Inpatient Diabetes Management • Osama Hamdy, MD, PhD, FACE • • • • •

Medical Director of Inpatient Diabetes Program, Medical Director of Obesity Clinical Program, Joslin Diabetes Center Assistant Professor of Medicine, Harvard Medical School

Objectives 1- Magnitude of the Inpatient Diabetes Problem 2- Hyperglycemia and Hospital Outcomes 3- Potential Benefits of Glycemic Control 4- Recommendations from Professional Societies 5- Protocols for Inpatient Diabetes Management

Objectives 1- Magnitude of the Inpatient Diabetes Problem 2- Hyperglycemia and Hospital Outcomes 3- Potential Benefits of Glycemic Control 4- Recommendations from Professional Societies 5- Protocols for Inpatient Diabetes Management

Diabetes Cost

– Total estimated cost of diabetes in 2012 was $245 billion (41% up from 2007), with $176 billion direct cost and 69 billion reduced productivity – Largest component of medical expenditures attributed to diabetes was hospital inpatient care (~43%% of costs)

10 8 43

9

12

18

Hospital Prescription for diabetes complications Antihyperglycemic medications Physician office visits Nursing/residential facility Others

Diabetes Care. 2013; 36(4): 1033-1046

The management of diabetes in the hospital was generally considered to be of secondary importance versus the condition that prompted the patient’s admission

ADA. Diabetes Care. 2009;32(suppl 1):S13-S61.

Blood Glucose >180 mg/dL Cook CE et al. J Hosp Med 2009; 4:E7-E14

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

Failure to identify diabetes is an independent predictor of rehospitalization Robbins JM & Webb DA. Med Care 2006; 44:292-296

Based on 2030 consecutive hospitalized patients whose charts were reviewed Normoglycemia

Known Diabetes

New Hyperglycemia

62%

26%

12%

Admission BG

108 mg/dL

230 mg/dL

189 mg/dL

Length of Stay

4.5 days

5.5 days

9 days

1.7%

3.0%

16%

Mortality

Medical, Surgical, and ICU Patients

Umpierrez GE et al. J Clin Endocrinol Metab. 2002;87(3):978-982.

ADA. Diabetes Care. 2008;31(3):596-615.

Patients with diabetes incurred an average of $3337 more in hospital costs

$11,858

$7,830

ICU

Non-Critical Care

Objectives 1- Magnitude of the Inpatient Diabetes Problem 2- Hyperglycemia and Hospital Outcomes 3- Potential Benefits of Glycemic Control 4- Recommendations from Professional Societies 5- Protocols for Inpatient Diabetes Management

*P < 0.001; †NS; ‡P < 0.017. n= 3,184 Source: Emory University Hospital (Atlanta, GA) between January 1st, 2007 and June 30th, 2007 Frisch A et al. Diabetes Care 2010; 33:1783-1788

Cardiac Surgery Patients

Deep sternal wound infection rate (%)

There is an association between postoperative blood glucose levels and the rate of deep sternal wound infections 70

67

*

P=0.002

60 50 40 30 20

25 13

16

10 0

100-150

150-200

200-250

250-300

Day 1 blood glucose (mg/dL)

n=1585

Zerr KJ et al. Ann Thorac Surg. 1997;63(2):356-361.

Krinsley et al. Crit Care Med 2008; 36: 3008-3013.

Documented *

No association

Pneumonia Sepsis Unstable angina Congestive heart failure Arrhythmia Stroke Gastrointestinal bleeding Acute renal failure Respiratory failure

COPD DKA Gastrointestinal neoplasm Musculoskeletal disease Hip fracture Liver failure Prostate surgery

* High risk patients: Recommended better glycemic control Falciglia et al. Crit Care Med 2009;37:3001-3009

Objectives 1- Magnitude of the Inpatient Diabetes Problem 2- Hyperglycemia and Hospital Outcomes 3- Potential Benefits of Glycemic Control 4- Recommendations from Professional Societies 5- Protocols for Inpatient Diabetes Management

Surgical ICU Patients

GLYCEMIC CONTROL AND Survival intreatment ICU (%) REDUCED MORTALITY Intensive per protocol reduced the risk of mortality

1

In-hospital survival (%)

100

100

96

96

92

92

Percent Surviving

Percent Surviving

ICU survival (%)

88

84 42.5% reduction in mortality with intensive treatment; P6.5% (preceded diabetes)

140 mg/dl, increase the AM dose by 2 units (an increase of 1-4 units may be considered)

Starting dose = Body weight (kg) x 0.2 divided equally for the 3 meals (for a blood glucose >80 mg and eating a meal) Calculate Correction Factor 1. For previously known total daily dose (TDD): 1700/TDD 2. For unknown total daily dose: 3000/Body weight (Kg) 3- Build the scale by increasing insulin dose by 1-2 units for every correction factor Example: 75 Kg person with unknown previous insulin dose. Starting insulin 75 X 0.2 = 15 (5 units for each meal). Correction 3000/75= 40 mg/dl Scale: 80-120 mg/dl = 5 units 120-160 mg/dl = 6 units 160-200 mg/dl = 7 units.....etc STAT Dose (Current blood glucose - 100) / CF Example: Current BG 340 and CF 40: (340-100)/40 = 6 units of short acting insulin

Hypoglycemia Management ICU: Regular ward and postpartum: Labor:

>140 mg/dl >100 mg/dl >80 mg/dl

Every 15-30 min If patient is conscious and on oral feeding give15-20 grams of sugars or carbohydrates Example: - Glucose tablets - 4 or 5 saltine crackers

- 4 oz (1/2 cup) of juice or regular soda - 4 teaspoons of sugar

ICU patients on insulin infusion: 1. Stop insulin infusion 2. Give a bolus of D50 cc = (100 – BG) x 0.4 followed by IV infusion of D10W 50 cc/hr 3. After reaching the target blood glucose, resume IV insulin at 1/2 previous rate Patients on SC insulin and NPO 1. Give a bolus of D50 cc = (100 – BG) x 0.4 followed by IV infusion of D10W 50cc/hr 2. After reaching the target blood glucose, resume insulin regimen after appropriate insulin adjustment if needed Glucagon 1mg SC if unconscious and no IV line

Pre-Operative and NPO Day Before the surgery

Maintain usual meal plan and insulin dose, insulin via pump (CSII), or oral anti-diabetes medications.

Day of the Surgery Aim for Early Morning Schedule Insulin management

• If fasting after midnight: • 75-80% of the usual dose of long-acting (glargine/detemir) • 50% of the usual dose of intermediate (NPH) • If on pre-mixed insulin (70/30, 75/25, 50/50) give 50% of the NPH component of the usual dose. • Continue same basal rate by the pump (CSII) • Omit short-acting insulin, OAD, exenatide, liraglutide, or pramlintide

Frequency of testing and Action

Check BG every 2 hours before and during surgery Insulin pump patients (CSII) can maintain basal rate during surgery or change to IV or SC insulin to maintain blood glucose target.

Parenteral Nutrition • Regular insulin at a dose of 0.1 unit/gram of carbohydrates in TPN • Correction dose of regular insulin q6 hr or rapid acting analog insulin q4 hr • Insulin dose in TPN can be adjusted daily by adding 80% of the previous day's correctional insulin • If blood glucose is severely elevated, use IV insulin • Once IV insulin dose is stable, add 75% of the insulin dose to the TPN • Alternative method for patients with pre-existing diabetes: 40% of known TDD as basal and 60% added to TPN Example: • Patient in the ICU with TPN of 1600 cal, 60% carbohydrates, weigh 75 Kg • Amount of carbs in grams = 1600 * 0.6 / 4= 240 grams • Regular insulin in TPN = 240 * 0.1 = 24 units • Correction dose = 3000/75 = 40 (1 units for every 40 mg above target q4-6 hrs) Transition to oral feeding Previous TDD divided into 50% basal and 50% as boluses before meals

Enteral Nutrition Continuous tube feeding

•TDD = 0.3-0.6 unit/kg body weight as basal insulin (2 doses of Glargine or Detemir or 2-3 doses of NPH) •Correction dose of regular insulin q6 hr or rapid acting analog insulin q4 hr •Basal insulin is adjusted by adding 80% of the previous day's correctional insulin Example: • Patient in the ICU on entetral nutrition, weigh 75 Kg • Basal insulin dose = 0.4 * 75 = 30 units (15 unit of glargine or Detemir q12 hours or 10 units of NPH q8 hours) Cyclic overnight tube feeding

• TDD = 0.3-0.6 unit/kg body weight as NPH insulin given 3-4 hours before the start of the feeding • If patients on nocturnal tube feedings are eating meals, they may require mealtime bolus insulin Bolus tube feedings

Covered the same as ingested meals with basal insulin and a dose of rapid-acting analog insulin for each bolus feeding

Interruption of tube feedings • Insulin should be adjusted appropriately if there is a planned withholding of feedings. • If the enteral feeding is unexpectedly interrupted for more than 2 hours, stop all insulins and give DW10% IV at the same rate as that of the enteral feedings to prevent hypoglycemia. • Monitoring electrolytes and providing adequate free water to prevent dehydration

SUMMARY

– New hyperglycemia in hospital is associated with high 30-day readmission rate and, if missed, significantly increased mortality – There is a strong association between the degree on hyperglycemia and in-hospital complications and mortality – Wide glucose variability is associated with increased mortality at all ranges of blood glucose level – Tight diabetes control in the ICU is controversial but seems to be of value in surgical ICU than in medical ICU. Medical nutrition therapy is a modifier of the outcomes

Thank You 9/28/2015

Thank You 9/28/2015