The Changing Landscape of Inpatient Glycemic Control

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The Changing Landscape of Inpatient Glycemic
Control

• Kara Aplin, MD
• Division of Hospital Medicine

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Outline

• Hyperglycemia, Morbidity, and Mortality
• Effects of Lowering Inpatient Glucose
• AACE/ADA Guidelines
• Starting an Inpatient Regimen
• Systems Changes

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Hyperglycemia Associated with Increased Mortality
by Setting

• ICU
• Finney, JAMA 2003
• Krinsley, Mayo Clinic Proc 2003
• Medical Floors
• Umpierrez, J Clin Endocrinol Metab 2002

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Normoglycemia on Admission Predicts Decreased
Mortality
Glucose (mg/dL) Odds Ratio (OR) of Death 95 Confidence Interval (CI)
80-100 1
100-200 1.32 1.22-1.43
60-80 1.06 1.04-1.07
Bruno, Diabetes Care 2008
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Increased Morbidity and Mortality in Acute
Disease States

• Acute Coronary Syndrome
• Ischemic Stroke
• Heart Failure
• Trauma
• Surgical Procedures

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Hyperglycemia in Community Acquired Pneumonia
Glucose (mg/dL) Hospital Mortality OR 95 CI Hospital complications OR 95 CI
lt 110 1 1
110-200 1.20 0.88-1.65 1.10 0.89-1.36
gt 200 1.79 1.01-3.16 1.53 1.01-2.32
McAlister, Diabetes Care 2005
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Acute Exacerbation of COPD
Glucose (mg/dL) Mortality () p0.003 Length of stay (days) p0.09 Multiple sputum pathogens () p0.03 S. Aureus sputum () p0.01
lt110 12 7 12 4
110-125 16 9 18 11
125-160 21 10 28 28
gt160 31 12 33 28
Baker, Thorax 2006
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• Changing Goals for
• Inpatient Glycemic Control

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DIGAMI 1995

• Population 620 Diabetic, Post-MI
• Intervention gt24 hours on insulin drip
• 3 months multiple
  insulin/day
• Outcome 29 decrease in mortality
• Unclear inpatient vs. outpatient effect
• Malmberg, J Am Coll Cardiol 1995

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Leuven SICU 2001

• Study population
• 1,500 SICU patients
• Intubated
• TPN
• Intervention
• Insulin drip goal 80-110
• vs.
• Insulin drip goal 180-200
• Van den Berghe, NEJM 2001

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Benefits of intensive glucose control in SICU
Outcome Decrease
12-month mortality 43
Mortality for ICU stay gt5 days 48
Overall in-hospital mortality 34
Bloodstream infections 46
AKI requiring dialysis 41
Median red cell transfusions 50
Critical illness polyneuropathy 44
Van den Berghe, NEJM 2001
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Leuven MICU 2006

• Study population
• 1,200 MICU patients
• TPN
• Presumed to require gt3 days ICU
• Intervention
• Insulin drip goal 80-110
• vs.
• Insulin drip goal 180-200
• Van den Berghe, NEJM 2006

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Leuven MICU 2006Mortality

• Mortality, all patients No significant
  difference
• Mortality, ICU stay lt3 days Increased
• Mortality, ICU stay gt3 days Decreased
• Van den Berghe, NEJM 2006

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Leuven MICU 2006Morbidity

• Hypoglycemia lt40 6-fold INCREASE
• Improved
• Acute Kidney Injury
• Weaning mechanical ventilation
• Discharge from ICU
• Discharge from Hospital

Van den Berghe, NEJM 2006
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NICE-SUGAR 2009

• Population gt6,000 patients
• 42 Hospitals
• Australia, New Zealand, Canada, US
• MICU and SICU
• Expected gt3 days ICU
• Intervention Insulin drip goal 81 to 108
• vs.
• Insulin drip goal 144 to 180
• NEJM 2009

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NICE-SUGAR Results

• 90-day Mortality
• 1.14 OR (1.02-1.28) for death in intensive group
• Morbidity
• Severe hypoglycemia 14.7 OR (9-25.9)
• No difference in
• ICU days
• Hospital days
• Ventilator days
• Need for dialysis

NEJM 2009
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Increased Mortality with Intensive Glucose Control
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• No randomized controlled trials of intensive
  glycemic control
• on general medical wards.

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• AACE/ADA Guidelines
• June 2009

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Guidelines ICU Patients

• Goal 140-180
• Insulin infusion if glucose gt180

Diabetes Care 2009
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Transitioning Off Insulin Drip

• 75-80 of total IV insulin in 24 hours
• Divide into basal and prandial
• Patient eating
• Give basal and short-acting insulin, overlap 1 hr
• Patient NPO, TF, or TPN
• Give basal insulin alone, overlap 3-4 hr

Diabetes Care 2009
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Guidelines Non-Critically Ill

• Goals Pre-meal lt140
• Random lt180
• Modifications Reassess if lt100
• Definitely modify regimen lt70

Diabetes Care 2009
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Guidelines Non-Critically Ill

• Subcutaneous insulin
• Basal
• Prandial
• Correction
• Avoid Sliding Scale only
• Avoid oral agents except
• Selected stable patients
• Expected to eat regularly

Diabetes Care 2009
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Guidelines Special Situations

• Tube feeds
• Basal with correction
• TPN
• Insulin recommended
• Glucose targets based on severity of illness
• Glucocorticoids
• Monitor gt48 hours
• Initiate insulin as appropriate
• Decrease insulin as taper steroids

Diabetes Care 2009
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Clinical Case I

• A 76 year-old woman with DM II normally
  well-controlled on metformin 500 mg po bid is
  admitted with left lower extremity cellulitis and
  decreased PO intake. In the ER, WBC 12,000 with
  92 PMNs, BUN 24, Cr 1.1, glucose 188. Temp
  101.2, HR 98, BP 100/58, weight 50 kg.
• What diabetes regimen do you start her on upon
  admission?

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RABBIT-2 Basal Bolus Insulin

• Total daily insulin
• 0.4 units/kg for glucose 140-200
• -or-
• 0.5 units/kg for glucose 201-400
• Basal ½ as once daily glargine
• Bolus ½ as pre-meal aspart in 3 equal doses
• Correction Supplemental sliding scale gt140

Umpierrez, Diabetes Care 2007
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RABBIT-2 Adjustments
Issue Adjustment
Fasting and premeal gt140 Increase glargine 20
Hypoglycemia lt70 Decrease glargine 20
Unable to eat Give glargine Hold pre-meal aspart
Umpierrez, Diabetes Care 2007
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RABBIT-2 Results
Outcome Intensive Group Sliding Scale Group P value
Glucose lt140 66 38
Mean glucose 166 193 lt0.001
Mean daily insulin 22 units glargine 20 units aspart 12 units regular lt0.001
Hypoglycemia lt40 0 0
Umpierrez, Diabetes Care 2007
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Choosing a Correction Scale
Patient Population Sliding Scale
Type I DM Lean Total insulin 30-40 units 1 unit for 150-199 2 units for 200-249, etc.
Type II DM Overweight Total insulin 40-100 units 2 units for 150-199 4 units for 200-249, etc.
Severe insulin resistance Obese Glucocorticoids 4 units for 150-199 8 units for 200-249, etc.
Inzucchi, NEJM 2006
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Adjusting Insulin

• 11 ratio basal to bolus
• Basal
• Fasting glucose
• Add 50 prior days correction dose
• Prandial
• Lunch and bedtime glucose

Inzucchi, NEJM 2006
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Clinical Case II

• A 56 year old man with obesity, poorly
  controlled DM II, CAD status post CABG, PVD is
  admitted with RLL community-acquired pneumonia.
  His admission labs are notable for WBC 15,000
  with 88 PMNs, Cr 1.2, normal cardiac enzymes,
  glucose 255. His weight is 140 kg. He takes an
  unknown insulin regimen at home.
• What should you start him on in the hospital?

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Clinical Case II

• 140 kg x 0.5 U/kg 70 Units
• Basal ½ x 70 35 Units
• Bolus 35 units / 3 12 Units each meal
• Correction Scale 2-4-6-8 standard correction
  scale for overweight, Type II diabetic

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Clinical Case I Revisited

• A 76 year-old woman with DM II normally
  well-controlled on metformin 500 mg po bid is
  admitted with left lower extremity cellulitis and
  decreased PO intake. In the ER, WBC 12,000 with
  92 PMNs, BUN 30, Cr 1.1, glucose 188. Temp
  101.2, HR 98, BP 100/58, weight 50 kg.
• Stop metformin
• 50 kg x 0.4 U/kg 20 Units
• 10 Units basal
• 3 Units each meal
• Conservative Correction Scale 1-2-3-4

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Protocols and Order Sets

• Sliding scale predominated basal-bolus (2006)
• Schnipper, J Hosp Med 2006
• Diabetes order sets promote basal-bolus
• Noschese, Qual Saf Health Care 2008
• Thompson, J Hosp Med 2009
• ICU insulin infusion protocols safe,
  effective Goldberg, Diabetes Care 2004

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Glycemic Control Mentored Implementation Program

• Sponsored by Society of Hospital Medicine
• Cooper Focus
• IV insulin in ICU
• Transition to SC insulin
• Hyperglycemia on floors
• Discharge planning and communication

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Transitions of Care

• Communicating with PMD
• Outpatient Diabetes Education Classes

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Conclusions

• Hyperglycemia associated with worse outcomes.
• Reducing glucose to normal levels does not
  consistently improve outcomes.
• AACE/ADA Guidelines aimed at safe targets in area
  of uncertainty.
• More studies needed.
• Application of basal-bolus regimen.
• Systems changes may be implemented at Cooper.

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