Hospital Management of Diabetes.pptx

Diabetes

1. Inpatient Diabetes Management Endocrinology Quality Improvement Nora Khoury, MD & Noreen Shaaban, MD Program Director: Eugenio Angueira, MD, FACE Cell Phone: [phone]

2. Diabetes Today: An Epidemic In 2018, 34.2 million Americans (10.5% of the population) were diagnosed with diabetes 1.5 million new cases in adults aged 18 years ~4100 new diagnoses each day Complications of diabetes are a major cause of mortality and morbidity 252,806 deaths 1 stroke every 2 minutes 1 MI ever 80 seconds 108,000 lower-limb amputations 1 every 5 minutes 52,159 begin treatment for ESKD 1 patient develops ESKD every 10 minutes 24,000 new cases of blindness each year Total cost in the United States in 2017: $327 billion http://www.diabetes.org/diabetes-basics/statistics/

3. Type 1 vs. Type 2 DM

4. Type 1 DM 5-10% of all diabetes Immune-mediated Auto-immune destruction of the Beta cells Peak onset below age 30 (75%) Typical Characteristics Younger Normal Body Weight Normal BP Absolute Insulin Deficiency!!

5. Type 2 DM 90-95% of Diabetes Insulin Resistance Syndrome Association with Obesity Typical Characteristics BMI >27 Hypertension Lipid Abnormalities High/Low Insulin Levels Acanthosis Nigricans

6. Diabetes Complications

7. Chronic Complications:

8. Diabetes in the Hospital

9. Diabetes in Hospitalized Patients At least 7.2 million patients with history of DM are admitted to hospitals annually in the US Hospitalization and illness-related stress can induce uncontrolled hyperglycemia Hyperglycemia may be related to: Medications Illness-related insulin resistance TPN Steroid use

10. Why care? It is easy to put DM at the bottom of a hospitalized patient’s problem list and write it off with a mindless therapeutic plan. For Example: 70 year old female with MI, Pneumonia & Ankle Fracture with a history of T2DM The Problems: MI – caused by CAD -> which was largely caused by DM Pneumonia – susceptibility increased by DM/Hyperglycemia Fall – caused by confusion/weakness/dehydration/neuropathy -> all brought on by Highs or Lows/DM

11. More… If her diabetes is not addressed: Her pneumonia will clear more slowly Her outcome from MI will be worse Her fracture will not heal well And worst of all: She will be back again, because the root of her problems was not addressed

12. Scope of the Problem DM & hyperglycemia in hospitalized patients leads to: Higher morbidity and mortality rates Longer Stay More Procedures & More Medications More infections More discharges to some form of long-term care facility

13. Effect of Hyperglycemia on Hospital Mortality Umpierrez GE et al. J Clin Endocrinol Metab . 2002;87:978-982.

14. Hyperglycemia & Hospital Mortality in ICU patients

15. Hyperglycemia and Poor Outcomes Following Myocardial Infarction *P <.05 compared with nondiabetic patients. IGT = impaired glucose tolerance. Bolk J et al. Int J Cardiol . 2001;79:207-214. * Mortality After 1 Year (%) Patient Categories Based on Admission Blood Glucose 140 180

16. Acute In-Hospital Complications

17. Benefits of Effective Management of DM in the Hospital

18. MI = myocardial infarction; DIGAMI = Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction. Malmberg K et al. BMJ. 1997;314:1512-1515. All Subjects (N=620) Risk reduction (28%) P =.011 Standard treatment 0.3 0.2 0.4 0.7 0.1 0.5 0.6 1 Follow-Up (y) 2 3 4 5 Low-Risk and Not Previously on Insulin (N=272) Risk reduction (51%) P =.0004 IV insulin 48 hours, then 4 injections daily 0.3 0.2 0.4 0.7 0.1 0.5 0.6 1 Follow-Up (y) 2 3 4 5 Mortality After MI Is Reduced by Insulin Therapy in DIGAMI-1

19. Benefits of IV Insulin Treatment Following Coronary Artery Bypass Open-heart surgery IV insulin infusion reduced the rate of mortality and deep sternal wound infection (DSWI) to the incidence observed in patients without diabetes Target blood glucose <150 mg/dL 3-day postoperative duration of CII CII = continuous intravenous insulin. Furnary AP et al. Endocr Pract . 2004;10(suppl 2):21-33. Risk Reduction (%) P <.0001 P <.0001

20. Benefits of IV Insulin Treatment in Critically Ill Hospitalized Patients Van den Berghe G et al. N Engl J Med. 2001;345:1359-1367. Reduction (%) 34% 46% 41% 50% 44% Intensive Glycemic Control BG = 80-110 mg/dL in ICU BG = 180-200 mg/dL after discharge from ICU

21. Effectively Managing the DM Allows us to better manage the current problems Allows us to prevent recurrent problems Improves patient outcomes Lowers mortality

22. How Do We Manage Diabetes in the Hospital?

23. Oral Medications Most oral agents are relatively contraindicated during the hospital stay

24. Limitations of Oral Agents for Managing In-Hospital Hyperglycemia Sulfonylureas No rapid dose adjustment or titration due to long duration of action Risk of unpredictable hypoglycemia Glitinides Allow for rapid adjustment and titration Risk of hypoglycemia is reduced Metformin No rapid dose adjustment Mostly contraindicated due to relatively increased risk of lactic acidosis in severely ill hospitalized patients ( ie , renal failure, congestive heart failure, critically ill) Thiazolidinediones No rapid dose adjustment Mostly contraindicated due to increased intravascular volume Clement S et al. Diabetes Care . 2004;27:553-591.

25. Limitations of Oral Agents for Managing In-Hospital Hyperglycemia DPP-4 Inhibitors Dose adjustment needed based on renal function Relatively slow onset of action SGLT-2 Inhibitors Effect independent of insulin action Contraindicated if renal function is compromised GLP-1 RA’s Long acting are impractical as onset may take days to weeks Short acting ( ie ., exenatide, lixisenatide ) have been shown to be useful in the hospital setting

26. Therefore, most patients who require diabetes management in the hospital will require insulin

27. Insulin Use in the Hospital Setting

28. Insulin is… One of the most important drugs used in the hospital BUT, it is one of the most common sources of medication-related errors.

29. Insulin: The Most Effective Treatment Easy to change dose with increased insulin requirements during acute illness Can be easily changed depending on patient’s nutrition IV Dextrose TPN Enteral Feeding Nutritional Supplements NPO

30. Physiologic Insulin Secretion

31. Insulin Formulations Insulin Onset Peak Duration Basal Detemir ( Levemir ) 2 hours Relatively peakless 16-24 hours Glargine (Lantus) 2-4 hours Relatively peakless 20-24 hours Degludec (Tresiba) 2 hours Peakless 36 hours NPH* (intermediate) 2-4 hours 4-10 hours 12-18 hours Prandial/Bolus Rapid-acting analog ( aspart, glulisine, lispro ) 5-15 min 1 hour 3-4 hours Regular 30-60 min 2-3 hours 6-10 hours *NPH not true basal – it peaks

32. Insulin Profiles

33. Sliding Scales and Their Dangers If used alone, they can easily lead to harm: T1DM patients Never should be treated with ISS alone Always require basal insulin T2DM patients Poor wound healing Increased susceptibility to infections Sliding Scale Insulin = Reactive Approach to DM Insulin only given after blood sugar rises (chasing tail) Does not prevent high sugars

34. A Better Solution… Use Basal Insulin for “background” insulin needs Levemir/Lantus/Tresiba Use Bolus Insulin to cover the carbs that are about to be eaten NovoLog/Humalog/ Apidra Use Sliding Scale – only as a supplement to correct a single glucose value that is out of range

35. Basal-Bolus Therapy: The Way the Pancreas Does It Insulin lispro, aspart, or glulisine Insulin glargine or detemir Breakfast Dinner Lunch Bedtime Insulin Effect

36. Basal-Bolus Basal Insulin Suppresses glucose production between meals and overnight Maintains nearly constant levels Provides ~50% of daily needs Pre-Meal/Bolus Insulin Limits hyperglycemia after meals Provides immediate rise and sharp peak Provides ~10-20% of daily requirement at each meal

37. Basal-Bolus Insulin Therapy Provides a proactive approach to prevent hyperglycemia, rather than a reactive “band-aid” approach. Remember: Silding Scale Insulin when used alone -> guarantees that you never have the right amount of insulin around when you need it -> can be harmful or even lethal.

38. Basal-Bolus + ISS Basal insulin Mealtime insulin (bolus) Sliding Scale

39. Timing is Key! Proper timing of glucose testing and insulin administration can reduce the risk of hypoglycemia and hyperglycemia Administer short-acting Regular insulin 30 min before meals Because the onset is 30-45 minutes Administer rapid-acting or bolus insulin analogs (Humalog/Novolog/ Apidra ) up to 15 min before meals Because the onset is 5-15 minutes

40. Inpatient vs. Outpatient What works for a patient at home will not necessarily work for them in the hospital In the hospital patients are: Sick Stressed Sedentary Suddenly “Twinkie-Deficient” Super-Compliant Thus, they may require either more or less therapy than they did as an outpatient

41. Things NOT to Do With SQ Insulin Therapy Use sliding scales as the sole treatment Use basal insulin in combination with premixed insulins Use basal insulin as the sole treatment for patients who can eat Hold insulin for normal glucose levels if patients are eating or receiving enteral feeding Hold insulin for patients with type 1 diabetes

42. How about IV Insulin?

43. Indications for IV Insulin Therapy Diabetic ketoacidosis Nonketotic hyperosmolar state Critical care illness (surgical, medical) Postcardiac surgery Myocardial infarction or cardiogenic shock Dose-finding strategy NPO status in type 1 or type 2 diabetes Labor and delivery Glucose exacerbated by high-dose glucocorticoid therapy Perioperative period After organ transplant Total parenteral nutrition therapy ACE Task Force on Inpatient Diabetes and Metabolic Control. Endocr Pract . 2004;10:77-82. 44

44. Switching from IV to Subcutaneous Insulin IV insulin has a short half-life (~6 minutes) and should not be discontinued until subcutaneous medication has been initiated Timing of administration of subcutaneous insulin before discontinuation of IV insulin 1 to 2 hours in advance for short- or rapid-acting insulins 2 to 3 hours in advance for intermediate- or long-acting insulins Clement S et al. Diabetes Care . 2004;27:553-591.

45. Guidelines

46. What are the Goals? ***If can be achieved without hypoglycemia*** In Critical Patients – can try for 110-140 Patients Pre-Meal Post-Meal Critical (CCU) 140 <180 Non-Critical <140 <180

47. Hypoglycemia

48. What is a Low Glucose? Blood glucose less than 70 with or without symptoms Severe Hypoglycemia – requires assistance Symptoms of Hypoglycemia: Anxiety Palpitations Tremor Sweating Hunger Paresthesias Cognitive dysfunction Seizures Coma

49. Preventing Hypoglycemia Low glucose is the primary limiting factor for achieving optimal glucose control Reduction of insulin dose may be needed if: Switched to NPO status Reduced PO food intake Enteral feeding discontinued TPN or IV Dextrose discontinued due to procedures/transport Timing of pre-meal insulin & meal time disrupted due to procedures/transport Reduction in steroid dosing ***Glucose monitoring should be increased in the event of any of the above circumstances ***

50. What to do with Low Glucose? 50-69 and Alert 1 tube (15g) Glucose Gel (if can swallow) 4oz of Apple juice or OJ. DON’T ADD SUGAR NPO: 25ml D50 IV and start D5W @100ml/h  Level of Conscious 50 ml D50 IV & start IV D5W @ 100ml/h <50 and Alert Call Physician (Primary/Endo) on patient & Re-check in 15 minutes & Repeat if needed Glucagon should NOT be repeated 2 tubes (30g) Glucose Gel (if can swallow) 8oz of Apple juice or OJ DON’T ADD SUGAR NPO: 50ml D50 IV and start D5W @100ml/h IF LESS THAN 70 REPEAT ACCUCHEK. IF STILL BELOW 70 TREAT ASAP. NO IV ACCESS and NPO: Glucagon 1mg IM/SQ and start IV D5W@100ml/hr or 50ml D50 Rectally

51. Insulin given too early… Patient requires regular insulin coverage Blood glucose checked at 0610 Insulin is given at 0620 Breakfast arrives at 0740 Potential harm: hypoglycemia Ideally Regular insulin should be given 30 min before meal If necessary, Regular insulin may be given with the meal Insulin should not be given more than 30 min before the meal

52. The Patient is NPO. Now What? Patients who are not eating require Basal insulin to prevent ketosis (T2DM) or ketoacidosis (T1DM) Should be ordered to continue Accu-Cheks Q4 Hours Continue the Basal Insulin Analog ( Levemir /Lantus) at the same dose Continue the Sliding Scale that is ordered Q4 hours ONLY OK to hold the pre-meal insulin boluses

53. Role of Nursing in Inpatient Diabetes Care Nurses are essential—and central—to successful implementation of glucose monitoring and educational programs to support improved glycemic control. Because nurses oversee inpatient care on a 24-hour basis, nurses have opportunities to coordinate care of patients with hyperglycemia. Nurses are an essential part of the team with physicians, dieticians, nutritionists that are vital to the patient’s glucose control.

54. Summary of Glucose Targets Treatment threshold: >180 mg/ dL Goal <140-180 mg/ dL for most patients in the ICU Lower threshold of 110 mg/ dL for selected, low-risk patients in the ICU On the medical floors – Goal is <140 Both the AACE & ADA all strongly discourage use of sliding scale insulin, which has been shown to lead to undesirable lows and highs as compared to basal-bolus insulin approaches.

55. Take Home Messages Give insulin as ordered Don ’ t be afraid When in doubt -> Call Endo If insulin needs to be held -> you need Dr.’s order