (51)
Risk reduction (28)
.5
.5
P .011
P .0004
.4
.4
.3
.3
.2
.2
.1
.1
0
0
0
1
2
3
4
5
0
1
2
3
4
5
Years of Follow-up
Years of Follow-up
Malmberg, et al. BMJ. 19973141512-1515.
6-11
30
Open Heart Surgery in DiabetesPortland St.
Vincent Medical Center Perioperative Blood
Glucose
Furnary et al, The 34th Meeting of The Society of
Thoracic Surgeons New Orleans, LA January 26, 1998
31
Mortality of DM Patients Undergoing CABG
Fumary et al J Thorac Cardiovasc Surg
20031231007-21
32
ICU Survival

• 1548 Patients
• All with BG gt200 mg/dl
• Randomized into two groups
• Maintained on IV insulin
• Conventional group (BG 180-200)
• Intensive group (BG 80-110)
• Conventional Group had 1.74 X mortality

Van den Berghe et al, NEJM 2001345(19)1359
33
ICU Survival

• Conventional
  Intensive
• Mean AM BG 153
  103
• Receiving Insulin 39
  100
• BG lt 40 mg/dl 6
  39

No serious hypoglycemic events
Van den Berghe et al, NEJM 2001345(19)1359
34
ICU Survival

• Intensive Therapy (80 to 110 mg/dL) resulted in
• 34 reduction in mortality
• 46 reduction in sepsis
• 41 reduction in dialysis
• 50 reduction in blood transfusion
• 44 reduction in polyneuropathy

Van den Berghe et al, NEJM 2001345(19)1359
35
ICU Mortality Effect of Average BG Van den Berghe
et al (Crit Care Med 2003 31359-366)
P0.0009
BGgt150
110ltBGlt150
P0.026
BGlt110
36
IV Insulin Based Studies DIGAMI, Portland, Leuven

• All three have IV insulin protocols
• Complex
• Require ICU housing
• Specially trained nurses
• Dedicated supervision
• Consequently not widely accepted

37
Portland Protocol Furnary et al J Thorac
Cardiovasc Surg 20031231007-21
1. Start Portland protocol during surgery and
continue through 7 AM of the third POD. Patients
who are not receiving enteral nutrition on the
third POD should remain on this protocol

until receiving at least 50 of
a full liquid or soft American Diabetes
Association diet. 2. For patients with previously
undiagnosed DM who have hyperglycemia, start
Portland protocol if blood glucose is greater
than 200 mg/dL. Consult endocrinologist on POD 2
for DM
workup and
follow-up orders. 3. Start infusion by pump
piggyback to maintenance intravenous line as
shown in Appendix Table 1. 4. Test blood glucose
level by finger stick method or arterial line
drop sample. Frequency of blood glucose testing
is as follows a. When blood glucose level
greater than 200 mg/dL, check every 30 minutes.
b. When blood glucose level is less than 200
mg/dL, check every hour. c. When titrating
vasopressors, (eg, epinephrine) check every 30
minutes. d. When blood glucose level is 100 to
150 mg/dL with less than 15 mg/dL change and
insulin rate remains unchanged for 4 hours
(stable infusion rate), then you may test
every 2 hours. e. You may stop testing every 2
hours on POD 3 (see items 1 and 8). f. At
night on telemetry unit, test every 2 hours if
blood glucose level is 150 to 200 mg/dL test
every 4 hours if blood glucose level is less than
150 mg/dL and stable infusion rate
exists. 5. Insulin titration according to blood
glucose level is performed as follows a. When
blood glucose level is less than 50 mg/dL, stop
insulin and give 25 mL 50 dextrose in water.
Recheck blood glucose level in 30 minutes.
When blood glucose level is greater than 75
mg/dL, restart with rate 50 of previous rate.
b. When blood glucose level is 50 to 75 mg/dL,
stop insulin. Recheck blood glucose level in 30
minutes if previous blood glucose level was
greater than 100 then give 25 mL 50
dextrose in water. When blood glucose level is
greater than 75 mg/dL, restart with rate 50 of
previous rate. c. When blood glucose
level is 75 to 100 mg/dL and less than 10 mg/dL
lower than last test, decrease rate by 0.5 U/h.
If blood glucose level is more
than 10 mg/Dl lower than last test, decrease
rate by 50. If blood glucose level is the same
or greater than last test, maintain same rate.
d. When blood glucose level is 101 to 150
mg/dL, maintain rate. e. When blood glucose
level is 151 to 200 mg/dL and 20 mg/dL lower than
last test, maintain rate. Otherwise increase rate
by 0.5 U/h. f. When blood glucose level is
greater than 200 mg/dL and at least 30 mg/dL
lower than last test, maintain rate. If blood
glucose level is less than 30 mg/dL lower
than last test (or is higher than last test),
increase rate by 1 U/h and, if greater than 240
mg/dL, administer intravenous bolus of
regular insulin per initial intravenous insulin
bolus dosage scale (see item 3). Recheck blood
glucose level in 30 minutes. g. If blood
glucose level is greater than 200 mg/dL and has
not decreased after three consecutive increases
in insulin, then double insulin rate. h. If
blood glucose level is greater than 300 mg/dL for
four consecutive readings, call physician for
additional intravenous bolus orders. 6. American
Diabetes Association 1800-kcal diabetic diet
starts with any intake by mouth. 7. Postmeal
subcutaneous Humalog insulin supplement is given
in addition to insulin infusion when oral intake
has advanced beyond clear liquids. a. If
patient eats 50 or less of servings on
breakfast, lunch, or dinner tray, then give 3
units of Humalog insulin subcutaneously
immediately after that meal. b. If patient
eats more than 50 of servings on breakfast,
lunch, or supper tray, then give 6 units of
Humalog insulin subcutaneously immediately
after that meal. 8. On third POD, restart
preadmission glycemic control medication unless
patient is not tolerating enteral nutrition and
is still receiving an insulin drip.
38
Complexity versus Simplicity
Van den Berghe Orders
Glucommander Orders

• .Arterial BG q 1-2 hours, then q 4 hours if
  stable
• .If BG gt220 give 4 units/hr
• .If BG gt110 mg/dl give 2 units/hr.
• .If F/U BG in 1-2 hours gt140 mg/dl Increase
  insulin 1-2 units/hr.
• .If F/U BG in 1-2 hours 121-140 mg/dl increase
  insulin 0.5-1 unit/hr.
• .If F/U BG 110-120 mg/dl increase insulin
  0.1-0.15 units/hr.
• .If BG 81-110 mg/dl then do not change.
• .If BG decreases gt50 decrease insulin 50.
• .If BG 61-80 mg/dl decrease insulin reduced as
  dictated by previous BG level.
• .Repeat BG in one hour.
• .If B 41-60 mg/dl discontinue insulin.
• .If BG gt40 mg/dl give 10 Gm glucose IV. Repeat q
  1 hr until BG 81-110 mg/dl.
• .If BGT decreases gt20 in 81-110 mg/dl range
  decrease insulin 20.
• .If patient transferred from ICU and insulin lt2
  units/hr, DC insulin.
• .If patient transferred from ICU and insulin gt2
  units/hr get endocrine consult.

Requires ICU nurses trained in protocol and study
physician
Administered by floor nurse and any physician
39
Glucommander

. Summary of Performance Glucose Averages for
3404 Patients
Glucose mgm/dl
Percentiles
Percentiles
90
50
10
Hours
40
INSPIRATION FOR GLUCOMMANDER
Practical Closed Loop Insulin Delivery
A System for the Maintenance of Overnight
Euglycemia and the Calculation of Basal Insulin
Requirements in Insulin-Dependent Diabetics NEIL
H. WHITE, M.D., DONALD SKOR, M.D., JULIO V.
SANTIAGO, M.D. Saint Louis, Missouri Ann Int
Med 1982 97210-214
1/slope Multiplier 0.02
6
5
4
Insulin Rate (U/hr)
3
2
1
0
0
100
200
300
400
Glucose (mg/dl)
41
Historical Perspective
Glucommander Multipliers

• IV Insulin Algorithm
• Insulin (BG-60) x Multiplier
• Whites Multiplier Not Applicable
• for Majority
• Based on Type 1 Pediatric Pump Patients
• IV Insulin Used Frequently in Stressed Type 2
• Only 14 Stabilized at 0.02

N2364 Runs
White 0.02
42
Glucommander 5802 Runs and 120,618 BGs 1985-1998
43
GlucommanderPrinciples
Insulin Units / Hour
Glucose mgm / dl
44
Typical Glucommander Run
Glucose
Glucose
Hi
Low
Multiplier
Multiplier
Insulin
Insulin
Hours
45
Glucommander Average and Standard Deviation of of
All Runs 1985 to 1998 5808 runs, 120,618 BGs
46
Glucommander

.Complete Data Set 1985 to 1998 Beyond
Data Analyzed by Boehringer Manheim/MiniMed in
1995

• 13 years of data from Glucommander.
• 5802 Runs over 120,618 hours.
• Correction of hyperglycemia
• Mean starting BG259 mg/dL (SD 127).
• Mean stable lt150 after three hours.
• Subsequent stability in target range for 60 hrs.
• 90 of patients achieved BGlt180 within 8 hrs.
• Experience with Hypoglycemia
• BGs lt50 were 0.6 of total BGs.
• 2.6 all runs had one BG lt40. All were
  immediately corrected to 100 with IV glucose,
  insulin held 30 min, then modified.
• No severe hypoglycemia.

47
Hypoglycemia on Glucommander 5772 Runs
Lauren lt40 mg/dl 5.2
48
Glucommander

.Correction of HypoglycemiaIV 50 Glucose
(100-BG) X 0.15 Grams
N 886
Glucose (mg/dl)
Time (min)
49
Conformity of Blood Glucose to Glucommander Target
50
IV Insulin Protocols

• Correct with minimal insulin
• Least reactive hypoglycemia
• Cut insulin quickly
• Correct hyperglycemia quickly
• Limit intracellular dehydration
• Start insulin aggressively
• Avoid prolonged hyperglycemia
• Less intracellular edema with correction
• Many protocols in use
• Few with outcomes

ADA Diabetes Care 26S109-S117,2003 Watts
Diabetes Care 10722-28,1987 Umpierrze Personal
Commication Markovitz Endocr Pract
810-18,2002 Metchick Am J Med 133317-323,
2002 Van den Berghe N Engl J Med 3461586-8,
2002 Fumary J.Thor CV Surg 1251007-1021, 2003
51
GlucommanderComparsion to Other Systems
ADA 38 u
WATTS 46 U
UMPIERRZE 34 u
IV DRIP 38 u
Glucommander 33 u
LEVETAN 32 u
MARKOVITZ 33 u
Insulin Units / Hour
METCHICK 37 u
VAN DEN BERGHE 41 u
MARKS 52 u
FUMARY 19 u
Glucose mgm / dl
52
GlucommanderSimilar Systems

• Features in Common
• Early high dose
• Decrease in parallel with BG
• End up at common dose
• Similar total dose

ADA 38 u
IV DRIP 38 u
Glucommander 33 u
MARKOVITZ 33 u
Insulin Units / Hour
Glucose mgm / dl
53
Glucommander

. Surgical Series Compared to Watts Algorithm
Watts
Glucommander
Watts et al Diab Care 1987 10722-728
54
Glucommander

. Surgical Series Compared to Watts Algorithm
Glucommander
Watts
55
How has the Glucommander been used?

• Treatment of ketoacidosis
• Hyperosmolar non-ketotic state
• Perioperative glucose management
• Labor and delivery
• Myocardial infarction
• Critically ill patients in ICU
• Hyperalimentation
• Gastroparesis with intractable nausea and
  vomiting
• Estimating a patients insulin sensitivity
• A guide for dosing insulin
• Estimating total insulin dose, correction factor,
  CHO/Ins

56
Clinical Experience with Glucommander

• Simple, safe, and effective method for
  maintaining glycemic control
• Extensively studied
• Standardized treatment method applicable in a
  wide variety of conditions
• Available for review, www.glucommander.com
• Opportunity to improve clinical outcome now

not when and if
57
Hospital Diabetes Plan

• NPO Pathway For All Diabetes Patients
• Finger Stick BG ac qid on ALL Admissions
• Check All Steroid Treated Patients
• Diagnose Diabetes
• FBG gt126 mg/dl
• Any BG gt200 mg/dl

Paul Davidson MDAtlanta Diabetes Associates
58
Hospital Diabetes Plan

• Document Diagnosis in Chart
• Hyperglycemia Is Diabetes Until Proven Otherwise
• Bring to All Physicians Attention
• Note on Problem List and Face Sheet
• Check Hemoglobin A1C
• Hold Metformin Hold TZD with CHF, Liver
  Dysfunction
• Use Insulin in All Hospitalized Persons with
  Diabetes Continue for Course of Hospitalization

Paul Davidson MDAtlanta Diabetes Associates
59
Hospital Diabetes Plan

• Get Diabetes Education Consult
• Instruct Patient in Monitoring and Recording
• See That Patient Has Meter on Discharge
• Decide on Case Specific Program for Discharge
• Arrange Early F/U with PCP

Paul Davidson MDAtlanta Diabetes Associates
60
Hospital Diabetes Plan

• Follow National Guidelines For Endocrinology
  Consults
• Any Type 1
• Any Hypoglycemia Requiring Intervention
• DKA or HHNC
• Patient on Insulin Pump
• Pregnant Diabetic
• Glucocorticoid Therapy in Diabetes
• Progressive Diabetic Complications
• HbA1c gt8, Microalbuminuria gt30 mg,LDL gt130, HDL
  lt35, TG gt400 mg/dl

61
Protocol for Insulin in Hospitalized Patient

• Treat Any Patient With BG gt 150 With Insulin
• Treat Any BG gt150 with Rapid-acting Insulin
  (BG-100) / (7000 / wt )
• Treat Any Recurrent BG gt200 with IV Insulin
• If More than 0.5 u/hr IV Insulin Required with
  Normal BG Start Long Acting Insulin

62
The Accurate Insulin Management (AIM) Formulae

• Prescription for insulin therapy includes
• Basal Insulin (BI)
• Carbohydrate-to-Insulin Ratio (CIR)
• Correction Factor (CF)
• 1801 Records from Pump Patients Studied
• Data from best-controlled of 591 pump patients
• Analyzed for optimum parameters
• Resulting formulae used as model for others
• The Accurate Insulin Management (AIM) formulae

63
RESULTS
64
AIM Nomogram
Carbohydrate to Insulin Ratio
( CIR 2.8 Wt / TDD )
25 20 15 12 10 9 8 7
6 5
Intial Dosing Plot BW and 25 CIR for BI Plot
BW and 12 CIR for TDD
4
125 100 75 50 25

3
Plot BW and TDDfor CIR Plot TDD and CF curve for
CF Follow-up Dosing Change CF as above
Change CIR by 20 toward CIRAIM
Correction Factor
2

CF Curve
( CF 1700 / TDD )

Davidson et al Diab Tech Ther 2003 Vol 5 No 2
65
Protocol for Insulin in Hospitalized Patient

• Daily Total Pre-Admission dose or Weight () x
  0.24 u
• 50 as Glargine (Basal)
• 50 as Rapid-acting Insulin (Bolus)
• Give in Proportion to CHO Eaten, CIR 12
• BG gt150 (BG-100) / CF
• CF 7000 / Wt()
• Do Not Use Sliding Scale As Only Insulin
• Do Not Hold Insulin When BG Normal

66
Protocol for Insulin in Hospitalized Patient

• Treatment of Hypoglycemia
• Any BG lt80 mg/dl D50 (100-BG) x 0.4 ml IV
• Do not treat with po CHO
• Do Not Hold Insulin When BG Normal

67
Correction of Hypoglycemia with Glucose100-BG X
0.2 Grams
100-BG X 0.15 Grams
Richardson Diabetes 1999 50A200
Before
After
68
Hospital Diabetes PlanConclusions

• Any BG gt200 mg/dl Is Diabetes (Fasting gt126
  mg/dl)
• Most Diabetes Is Type 2
• No BG gt150 mg/dl Should Go Untreated
• Most Hospitalized DM Patients Should Be on
  Insulin
• IV Insulin is Most Effective, Efficient, Safest
  Rx in Acute Illness (Glucommander)

69
Hospital Diabetes Plan Conclusions 2

• Switch to Basal Insulin Glargine
• IV Hourly Dose X 24 / 2
• DC IV Glucose
• Feed and Give Rapid Acting Insulin p.c.
• One Unit Per 12 Grams CHO
• BG ac tid, hs, 3 am
• Correct with Rapid Insulin
• (BG - 100) / 7000 / BW
• Type 2 Diabetics Are Resistant to Insulin
  Reactions
• Treat Insulin Reactions in Hospital With IV
  Glucose
• Do Not Be Hold Insulin for Normal BG, i.e. 80-120
• HbA1c Values gt7 Indicates Sub-optimal Care

70
The Paradigm for the MilleniumHyperglycemia A
Mortal Sin

• A blood glucose over 110 in a hospitalized
  patient causes increased morbidity and mortality.
• In the 21st Century
• Neglecting BG gt200
• Is Malpractice

71
Conclusion

• All hospital patients should have normal glucose

72
Insulin

• only

powerful
powerful

• The agent we haveto
  control glucose

most
73
QUESTIONS?

• For a copy or viewing of these slides
• Contact
• www.adaendo.com
• How can I get use of Glucommander?
• Available for review on internet,
• www.glucommander.com
• Contact us
• Glucommander_at_adaendo.com