GET TO GOAL:

INPATIENT GLYCEMIC CONTROL

Melanie E. Mabrey

DNP, BC-ADM, FAANP

Acute Care Nurse Practitioner

Three Best Resources I Know…

Practical Management of DKA, HHS,

Hyperglycemia and Diabetes in the Hospital

Why? Key Points

◦ Epidemiologic studies show - glucose control

in hospitals is woefully inadequate

◦ As glucose levels rise, so does mortality risk, as

well as the risk of dehydration, hypotension,

eventual renal shutdown, poor healing, and

impaired immune system function.

◦ 6% to 7% of patients have experience

hypoglycemia.

Clinical Trials Summary

5

Hyperglycemia is associated with poor clinical outcomes across many disease states in the hospital setting

Despite the inconsistencies in clinical trial results, good glucose management remains important in hospitalized patients

More conservative glucose targets should result in lower rates of hypoglycemia while maintaining outcome benefits

Content from AACE

What Should We Take AwayFrom These

Trials?

Good glucose control, as opposed to near-normal control, is likely sufficient to improve clinical outcomes in the ICU setting

Hyperglycemia and hypoglycemia are markers of poor outcome in critically and noncritically ill patients

Importantly, the recent studies do not endorse a laissez-faire attitude toward inpatient hyperglycemia that was prevalent a decade ago

Content from AACE

Hyperglycemia in Patients

With Undiagnosed

Diabetes

• 26% had known history of diabetes• 12% had no history of diabetes

Hyperglycemia occurred in 38% of patients admitted

• Higher in-hospital mortality rate (16%) compared with patients with a history of diabetes (3%) and patients with normoglycemia (1.7%; both P<.01)

• Longer hospital stays; higher admission rates to intensive care units (ICUs)

• Less likely to be discharged to home (required more transitional or nursing home care)

Newly discovered hyperglycemia was associated with:

Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87:978–982.

Glycemic Goals – ADA

“Insulin therapy should be initiated for treatment of persistent hyper-glycemia starting at a threshold 180 mg/dL. Once insulin therapy is started, a target glucose range of 140– 180 mg/dL is recommended for the majority of critically ill patients and non- critically ill patients.”

“More stringent goals, such as 110–140 mg/dL, may be appropriate for selected patients, if this can be achieved without significant hypoglycemia.”

POCT in the Hospital

◦ FDA - separate category for POC glucose

meters; guidance on in-hospital use with

stricter standards

◦ Significant discrepancies have been

observed with low or high hemoglobin

concentrations and with hypoperfusion

◦ Any POC glucose that does not correlate

with the patient’s clinical status should be confirmed by laboratory glucose test.

HOW???

In most instances in the hospital setting, insulin is the preferred treatment for hyperglycemia

Indications for IV insulin

DKA and HHS

Stroke

Cardiac Surgery

Critical Illness

Glucocorticoids

Organ transplantation

MI or Cardiogenic Shock

Labor and Delivery

Prompt glycemic control critical to

recovery

Transitioning from to Readiness

◦ Resolution of hyperglycemia1

◦ Low variability of insulin infusion rate2

◦ Glucose toxicity (evidenced by high insulin infusion rates) has resolved2

◦ Anion gap closed1

◦ No significant edema (may affect absorption of subcutaneous insulin)3

◦ Resolution of critical illness3

◦ Not requiring ventilator support4

◦ Vasopressors (inotropic support) d/c’d or weaned to physiologic doses3

1Kubacka, B. 2019. Acute hyperglycemic emergencies: Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State. Nursing2019 Critical Care, 14(2). 2Lien LL. et al. 2016. Transitioning from intravenous to subcutaneous insulin. In B. Draznin (Ed.), Managing diabetes and hyperglycemia in the hospital setting (pp. 115-28).3Jacobi J. et al. 2012. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Critical Care Medicine, 40(12):3251–76.4O’Malley CW. Et al. 2008. Bridge over troubled waters: Safe and effective transitions of the inpatient with hyperglycemia. Journal of Hospital Medicine, 3(5):S55-65.

Tips for Transitioning IV to Subq

Insulin

◦ IV insulin has a short half-life

◦ Do not stop until subcutaneous onboard

◦ Timing of administration of subcutaneous

insulin before discontinuation of IV insulin

◦ 1 to 2 hours in advance for short acting insulins

◦ 2 to 3 hours in advance for NPH or basal

insulins

◦ Consider continuing IV

◦ Consider starting basal insulin the night before

transitioning

◦ Patients on an insulin gtt may eat but will need

insulin for meal coverage

Current Recommendations

for Inpatient Diabetes Care

AACE/ADA recommendations

• “Outside of critical care units, subcutaneous administration of insulin is used much more frequently. Orally administered agents have a limited role in the inpatient setting.”

Endocrine Society Clinical Practice Guideline

• “We recommend insulin therapy as the preferred method for achieving glycemic control...

• We suggest the discontinuation of oral hypoglycemic agents and initiation of insulin therapy for the majority of patients…”

Endocrine Practice. May/June 2009

J Clin Endocrinol Metab. January 2012, 97(1):16 –38

Question◦ My patient takes oral agents at home to treat his

diabetes at home. He is now NPO, I’m just

going to put him on “sliding scale insulin”.◦ Diabetes exists even when patients are NPO

◦ In a pt with HTN, would you order medications

to be given only when BP > 180/90…..or◦ In a pt with infection, would you order Antibx

only if temp > 38.5….◦ Hmmm – why order insulin only when BG >

150.

Limitations Associated With Sliding Scale Insulin (SSI) Delivery◦ It is reactive rather than proactive 1

◦ Treats hyperglycemia after it happens 1-3

◦ Patients do not receive insulin if their glucose level is normal3

◦ If glucose increases, insulin is given—regardless of basal or prandial needs 1-3

1.Clement S et al. Diabetes Care. 2004;27:553-591.2.Queale WS et al. Arch Intern Med. 1997;157:545-552.3.Browning LA, Dumo P. Am J Health-Syst Pharm. 2004;61:1611-1614.

Theoretical glucose levels with SSI

Sliding Scale Insulin (SSI)

Insulin

Insulin Insulin

Insulin

BG

(m

g/d

L)

Target range

ASSESS THE EFFICACY

OF THE HOME

REGIMEN

A1c (%) Mean plasma glucose (mg/dL)

6 135

7 170

8 205

9 240

10 275

11 310

12 345

There is little point in sending

a patient home on a regimen

that has not been effective

Basal – Bolus Insulin Therapy

• Basal Insulin – Long acting; regulates BG overnight and between meals

• Bolus Insulin – Rapid acting; given with each meal to prevent glucose spike from carbohydrate consumption

• Correction Insulin – Rapid acting; given to bring an elevated BG back into target range

Basal Insulin Review

• Administered regardless of meal intake

• May be given once or twice daily

• Long-acting Insulin

• Glargine (Lantus)

• Detemir (Levemir)

• Intermediate-acting Insulin

• NPH

NEVER discontinue basal insulin in a

patient with Type 1 Diabetes unless on an IV

insulin infusion or an insulin pump. Holding

even a single dose can result in DKA.

• SCHEDULED insulin that accompanies each meal to prevent glucose

spikes with carbohydrate intake

• May be administered 15 minutes before the meal or up to 15 minutes

after completion of the meal for those with variable meal intake

• Rapid-acting Insulin

• Aspart (Novolog)

• Lispro (Humalog)

• Glulisine (Apidra)

Meal Bolus Insulin should be held for patients who are NPO or will not eat.

Bolus Insulin Review

Determining Initial Insulin Dosing

0.1 – 0.3 units/kg/day

divided into 4 shotsInsulin naïve

Low insulin resistance

(thin, frail elder, diet controlled)

0.5 – 1.0 units/kg/day

divided into 4 shotsHigher insulin resistance

(High stress, Obese)

Long-standing, or poorly controlled DM

Point system:

Add 0.1 unit/kg/day

Each 30 kg >100 kg

> 5 years of DM

multiple oral medications

steroids

Subtract 0.1 unit/kg/day

CKD, ARF, frail elder, hepatic failure, hypoglycemia unaware

Determine Insulin Administration Pattern

Basal insulin or a basal plus bolus correction insulin regimen with poor oral intake or NPO

Basal, prandial, and correction components is the preferred treatment for noncritically ill patients with good nutritional intake.

Rapid- or short- acting insulin to correct hyperglycemia (before meals or every 4-6 hours if NPO or continuous nutrition)

Obtain Blood Glucose

Insulin Administration

Meal Tray Delivery

Timing of Meal Bolus Insulin

30-45 MINUTES

Insulin Dosing

Basal Bolus insulin is usually 50/50 split of Total Daily Dose (TDD)

Regular and NPH is usually 25% of TDD

• Regular 30 minutes before each meal

• NPH at hs

Example: Pt wt = 120 kg, DM-2 on metformin only as outpatient

• Consider 0.5 units/kg for TDD

• TDD = 60 units

• 30 units basal and 30/3 = 10 units with each meal

• 15 units Regular before each meal and 15 units of NPH at hs

How do you adjust

insulin daily?

Breakfast Lunch Supper Bedtime

BG 198 213 243 222

Scheduled

Insulin

10 units RA 10 units RA 10 units RA 30 units

basal

Correction 3 units 6 units 6 units

BG 191

Scheduled

Insulin

10 units RA

Correction 3 units

Yesterday’s total insulin = 75 units 60 (scheduled) + 15 (correction)

= 75 X 20% = 15 units

= 75 + 15 = 90 units

Today’s regimen = 15 units bolus tidac and 45 units basal qhs

Adjusting SQ insulin

Assess the total amount of insulin the patient received on the previous day

Assess overall glucose control previous day

Did the patient require correction dose or have a low BG. ALWAYS look at fasting BG

If close to goal increase TDD by 10% over the previous days total

If BGs significantly elevated (>180) increase by 20%

Adjusting Insulin Example

Yesterday’s total insulin = 19 (scheduled) + 2 (correction) = 21 units

= 21 X 20% = 4 units

= 21 + 4 = 25 units

Today’s new regimen = 4 units bolus tidac and 12 units basal qhs

Breakfast Lunch Supper Bedtime

BG 198 253 264 222

Insulin 3 units RA 3 units RA 3 units RA 10 units basal

Correction 0 units 1 units 1 units

BG 191

Insulin 3 units RA

Correction 0 units

Correction

therapy

Day 1 Day 3

Scheduled Correction

Units

Correction insulin

signals the need to

change scheduled dose

of insulin in order to

prevent ongoing

hyperglycemia

Mel’s tips

◦ FOLLOW UP, be available and ready to adjust insulin frequently after

transitioning, initiating, or adjusting

◦ Talk with nursing staff, provide education and let them know you are

a resource

◦ Call orders if BG elevated (don’t wait until BG > 350 to be notified)Renal failure, elderly, Type 1,

and hypoglycemic unaware

Condition Blood Glucose Monitoring

IV insulin q1hour – may Δ to q2h when BG within 100-150 mg/dl for 4

consecutive hours. If BG < 100 mg/dl or >150 mg/dl monitoring

MUST return to q1h.

New TPN or tube feeding (when blood

glucose monitoring not already ordered)

q4-6 hours X 72hrs. If all glucoses <140 x72h, then d/c BG

monitoring; otherwise continue monitoring until TF d/c’d.

If glucose >180mg/dl, call provider for insulin orders. Consider

diabetes consult.

TPN or tube feeding receiving insulin q4-6 hours: if TF held, obtain BG q3hours X 2 (from last check),

then resume q6hour monitoring (provided BG ≥70); notify provider if BG <70 while TF held.

NPO or q6hour Regular insulin q4-6 hours

Regular, NPH, 70/30, 75/25 or any other

combination insulin

ac, hs, and 0300

Glargine (Lantus) insulin and/or rapid

acting insulins (aspart, glulisine, or lispro)

ac and hs

Safety with insulin

◦ Subcutaneous Insulin orders usually include:

◦ Decrease Regular insulin usually by ½ when NPO

◦ Give full dose of NPH at hs even if NPO

◦ Always give full dose Lantus or Levemir and hold rapid acting insulins (aspart, lispro, apidra) if NPO

◦ Give correction scale even when NPO

◦ Protocol for treating hypoglycemia:

◦ 15 g CHO (1 juice or ½ amp D50) recheck in 30 min.

◦ Rarely appropriate to hold insulin dose

◦ Rebound hyperglycemia

◦ When in doubt – monitor more frequently