Hyperglycemia management

Hyperglycemia management in non critically ill inpatients

1. IN-PATIENT HYPERGLYCEMIA MANAGEMENT IN NON-CRITICALLY ILL PATIENTS Presented By Dr. Reshma Francis Pharm D (PB) 1

2. Introduction The selection of method for the glycemic control in non-critically ill in-patients was done based on the results from a prospective, multicenter randomized trial It was done by Emory University School o f Medicine, Atlanta Georgia and The University Of Miami School of Medicine Miami, Florida Ra ndomized study of B asal – B olus I nsulin T herapy in the Inpatient M anagement of patients with T ype 2 Diabetes (RABBIT 2 Trial) RABBIT 2.pdf 2

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4. Study Type : Prospective , randomized, open- label trial Study Sites: Grady Memorial Hospital, Atlanta Jackson Memorial Hospital, Miami Patient Population 4 Total 130 patients with DM Oral hypoglycemic agents or insulin therapy 65 patients Insulin Glargine OD + supplimental insulin Glulisine 65 patients Sliding scale regular insulin 4 times daily

5. Methodology Discontinue oral antidiabetic drugs on admission Starting total daily dose (TDD): 0.4 U/kg/d x BG between 140-200 mg/ dL 0.5 U/kg/d x BG between 201-400 mg/ dL Half of TDD as insulin glargine and half as rapid-acting insulin ( lispro , aspart , glulisine ) Insulin Glargine - once daily, at the same time/day. Rapid-acting insulin- three equally divided doses 5

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7. Conclusion 7 The percentage of patients within the mean glucose target (140 mg/dl) was 66% in patients treated with Glargine and Glulisine versus 38% in those treated with SSI Basal bolus regimen is best for the better glycemic control in non-critically ill in-patients No difference in hypoglycemia ( 3% of patients in each arm)

8. BASAL BOLUS REGIMEN Basal bolus regimen involves taking a longer acting form of insulin to keep blood glucose levels stable through periods of fasting and separate injections of a shorter acting insulin to prevent rises in blood glucose levels resulting from meals . 8

9. BASAL INSULIN It is also know as background insulin, is to keep blood glucose levels at consistent level during periods of fasting. It is needed to keep blood glucose level under control and allow the cells to take in glucose for energy. Body needs a basic amount of insulin all the time - day and night - even between meals. This is called ‘basal ’ insulin. It helps control blood glucose at times when not eating but body still needs energy . The amount of insulin you require can vary due to changes in the food you eat and activity or exercise you undertake 9

10. It is usually taken once or twice a day depending on the insulin. Basal insulin - act over a long period of time and therefore it will either long acting or intermediate acting. Types of basal (long acting) insulin Intermediate acting insulin – e.g. Insulatard or Humulin I Long acting insulin – e.g. Glargine ( Lantus ) or Detemir ( Levemir ) 10

11. BOLUS INSULIN A bolus dose is insulin that is specifically taken at meal time to keep blood glucose level under control following a meal. Bolus insulin acts quickly. Eg ; short acting or rapid acting It is often taken before meals. When you eat a meal your blood glucose level rises as carbohydrate food is turned into glucose. Insulin helps glucose move from the blood stream into the body cells to make energy. You need ‘bolus ’ insulin to cope with the rise in glucose level after meals. 11

12. Types of bolus (short acting) insulin Short acting insulin such as Actrapid or Humulin S should be given 20-30 minutes before a main meal. Rapid acting insulin such as Novorapid , Humalog, and Apidra can be given immediately before or immediately after main meals . 12

13. Advantage of basal bolus regimen It matches how our own body would release insulin It allows flexibility as to when meals are taken. Disadvantage of basal bolus regimen More insulin injection per day Basal bolus regimen in type 1 diabetes Basal bolus regimen in type 2 diabete s Rapid acting insulin at meal time & long acting insulin once or twice a day Short acting & intermediate acting or rapid acting and long acting insulin 13

14. CALCULATING TOTAL DAILY INSULIN Calculate starting basal and bolus doses of insulin by working out the patient’s total daily insulin dose (TDD) requirements. Current diabetes treatment Total initial daily insulin dose Diet 0.3 units/kg Oral / injectable agents 0.3 units/kg > Underweight Older age Hemodialysis 0.4 units/kg > Normal body weight 0.5 units/kg > Over weight 0.6 units/kg > Obese Insulin resistant 14

15. Examples 80kg patient diet-controlled TDD = 0.3 x 80kgs = 24 units 90kg patient taking metformin and gliclazide TDD = 0.4 x 90kgs = 36 units 15

16. CALCULATING BASAL-BOLUS SPLIT Glargine (basal) - Write up 50% of calculated total daily insulin dose as the glargine (basal) dose . Rapid insulin with meals (bolus) - 50% of the calculated total daily insulin dose divided into 3 equal doses of rapid acting insulin ( Humalog or NovoRapid ) with meals. Correctional rapid insulin (bolus) - rapid acting insulin given in addition to meal time bolus. 16

17. CALCULATING A CORRECTION DOSE If a patient’s blood glucose level rises above a pre-determined value, he or she may need an insulin bolus to bring it down. Calculating the supplemental dose is a 2-step process. First, an insulin sensitivity factor (ISF) is calculated; then, the desired blood glucose level is subtracted from the actual blood glucose reading and divided by the ISF. ISF determines how much the blood sugar will drop in response to 1 unit of insulin . 17

18. Step 1 Divide 1500 by the total daily dose ( eg , 30 units) 1500/ 3 0 = 50 (ISF) [regular insulin : factor is 1500 Rapid acting insulin : factor is 1800] Step 2 Subtract the desired blood glucose level (110 mg/ dL ) from the actual blood glucose reading ( eg , 240 mg/ dL ) and divide by the ISF 240 – 110/50 = 2.6 additional units 18

19. Example of Correction dose of Insulin 19 ACTRAPID 150 scale (FBS; Insulin dose) ACTRAPID 200 scale (FBS; Insulin Dose) <150 – NO INSULIN 151-200 ; 2 Units 201-250 ; 3 units 251-300 ; 4units 301-350 ; 6 units 351-400 ; 8 units > 400 ; 10 units <200 - NO INSULIN 201-250 ; 2 units 251-300 ; 3 units 301-350 ; 4 units > 350 ; 5 units

20. ADJUSTING INSULIN DOSES: EXAMPLES General principles Before adjusting doses review any clinical changes to the patient which may influence insulin requirements E g infection is improving, appetite returning or increasing mobility. If there is hyperglycaemia - Dose increases are generally between 10-25%. If there is hypoglycaemia - Reduce the appropriate insulin by 20-25%. All Blood Glucose Level’s (BGL) consistently high - Indicates not enough basal insulin, suggest increasing the glargine dose. 20

21. ADJUSTING INSULIN DOSES: EXAMPLES Fasting BGL - the only insulin impacting on this BGL is the G largine . There will be no impact from the rapid acting insulin administered at tea time the night before. high fasting BGL - increase evening G largine dose low fasting BGL - decrease evening G largine dose Lunchtime BGL - mainly influenced by the breakfast rapid acting insulin dose. high BGL before lunch - increase breakfast rapid acting insulin low BGL before lunch - decrease breakfast rapid acting insulin 21

22. ADJUSTING INSULIN DOSES: EXAMPLES Teatime BGL - mainly influenced by the lunch time rapid acting insulin dose. high BGL before tea - increase lunch rapid acting insulin low BGL before tea - decrease lunch rapid acting insulin 21: 00 hours BGL - mainly influenced by the teatime rapid acting insulin dose. high BGL at 21:00 - increase teatime rapid acting insulin low BGL at 21:00 - decrease teatime rapid acting insulin 22

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24. Carbohydrate counting It is one of many meal planning options for managing blood glucose levels, most often used by people who take insulin twice or more times a day. It gives you more choices and flexibility when planning meals. It involves counting the number of carbohydrate grams in a meal and matching that to your dose of insulin. A food that contain 15 grams of carbohydrate is called “one carb serving” Eg : one slice of bread, a small slice of fruit have around 15 grams of carbohydrate. 24

25. Counselling points 25

26. Importance of rotation of injection sites Insulin should not be injected at a site more than one month Repeated injection at the same site in the body Accumulation of extra fat at the site Improper absorption of insulin Improper glycemic control 26

27. Lipohypertrophy 27

28. Storage Storage of insulin is very important More chances of error in storage of insulin insulin_stability_chart.pdf F or short term travelling you can take the vial from fridge in a polythene cover with ice cubes (max 3 hrs) 28

29. General counseling points Don’t use insulin if any particles or any turbid appearance. Don’t use needle more than 3 times. Don’t keep the finger at the top of the needle or insulin pen during injection. Don’t immediately remove the needle or insulin pen after injection. If any symptoms of hypoglycemia occurs like palpitation, shaking limbs , excessive sweating, dizziness, you should immediately take some sugar (4 tea spoons). Keep some chocolate and the glucometer with you while travelling. 29

30. Fruits in Diabetes Can take 2 slices of water melon 2 slices of papaya Guava Apple Orange Musambi Can’t take Sapota Banana Dates Mango 30

31. Reference Umpierrez G.E, Smiley D, Zisman A, Prieto.L.M , Palacio A , Mceron A, Puig A, et al; Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT 2 Trial ); Diabetes Care 30:2181–2186, 2007 31

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