Glycemic Management

Shruti Scott, DO, MPHUCI Hospitalist Program

July 24, 2013

Rapid (lispro, aspart, glulisine) (Humalog/Novolog/Apidra)

Hours

Long (glargine)

Short (regular)

Intermediate (NPH)

Long (detemir)

InsulinLevel

0 2 4 6 8 10 12 14 16 18 20 22 24

Pharmacokinetics of Insulin Products

Adapted from Hirsch I. N Engl J Med. 2005;352:174–183.

Tom has Type 2 DM, weighs 85 kg and is admitted for diabetic foot ulcer. He takes Metformin 1000mg bid, glipizide 10mg daily at home. His hemoglobin A1c is 10 and his blood sugars since admission have ranged 250-300. How do you manage his DM?

Case 1

Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: Effect of structured subcutaneous insulin orders and an insulin management algorithm

Journal of Hospital MedicineVolume 4, Issue 1, pages 3-15, 12 JAN 2009 DOI: 10.1002/jhm.391http://onlinelibrary.wiley.com/doi/10.1002/jhm.391/full#fig2

Case IAnswer:• Tom weighs 85kg, normal GFR• Using standard, 0.4unit/kg = 34 units TDD• Lantus 17 units QAM and Lispro 5 units tid before meals• Lispro Correctional

Learning Points:• Hold oral diabetes meds when inpatient (to minimize hypoglycemia and for

better glycemic control)• DO NOT place diabetic patients only on Correctional Insulin• Use weight based method to get accurate insulin requirement• Adjust insulin dose for GFR: GFR > 50, no correction

GFR 30-50, 20% reduction GFR < 30, 30-50% reduction

Case 1Learning Points• Each order will have 2 or 3 types of insulin:

Basal- provides continuous insulin coverage to diminish BS swings

Correctional- corrects current BS level

Nutritional- treats the anticipated BG increase with meals

• Nutritional and Correctional coverage should be the same type of insulin (both Lispro or both Regular)

Case 2

Tom has Type 2 DM and was admitted for diabetic foot ulcer. Today is HD3 and his blood sugars have been stable with Lantus 22 units qhs, Humalog 5 units tid and Humalog Correctional. Tomorrow he is having a L foot amputation. How should his insulin regimen be adjusted?

Case 2

Answer Choices• Hold Humalog morning dose • Cont Humalog morning dose• Hold Lantus evening dose• Decrease evening dose of Lantus• Cont evening Lantus dose• Start IVFs (NS, D5 or D10 – does it matter?)• Do nothing• Page endocrine fellow and ask him/her

Case 2

Answer• Hold Humalog nutritional dose while pt is NPO• Cont evening Lantus dose• Start IVFs (either D5 or D10)• Continue Humalog correctional coverage

Case 2Learning Points• Start D5 or D10 if carb source is interrupted (NPO). The infusion

rate will have to take into account the patient’s general condition (CHF, CKD)

• Do not hold basal insulin if long acting (levemir or glargine)• 1 L of D5 1/2NS provides less calories than a small candy bar (170

calories per L)• In the Quest NPO Order Set, the number of calories (per liter IVF)

is provided for you• Remember, Type I DM requires insulin AND carb source (D5 or

D10) at all times (even when NPO). So if Type I diabetic is NPO, DO NOT hold basal insulin and DO start D5 or D10

Case 3

Tom has Type 2 DM and was admitted for diabetic foot ulcer. Today is HD3 and his blood sugars have been stable with NPH 22 units bid and Regular Correctional. Tomorrow he is having a L foot amputation. How should his insulin regimen be adjusted?

Rapid (lispro, aspart, glulisine) (Humalog/Novolog/Apidra)

Hours

Long (glargine)

Short (regular)

Intermediate (NPH)

Long (detemir)

InsulinLevel

0 2 4 6 8 10 12 14 16 18 20 22 24

Pharmacokinetics of Insulin Products

Adapted from Hirsch I. N Engl J Med. 2005;352:174–183.

Case 3

Answer• Continue evening NPH dose• Half morning NPH dose• Start patient on D5 or D10• Continue Correctional insulinAlternatively• On admission, change from NPH to Lantus for

better glycemic control

Tom has Type 2 DM, admitted for diabetic foot ulcer and today is HD3. He is treated with Humalog 5 units tid & Lantus 22 units qhs. Tom has premeal bs of 65 before lunch, does not have any symptoms of hypoglycemia, what should you do?

Case 4

PRIORITY: DRINK UP!• If possible, PO FIRST• Treat the SYMPTOMS, not just the number• 4 oz Juice/8 oz FF milk = 15 gram carb• 15 grams carb can increase BG 30-50mg/dl

The 15-15 Rule• Treat with 15 grams of carb• Recheck in 15 minutes– Retreat with 15 grams of carb and recheck every 15

minutes until BG is > 75mg/dl

Things to think about

• BG within range 70-100mg/dl- DO NOT HOLD INSULIN- may need dose adjustment

• Check to see how much patient is eating• Has patient been experiencing nausea or vomiting

For our patient Tom, if he has few premeal blood glucose readings that are low, need to decrease Lispro nutritional insulin from 5 units tid to 3 units tid

Case 5

Jerry is a 65 yo male who is receiving continuous TPN. He has a h/o DM, weighs 80kg and is on continuous TPN. His blood glucose readings have ranged 250-300, how do you manage his DM and hyperglycemia?

Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: Effect of structured subcutaneous insulin orders and an insulin management algorithm

Journal of Hospital MedicineVolume 4, Issue 1, pages 3-15, 12 JAN 2009 DOI: 10.1002/jhm.391http://onlinelibrary.wiley.com/doi/10.1002/jhm.391/full#fig2

Case 5Answer• Start Lantus 12 units qhs• Start Regular 5 units Q6H• Regular Correctional

Learning Points• For patients who are receiving continuous feeds (either TPN or

tube feeds), check blood glucose levels Q6H• Regular correctional insulin preferred over Rapid acting

(Aspart/Lispro) since patient is not taking food in orally and regular lasts longer then rapid acting

Diabetic Goals

1. Avoid Hypoglycemia

2. Avoid Severe Hyperglycemia

3. Glucose targets: 140-180

4. Adequate Nutrition

5. Pre-discharge education