Download - Treatment of diabetes mellitus in hospitals
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Treatment of diabetes mellitus
in hospitals
Done by:
Fatimah Al-ShehriPharm.D Candidate
King Abdulaziz university
Supervised by:
Dr.Hani Hassan
Clinical pharmacist/internal medicine.
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Outline
-Introduction.
-Goals in the hospital settings.
-Prevention of hyperglycemia and hypoglycemia.
-Treatment.
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Introduction:
Glycemic control is unstable
in hospitalized patients because of:
-Stress of the illness or procedure .
-Concomitant changes in dietary intake
-Physical activity .
- Frequent interruption of the patient's usual antihyperglycemic regimen.
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Goals in hospitals:
-Avoid hypoglycemia.
-Avoid severe hyperglycemia.
-Avoid volume depletion--Avoid electrolyte abnormalities.
-Ensure adequate nutrition.
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Avoidance of hypoglycemia:
Hypoglycemia (ie, serum glucose conc <70 mg/dL [3.9 mmol/L])
Hospitalized patients are particularly
vulnerable to severe, prolonged hypoglycemia.???
Consequences of hypoglycemia:
-It effects the counter-regulatory hormones, especially catecholamines, which may possibly induce arrhythmias and other cardiac events .
-If the blood glucose falls to 50 mg/dL (2.8 mmol/L), transient cognitive deficits ..
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Avoidance of hyperglycemia:
It is a long-standing clinical observation when blood glucose
sugar is above 110mg/dl.
Hyperglycemia consequences :
-Volume and electrolyte disturbances mediated by osmotic diuresis.
-caloric and protein loss in under-insulinized patients .
-Immune and neutrophil function is impaired.
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Glycemic targets in hospitals:
Target of the blood sugar deepens on the severity of the illness.
A-Critically ill patients.
B-Non-critically ill patients.
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:Non-critically ill
Glycemic goals in non-critically ill patients : <140 mg/dL (7.8 mmol/L) for general hospitalized patients, with all random glucose <180 mg/dL (10.0 mmol/L)
To avoid hypoglycemia : FBG concentrations : 90 to 100 mg/dL (5.0 to 5.6 mmol/L) .
In general, all glucose levels should be kept below 180 mg/dL (10.0 mmol/L) to avoid dehydration, caloric loss, glycosuria, and to reduce the risk of infection and, although rare, ketoacidosis.
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Treatment
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Treatment of hyperglycemia in hospital:
1 -The type of diabetes.
2-The patient's current BG concentrations .
3-Prior treatment .
4-The severity of illness .
5 -The expected caloric intake during the acute episode.
.
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Treatment options:
-Insulin .
-Oral hypoglycemic.
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1-Insulin: Types of insulin :
1-long-acting insulin: such as glargine or detemir.
2-Intermediate-acting insulin:such as NPH .
3 -Premeal rapid or short-acting insulin such as :regular insulin, aspart , lispro.
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Insulin analogs:
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Insulin regimen used in hospitalized patients:
1-Fixed dose regimen :-Basal –bolus insulin regmin (BBI).
-Regular regimen.(
2-Sliding scale insulin regimen .( SSI)
3-Insulin correction.
3-Insulin infusion.
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1-Basal bolus insulin regimen:
1-Basal –bolus regimen:Basal Insulin: Prevents between meal and overnight hyperglycemia
Bolus insulin: Limits hyperglycemia after meals.
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1-Basal bolus insulin regimen:Proactive Approach :
Anticipate major change in blood
glucose levels and prevent them from occurring
Insulin therapies that mimic
physiological release of insulin.
Individualized basal-bolus
insulin therapies (BBI)
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:2-Sliding-scale insulin
SSI: involves use of regular insulin or a rapid-acting insulin analogue provided without any other scheduled short-acting or long-acting insulin.
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2-Sliding scale insulin:
Urine glucose monitoring.
Boil urine sample with solution containing copper sulfate.
1934 Sliding Scale by Elliot Joslin.
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3-Today’s Insulin Sliding Scale:
Blood glucose monitoring, Use of glucometer.
Regimens for rapid-acting or short-acting insulin .
Schedule:TID-QID.
Units: Blood glucose level :
0 Unit. <6mmol/L
2 Units. 6.1-8 mmol/L
4 Units. 8.1-10 mmol/L
6 Units. 10.1-12 mmol/L
8 Units. 12.1-14 mmol /L
10 Units. 14.1-16mmol/L
12 Units. 16.1-18 mmol/L
14 Units. 18.1-20 mmol/L
Call MD. <20
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Which sliding scale:
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Advantages & Disadvantages of ISS:
Advantages Disadvantages
Not individualized
Creates a “roller coaster” effect
“Reactive Approach”
Not evidence based practice
Can initiate right away
Simple
Convenient
Umpierrez GE, Palacio A, Smiley D. Sliding scale insulin use: myth or insanity? Am J Med 2007; 120: 563– 567
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2-Insulin sliding scale:
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SSI -Traditional Insulin Sliding Scales:
No basal insulin.
-Supplemental Scale or Correction Scale:ISS + (basal insulin +/- bolus insulin)
Primarily used AS :
dose-finding strategy (bolus insulin dosage)
-As a supplement when rapid changes in insulin requirements (i.e. stress or illness)
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ISS vs. BBI?
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Evidence against SSI :
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Rabbit trial 2:
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Evidence against the SSI:
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Evidence against the SSI:
Although sliding scale insulin regimens are prescribed for the majority of inpatients with diabetes, they appear to provide no
Benefit..
in fact, when used without a standing dose of intermediate-acting insulin, they are associated with an increased rate of hyperglycemic episodes.
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Evidence against SSI:
MJA 2012; 196: 266–269 doi: 10.5694/mja11.10853
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Mean change in BGL from baseline in the two insulin therapy groups.
MJA 2012; 196: 266–269 doi: 10.5694/mja11.10853
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Conclusion: under routine clinical conditions, implementation of a BBI protocol to manage hyperglycaemia in hospitalised patients resulted in a lower mean daily BGL than did SSI .
BBI is associated with an increase in mild, but not severe, hypoglycaemia. We recommend that protocols for inpatient glycaemic control based around BBI be widely implemented.
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Time to stop SSI:
1-Unaware of problems associated with ISS
2- Unwilling to make changes to therapies initiated by another physician
3 -Lack of evidenceLong-term care (LTC) setting
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QUESTION: AS clinical pharmacist , When making your recommendation to
the physician, what information might you want to include about SSI and BBI?
A-Basal-bolus is a proactive approach to management, preventing hyperglycemia without increasing the risk of hypoglycemia.
B-The use of insulin sliding scale is not evidence-based practice.
C-Insulin sliding scale is most likely the medication causing the patient to fall and affecting patient’s ability to focus.
D- All of the above.
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:3 -Correction insulin
The dose of correction insulin should be individualized based upon relevant patient characteristics such as:
-Previous level of glucose control.
-Previous insulin requirements .
- The carbohydrate content of meals .
Correctional insulin needs: -1800 rule: 1800/TDI=number of mg/dl of glucose lowering per 1 unit of
rapid acting insulin .
))1 unit of rapid actin insukin will reduce the BG concentration by x mg/dl.
-1500 rule :1500/TDI .
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:3 -Correction insulin
Correction insulin alone may also be used :
- As initial insulin therapy in patients with type 2 diabetes previously treated at home with diet or an oral agent, who will not be eating regularly during hospitalization.
It is typically administered every six hours as regular insulin .
However, if the patient is eating and finger stick glucoses are consistently elevated (<180mg/dL [10.0 mmol/L]) :
)basal-bolus regimen.(
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Insulin requirements:
50 % of the total daily dose can be given as BI.
The remaining 50% can be given in equally divided doses prior to meals (1/3 prior to each meal).
2-Regular insulin: 1-Basal –bolus regimen:
70%)2/3 (of the dose given in the morning.
30%)1/3 (of the dose given in the evening.
50% basal insulin .
50% bolus insulin .
e.g: 25 units/day (NPH). -16 units in the morning.
-9 units in the evening.
e.g: 25 units/day. -Glargin:12.5 unit as basal
-Lispro: 12.5 ( 4.4.4 ) as bolus.
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http://diabetesmanager.pbworks.com/w/page/17680263/Management%20of%20the%20Hospitalized%20Diabetic%20Patient
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4-Insulin infusion:
Insulin infusions are typically
used in critically ill ICU patients, rather
than in patients on the general medical
wards of the hospital.
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Oral hypoglycemic agents:
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References:
http://diabetes.niddk.nih.gov/dm/pubs/causes.
http://care.diabetesjournals.org/content/29/suppl_1/s43.full
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