Hyperglycemia in icu patients[9243]

Hyperglycemia in icu patients[9243]

1. Clinical Guidance on Diabetes Management at COVID 19 Patient Management Facility Article by : Ministry of Health & Family Welfare Dated : 26 th August , 2020 Presenter DR. SUKRATI MAHESHWARI Moderator DR. S.B. GAWARIKAR DR. VIPIN PORWAL

2. Screen every patient at the admission for hyperglycemia with at least two capillary blood glucose levels (1 pre-meal and 1 post-meal value) by a glucometer. Every patient with Diabetes should be started on diabetic diet. Kindly ensure that the patient strictly adheres to the timing and quantity advised in the diet chart.

3. Ensure ALL newly admitted patients are evaluated for diabetes/hyperglycemia Any value ≥200 mg/dL with osmotic symptoms Send FPG and HbA1c to lab next day *Pre-meal ≥140 mg/dL or Post-meal ≥180 mg/dL Pre-meal <140 mg/dL and Post-meal <180 mg/dL Check CBG - one value pre-meal and one value 2 hours after major meal (post-meal) Significant elevation (≥ 2 values) Pre-meal ≥ 150 mg/dL Post-meal ≥ 200 mg/dL Modest elevation of 1 or more values Pre-meal 140 to 150 mg/dL Post-meal 180 to 200 mg/dL CBG testing over next 24 hours BBF BLN BDN ADN Send FPG and HbA1c to lab next day Advise healthy diet No need for further monitoring Send FPG and HbA1c to lab next day Monitor CBG values: BBF, BL, BDN and ADN Titrate OAD/Insulin based on these values Diabetic diet advised Diabetic diet advised Initiate OAD Insulin as per protocol Section 1: Screening of hyperglycemia in every patient hospitalized with COVID-19 (at admission and on starting steroids # )

4. INDICATIONS OF REPEAT MONITORING If patient is started on steroids or on drugs with a potential to affect glycemic status. If there is increase in the severity of COVID 19 infection m as it can lead to stress hyperglycemia statins Thiazide beta-blockers proton pump inhibitors fluoroquinolones

5. EFFECT OF STEROIDS Short acting – hydrocortisone : Short episodes of hyperglycemia & associated with higher glycemic variability Intermediate acting – methylprednisolone Single dose: hyperglycemia during the afternoon and night without effect in fasting glucose  Divided doses: persistent hyperglycemia Long acting – dexamethasone : Hyperglycemia that lasts >24 h, with a slight decline during an overnight fast

6. Known Diabetic who are on OAD at admission C ONDITION 1

7. OAD in patients newly detected to have Diabetes at admission *Pre-meal BG- 150-180mg/dl* *Post meal BG- 200-250mg/dl* CONDITION 2

8. Consult endorcrinologist / physican to initiate and optimize OAD If delay  start Tab Metformin 500mg BD + Gliptin Tab Sitagliptin 100mg OD Tab Linagliptin 5mg OD Tab Vildagliptin 50mg BD Tab Teneligliptin 20mg OD

9. Insulin in patients with newly detected Diabetes *Pre-meal BG- >=18mg/dl* *Post meal BG- >=250mg/dl* CONDITION 3

10. Total Daily Dose (TTD) = 0.4 units/kg/day If age >65yr / nephropathy / liver disease = 0.2unit/kg/day Total daily dosage divided equally into 4 doses (25% each) 3 doses of bolus insulin ( Inj Regular insulin BBF , BL, BD) 1 dose of basal insulin ( Inj NPH HS)

11. If rapid acting insulin analogues are used( aspart / glulisisne /lispro) with long acting basal analogue(glargine/ degludec ) : Gap of 5-15mins is adequate before the meals Long acting insulin can be given at any relatively fixed time of the day If used for basal-bolus regimen , basal insulin = 50% of TDD, bolus insulin = rest 50% (further divided into 3 parts for each meal)

12. Uncontrolled blood glucose levels in patient on OAD *Pre-meal BG >=140mg/dl* *Post meal BG>=180mg/dl8 CONDITION 4

13. If post meal BG increment is >40mg/dl , Inj regular insulin can be increased in dose at individual times also .

14. INSULIN INFUSION INDICATIONS Patients with NPO status or having erratic diet pattern Diabetic ketoacidosis Uncontrolled hyperglycemia despite MSII(multiple subcutaneous insulin injections) Severe hyperglycemia at onset (pre meal BG >=300mg/dl , post meal BG >=400mg/dl) Critically ill patients like in sepsis and septic shock. CONDITION – 5

15. Initiation : dose of 0.05-0.1 units/kg/hour Infusion preparation : 50units regular insulin + 50ml NS(1unit/ml) Frequency of BG monitoring : 2hourly 4hourly Glycemic target : achieve and maintain BG level of 140-180mg/dl Infusion rate(units/ hr ) = BG level(mg/dl) /100 Target rate of BG change – between 50-75mg/dl/ hr , if rate <50mg/dl or >100mg/dl , consider increasing/decreasing the rate, resp.

16. For prandial coverage , increase infusion rate by 2-4units/hour over and above the basal rate , just before taking the major meal and continue the increased rate for next 2 hours. Therefore , IV insulin to be given in 2 components : Basal coverage provided by the maintenance rate of IV insulin Prandial coverage provided by an increment in the maintenance rate for 2 hours around a meal. S. potassium should be monitored every 6 hourly in NPO patients and every 12 hourly in those who are accepting orally.

17. Switch to basal-bolus insulin regimen from insulin infusion CONDITION - 6

18. Calculate total daily dose(TDD) based on insulin infusion requirement for last 24 hours TDD= 80% of total insulin requirement on IV infusion in last 24 hours. Divide according to basal-bolus regimen(25% each) Switch only when : BG levels are controlled on insulin infusion Patient is accepting orally or on Rtfeeds Hemodynamically stable patient Insulin infusion has to be overlapped with basal-bolus regimen for 60-120mins before stopping (insulin infusion should not be interrupted abruptly)

19. Patient on RT feeds Divided into 3 major and 3 minor feeds. Major and minor feeds are defined by calories/quantity of feeds (300/150) Timing of major feeds : 9am , 1:20pm , 7pm Timing of minor feeds : 11am , 4:30pm, 10pm Bolus insulin – before every major feed , basal insulin at 10pm

20. TITRATION OF INSULIN DOSE Titrated proactively and not reactively i.e. to be adjusted based on previous day’s BG log and not the current BG value. Pre-meal to post-meal incrememt should be 30-50mg/dl. If above : Check technique Check time gap bwteen injection of prandial insulin and the meal Check quality and quantity of carbohydrate in the meal Basal dose is adjusted based of FPG .

21. Titration in patients on Steroids High dose intermediate acting steroids (prednisolone/methylprednisolone) , if administered at 9-10am single dose Peak hyperglycemia is expected in the afternoon and evening. Inj NPH may be useful at 9am (similar pharmacokinetics)

22. DIABETIC DIET

23. Scenario BG level Action* 1. Detected to have hyperglycemia at admission or on starting steroids Pre-meal <140 mg/dL and post-meal <180 mg/dL Healthy diet. No further monitoring Pre-meal ≥140 mg/dL and/or post- meal ≥180 mg/dL Monitor BG levels and diabetic diet Pre-meal between 150 and 180 mg/dl and/or post-meal between 200 and 250 mg/dl Start Tab Metformin 500 mg twice daily and a Gliptin@ Pre-meal: ≥180 mg/dl and/or post- meal ≥250 mg/dl Start on basal-bolus insulin Pre-meal: ≥300 mg/dl and/or post- meal: ≥400 mg/dl Start on IV insulin infusion DKA Start on IV insulin infusion (DKA protocol)

24. 3. On basal-bolus regimen at admission/during follow-up Pre-meal <140 mg/dL and post-meal <180 mg/dL Continue basal-bolus regimen$ Pre-meal: ≥140 mg/dl and/or post- meal: ≥180 mg/dl Optimise insulin doses Pre-meal: ≥300 mg/dl and/or post- meal: ≥400 mg/dl Start on IV insulin infusion DKA Start on IV insulin infusion (DKA protocol) 4. Patient is NPO BG level (2 hrly ): If ≥ 2 values ≥180 mg/dl Start IV insulin infusion

25. 2. Patient on OAD at admission/during follow-up Pre-meal <140 mg/dL and post-meal <180 mg/dL Continue existing OAD Pre-meal: ≥140 mg/dl and/or post- meal: ≥180 mg/dl Uptitrate OAD Pre-meal: ≥180 mg/dl and/or post- meal: ≥250 mg/dl Start on basal-bolus insulin Just FPG is ≥140mg/dl Add basal insulin at bed time Pre-meal: ≥300 mg/dl and/or post- meal: ≥400 mg/dl Start on IV insulin infusion DKA Start on IV insulin infusion (DKA protocol)

26. DRUG EFFECTS INSULIN : Hypoglycemia Local reactions (swelling/erythema) , lipodystrophy METFORMIN : Abdominal pain / metallic taste / nausea Lactic acidosis Vitamin b12 deficiency C/I in hepatic /renal diseases