inpatient management of diabetes mellitus william harper, md, frcpc endocrinology & metabolism...
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Inpatient Management of Diabetes Mellitus
William Harper, MD, FRCPC
Endocrinology & Metabolism
Assistant Professor of Medicine, McMaster University
DKA
1. Monitored setting if Hi-risk• elderly & CAD, pH < 7.0, severe K disturbance,
decreased LOC
2. IV Fluid Resuscitation (6-8L deficit)
3. Potassium (“no pee no K”)
4. IV insulin
5. Identify & Rx underlying cause• Noncompliance, infection, MI, etc.
DKA: IV Fluids
• IV NS 1L/h x 2-3h or longer so no more tachycardia, hypotension, orthostatic changes, low JVP.
• Then change to 1/2 NS:• 500 cc/h x 1-3h
• 250 cc/h x 4-6h
• If hypotension recalcitrant to fluids consider AI (Schmidt PGAS II) and send stat cortisol then give solucortef 100 mg IV q8h.
DKA: Mortality
• Adults 2-4%• Hypokalemia
• MI, CVA, etc.
• Kids 0.2-0.4%• Cerebral edema
DKA: Potassium• Need K with initial IV fluid & insulin Rx
unless:• Anuric
• K > 5.5 mEq/L or hyperkalemic ECG changes
Initial [K] Replacement
> 5.5 mEq/L nil (initially)
5.2-5.5 mEq/L 10 mEq/h
4-5.2 mEq/L 20 mEq/h
3-4 mEq/L 30 mEq/h
< 3 mEq/L 40 mEq/h
> 20 mEq/h:Cardiac monitor
> 60 mEq/L:Central line
DKA: IV Insulin
• Humulin R or Novolin Toronto• Bolus 0.1-0.2 U/kg IV• Then IV gtt @ 0.1-0.2 U/kg/h (50 U of regular insulin in 500cc D5W; 1U/10cc)• Monitor: CBG q1h• Monitor: Venous BS, electrolytes, creatinine q2h• Aim is to demonstrate correction of Anion Gap (AG) and
decrease in BS 4.4 mM/L/h• Monitoring serial serum ketones NOT useful:ßHß (not detected) DKA Rx Acetoacetate (detected)
DKA: IV Insulin
• Using insulin to treat 2 different and separate metabolic disturbances in DKA:
1. Ketoacidosis
2. Hyperglycemia
DKA: IV Insulin
• If AG not correcting and/or BS not decreasing then increase IV gtt rate 1.5-2X
• If BS < 13 but AG still not corrected do NOT decrease insulin IV gtt.
• Instead start IV glucose gtt:• D5W-D10W @ 100-200 cc/h
• Once AG corrected than titrate IV insulin to BS
• When BS < 13 and AG normal: reduce IV insulin gtt to 1-2 U/h and add IV glucose if not already done.
DKA: IV Insulin
• Can consider switch to SC insulin when:• AG normalized
• BS < 15 mM
• Insulin IV gtt requirements < 2U/h
• Patient able to eat
• Overlap insulin IV gtt with 1st SC insulin by 3-4h to avoid recurrent ketosis.
DKA: Other Rx
• Bicarbonate• May exacerbate hypokalemia• Only give if pH < 6.9 AND evidence of cardiovascualr
instability (arrythmia, CHF, hypotension)• 1-2 amps bicarb in 1L D5W IV over 2h until pH > 7.1
• Phosphate• Routine IV not recommended• Rx symptomatic hypophosphatemia (rhabdo, unexplained
CHF or respiratory failure, severe confusion)• 10cc K Phos soln (3.0mEq Pi and 4.4 mEq K/cc) in 1L NS IV
over 8-12h
DKA: Other Rx
• Cerebral Edema• Usually only kids
• Persistent decreased LOC despite standard Rx of DKA
• CT scan to confirm diagnosis
• Decadron 10 mg IV
• Mannitol 25 mg IV
HONC
• BS > 55
• Serum OSM > 350
• Coma 25-50%
• Mortality rate 25-70%
HONC
1. Coma Management• ABCs, O2, narcan, D50W, thiamine, etc.
2. IV Fluid Resusciation (10L free water defecit)
3. Insulin• IV fluids will decrease BS by 4 mM/L/h by itself
• For most patients insulin not absolutely neccesary
• Insulin IV bolus 5-10 U, gtt @ 1-2 U/h
4. Potassium (replace as in DKA)
5. Identify & Rx underlying precipitant
BS > 11.1 mmol/L
Renal threshold for glycosuria (normal GFR)
Decreased WBC functionChemotaxsisPhagocytosis
Decreased Wound Healing
Goals of Inpatient DM Management
• “Avoid hypoglycemia and marked hyperglycemia”
• Target BS: 7.0 - 11.0 mM
• Avoid Hypoglycemia
• Precipitating arrhythmia or other cardiac events
• Inducing seizure, focal or cognitive defects periop
• Avoid Marked Hyperglycemia (BS > 11.1 mM)
• Treat (and avoid) DKA, HONC
DM Inpatient Management
1. Eating
2. NPO: temporary (for a test)
3. NPO: prolonged
DM Inpatient Management
1. Eating:OHA (T2DM)
Insulin (T2DM and T1DM)
OHA: Drug BG HbA1c Side-effects
Sulfonylurea FBG 20% 1.5-2.0% Hypoglycemia
Weight gain
Biguanide FBG 20% 1.5-2.0% Lactic acidosis
GI intolerance
TZD FBG 2.2-3.6 mM
1.0-1.6% Edema
Weight gain
α-glucosidase Inhibitor
FPG 14%
PPG 25%
0.5% GI intolerance
Meglitinide FPG 4 mM
PPG 5.6 mM
1.8% Hypoglycemia
Insulin
Type Starts Peaks Duration
Humalog
NovoRapid
5-10 min 1-2 hrs 3.5 hrs
Regular 30 min 2-4 hrs 6-8 hrs
NPH
Lente
1-2 hrs 6-10 hrs 16-24 hrs
Ultralente 4-6 hrs 8-24 hrs 24-36 hrs
Glargine Immediately None Up to 24 hrs
BIDS Therapy
• T2DM: “Introduction to insulin”
• Keep on OHAs
• Start NPH 0.2 U/kg SC qhs
• Increase by 2-4 U q4d until FBS 4-7
• If dose > 30-40U or if BS high late in day despite OK FBS than split into 2 injections with 2/3 acB and 1/3 acD
Starting Insulin Regimen• TDD = 0.5-0.7 U/kg
• “2/3, 1/3” Regimens• 2/3 of TDD acB, 1/3 acD
• 2/3 of TDD as Long-acting, 1/3 as short acting
• Pre-mix: acB 30/70 acD 30/70
• MDI Regimens• 2/3, 1/3 Regimen: move acD long acting to qhs
• i.e. acB N, H acD H qhs N
• ac meals H qhs N (bolus 60%, basal 40%)
• ac meals H UL q12h (bolus 50%, basal 50%)
Insulin Regimens
acB acL acD qhs
Bedtime NPH (+/-bids) N
NPH bid N N
30/70 bid 30/70 30/70
MDI (3 injections) H + N H N
MDI (>4 injections) H (+/-N) H H N
MDI (>4 injections) H + UL H H UL
CSII (Insulin Pump)
Guideline for Insulin Adjustments
1. Adjust the insulin that accounts for the high or low reading.
2. Always compare an abnormal BS reading with the one previous.
3. If insulin dose is:• Less than 8U, adjust by 1U
• 8-20U, adjust by 2U
• > 20 U, adjust by 10% (increase), 20% (decrease)
4. Don’t forget to compensate for a successful adjustment
acB acL acD qhs Rx
22
(5R)
9 3.1
(O.J.)
15 acB N20 R10
acD R5
qhs N10
20 15 7 8 acB N20 R10
acD R5
qhs N10
22 17(RN calls)
acB N20 R10
Surgeon: ?Internal Medicine: ?Endocrinologist: ?
acB acL acD qhs Rx
22
(5R)
9 3.1
(O.J.)
15 acB N20 R10
acD R5
qhs N10
20 15 7 8 acB N20 R10
acD R5
qhs N10
22 17(RN calls)
acB N20 R10
Surgeon: Give 5 U Regular SC now
Internist: Increase qhs N to 12 tonight and acB R to 12 tomorrow
Endocrine: Increase qhs N to 12 start tonightDecrease acB N15 R7 starting tomorrow AMCheck 3AM BS tonight
Guideline for Insulin Adjustments
1. Adjust the insulin that accounts for the high or low reading.
2. Always compare an abnormal BS reading with the one previous.
3. If insulin dose is:• Less than 8U, adjust by 1U
• 8-20U, adjust by 2U
• > 20 U, adjust by 10% (increase), 20% (decrease)
4. Don’t forget to compensate for a successful adjustment
SC Insulin Supplemental Scale
CBG Action
< 4.0 Call MD
4.1-11.0 nil
11.1-15.0 Humalog 7U SC (0.1U/kg)
15.1-19.9 Humalog 10U SC (0.15 U/kg)
> 20.0 Call MD
DM Inpatient Management
1. Eating
2. NPO: temporary (for a test)
3. NPO: prolonged
NPO for a test: T2DM on Diet Rx
• Schedule test for the AM
• Hold OHAs on AM of test
• CBG @ 7AM:
< 3.0 Consider postpone test
3.1-4.0 IV D5W gtt @ 75-100 cc/h
4.1-11.0 Proceed with test, no Rx necessary
> 11.1 IV insulin gtt
IV D5W gtt @ 75-100 cc/h
> 20.0 Check urine ketones, consider postpone test
NPO for a test: T1/T2DM on Insulin
• Schedule the test for the AM
• Hold AM Insulin on day of test
• CBG @ 7AM:
< 3.0 Consider postpone test
3.1-11.0 Give ½ of total AM insulin dose as NPH SC
IV D5W gtt @ 75-100 cc/h
> 11.1 IV insulin gtt
IV D5W gtt @ 75-100 cc/h
> 20.0 Check urine ketones, consider postpone test
DM Inpatient Management
1. Eating
2. NPO: temporary (for a test)
3. NPO: prolonged• Patient put on D5W if not on feeds or TPN
• IV insulin gtt
• SC NPH or UL q12h (+/- supplemental scale)
Insulin IV gtt
• Add 50 U of Human regular insulin (Humulin R or Novolin Toronto) to 500cc D5W (1U/10cc).
• Flush & discard first 50cc.• Infuse insulin solution by IVAC (intravenous
infusion pump), piggybacked into D5W running at 100cc/h.
• Start insulin @ 0.9 U/h (9cc/h) or start at a rate dependent on patient’s insulin dose: IV insulin gtt rate = ( ½ TDD ) / 24
Insulin IV gtt
CPG q1h x 2, then q2h (if BS stable x 2-3 readings consider q4h):
Adjust Insulin IV infusion rate as per scale below:
<4.0 Call MD
4.1-5.0 0.7 U/h ( 7cc/h)
5.1-6.0 0.9 U/h ( 9cc/h)
6.1-7.0 1.2 U/h (12cc/h)
7.1-9.0 1.5 U/h (15cc/h)
9.1-11.0 2.0 U/h (20cc/h)
11.1-13.0 2.5 U/h (25cc/h)
13.1-15.0 3.0 U/h (30cc/h)
15.1-17.0 3.5 U/h (35cc/h)
17.1-20.0 4.0 U/h (40cc/h)
>20.1 Call MD
Evidence to support Inpatient BS control?
DIGAMI• AMI, prior dx DM or BS > 11 mM• IV insulin gtt started @ 5 U/h• Titrated to keep BS 7-10.9 mM• Insulin IV > 24h MDI > 3 months• No in-hospital mortality benefit.• Rx Increased hospitalization by 1.8d• 0.5% reduction HbA1c @ 3 months• @ 1 year % on Insulin: 72% Rx Group 49% Cntrl Group• 1 year mort: ARR 7.5% NNT 13• 3.4 y mort: ARR 11% NNT 9
Evidence to support Inpatient BS control?
Leuven, Belgium Study• ICU patients (63% CV Sx)• If BS > 6.1 mM: Rx with IV insulin gtt & TPN +/- tube feeds• Start IV insulin @ 2-4 U/h, titrated to BS 4.4-6.1 mM• Ave insulin dose: Rx group 3.0 U/h Cntrl group 1.4 U/h• Once out of ICU relaxed treatment goal to < 11.1 mM• Mortality in ICU: ARR 3.4% NNT 29• Mortality in-hospital: ARR 3.7% NNT 27• Greatest reduction in mortality was sepsis-related.• Insulin Rx reduced: bacteremia, ARF needing HD, need for PRBC,
critical illness polyneuropathy, duration of ventilation and length of stay in ICU
• To what extent were benefits nutrition related as opposed to insulin related?