Inpatient Diabetes
Treatment Goals, Strategies, Safety
Amish A. Dangodara, MD, FACP
Professor of Medicine
Internal Medicine, Hospitalist Program
University of California, Irvine
School of Medicine
7.18.14
Disclosures
None
Case
Ms Dianne Beades is a 63 yo F admitted with (L) foot ulcer/cellulitis, not
responding to outpatient Abx. Weight 100 Kg. She is NPO for LE
angiogram.
PMHx: PVD s/p (L) distal tibial artery bypass, DM II, CRI
Meds: 70/30 insulin 70 units in AM, 30 units in PM, Metformin 1000 mg BID
(takes after breakfast & bedtime)
Labs: HgbA1c=11.4, glucose 325, BUN 20, creatinine 1.8
What is basal insulin [choose single best answer]?
A.
B.
C.
D.
E.
The NPH component of 70/30 insulin
The NPH component of 70/30 insulin PM dose only
Lantus insulin equivalent of NPH component of 70/30 insulin
Amount of insulin required for fasting state
The amount of insulin to which sliding scale is added
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Case
Ms Dianne Beades is a 63 yo F admitted with (L) foot ulcer/cellulitis, not
responding to outpatient Abx. Weight 100 Kg. She is NPO for LE
angiogram.
PMHx: PVD s/p (L) distal tibial artery bypass, DM II, CRI
Meds: 70/30 insulin 70 units in AM, 30 units in PM, Metformin 1000 mg BID
(takes after breakfast & bedtime)
Labs: HgbA1c=11.4, glucose 325, BUN 20, creatinine 1.8
In addition to holding Metformin, what should you do with insulin?
A.
B.
C.
D.
E.
Hold 70/30 and start sliding regular insulin scale q4h
Reduce 70/30 to 35 units in AM and 15 units in PM
Change 70/30 to Lantus 20 units/d & use corrective insulin scale q6h
Change 70/30 to Lantus 50 units/d & use corrective insulin scale q6h
Change to NPH 24 AM + 10PM & use corrective insulin scale q6h
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Home Insulin Treatment Strategy
Consolidated insulin:
 Schedule AC breakfast and dinner with combined long & short-acting
insulin with 2/3 total daily dose in AM and 1/3 total daily dose in PM :
Split NPH/Regular in any ratio and give mixed simultaneously
70/30 NPH/Regular
75/25 NPH/Regular
NPH treats both basal
50/50 NPH/Regular
Insulin Effect




AND nutritional needs
Reg
Reg
For consolidated
strategy, 50% NPH
estimates basal dose
NPH
B
L
NPH
D
HS
B
Meals
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Inpatient Diabetes Treatment
Consolidated insulin:
Consolidated Insulin
Glucose
Breakfast Lunch
Time
Reg
Dinner
NPH
Reg
8:00
B
12:00
18:00
NPH
21:00
D
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Inpatient Diabetes Treatment
Basal-Bolus insulin (Glargine):
Basal insulin for fasting & nutritional insulin for meals
Glucose
Breakfast Lunch
Analog
Analog
Dinner
Analog
Long-acting
Time
8:00
12:00
18:00
Nutritional Insulin
21:00
Basal Insulin
Umpierrez GE et al. [RABBIT-2 Trial] Diabetes Care 2007;30:2181-2186.
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Inpatient Diabetes Treatment
Basal-Bolus insulin compared to Consolidated insulin:
Basal-Bolus versus Consolidated
Glucose
Breakfast Lunch
Time
Analog
Reg
Analog
Dinner
Analog
NPH
Reg
8:00
12:00
18:00
Nutritional Insulin
NPH
Long-acting
21:00
Basal Insulin
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Inpatient Diabetes Treatment
Basal-Bolus Insulin (NPH):
Insulin Effect
 Dose NPH q8-12h depending on GFR = 50% TDD
 Analog insulin qAC for meals = 50% TDD
Analog Analog Analog
NPH
B
L
NPH
D HS
NPH
B
Meals
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Match Home Treatment Strategy to Basal
Home Treatment
1. Consolidated 70/30 insulin
BID dosing
2. Nighttime NPH basal insulin
and oral drugs
3. Basal-bolus insulin with long
and short acting insulins
4. Long-acting basal insulin and
oral drugs
Basal Insulin
A. Same dose of long-acting
insulin as home dose
B. Half dose of home longacting insulin
C. None of the above
Basal dosing has to do with insulin
STRATEGY, not the type of insulin!
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
What’s Wrong With Sliding Scale Alone?
•
In addition to holding Metformin, what should you do with insulin?
Corrective Insulin Dose
A.
Hold 70/30 and start sliding regular insulin scale q4h
Glucose
Insulin Level
241
6
264
4
223
185
2
Time q4 h
?
Units
180 - 200
2
201 - 250
4
251 - 300
6
301 - 350
8
351 - 400
10
>400
12
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
What’s Wrong With Using Home Dose To
Estimate Basal Dose?
Medication: 70/30 insulin 70 units in AM, 30 units in PM
•
In addition to holding Metformin, what should you do with insulin?
A.
B.
C.
D.
E.
Hold 70/30 and start sliding regular insulin scale q4h
Reduce 70/30 to 35 units in AM and 15 units in PM
Change 70/30 to Lantus 20 units/d & use corrective insulin scale q6h
Change 70/30 to Lantus 50 units/d & use corrective insulin scale q6h
Change to NPH 24 AM + 10PM & use corrective insulin scale q6h
Home
Hospital
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Glucose Regulation
1
3
2
2
3
4
2
1
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Normal Glucose Response to Meal
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Normal Pancreas Response to Meal
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Diabetes, Type II
NGT - normal glucose tolerance
T2DM - Type 2 Diabetes Mellitus
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Insulin Strategy: Goal Glucose = 140-180
Corrective Insulin
Severe Hyperglycemia
Insulin resistance or DM
180
Post-prandial Hyperglycemia
Nutritional Insulin
Insulin, GLP, Incretins
126
Fasting Euglycemia
Basal Insulin
Sliding
Scale
Insulin
Nutrition, Glycogenolysis, Insulin
80
Hypoglycemia
Hypoglycemia Tx
0
Cortisol, Epinepherine, Glucagon, Glycogenolysis
Basal-Bolus (Basal-Nutritional) Strategy
 D/C all home diabetic therapy
 Estimate initial Total Daily Dose (TDD):
 TDD = Weight (Kg) x 0.3 units/d for DM I
 TDD = Weight (Kg) x 0.4 units/d for controlled DM II (FBS<200)
 TDD = Weight (Kg) x 0.5 units/d for uncontrolled DM II
 Correct for renal clearance (adjusted TDD):
 GFR >50%, no change in TDD
 GFR 30 - 50%, reduce initial estimated TDD by 20-30%
 GFR <30%, reduce initial estimated TDD by 30-50%
 Basal-Bolus (Nutritional) dosing:
 Basal dose = 50% adjusted TDD (not needed if endogenous insulin ok)
 Nutritional dose = 50% adjusted TDD
 Bolus dose per meal = (Nutritional Dose)/(meals/d)
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Basal-Bolus (Basal-Nutritional) Strategy
Adjust dose after 24 hours:
 If zero events of hypoglycemia in past 24h and glucose >180:
 Increase adjusted TDD by 20%
 If one or more events hypoglycemia in past 24h:





Decrease adjusted TDD by 20% and consider holding nutritional insulin
Evaluate nutrition intake
Assess for nutrition-insulin mismatch
Assess for improving insulin resistance as acute illness improves
Assess for worsening renal function
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Inpatient Diabetes Treatment
Corrective insulin sliding scale:
 Schedule qAC & qHS if eating or q4 hrs if NPO or q6 hrs if NPO with
GFR < 30 using short-acting insulin: aspart, glulisine, humalog, regular
Insulin sensitive/Type 1:
Glucose at treatment goal
= 0 units
Glucose >goal - 180 = 2U
181 - 220 = 4 units
221 - 260 = 6 units
261 - 300 = 8 units
301 - 350 = 10 units
351 - 400 = 12 units
>400 = 14 units
Usual treatment/Type 2:
Glucose at treatment goal
= 0 units
Glucose >goal - 180 = 4U
181 - 220 = 6 units
221 - 260 = 8 units
261 - 300 = 10 units
301 - 350 = 12 units
351 - 400 = 14 units
>400 = 16 units
Insulin resistant:
Glucose at treatment goal
= 0 units
Glucose >goal - 180 = 6U
181 - 220 = 8 units
221 - 260 = 10 units
261 - 300 = 12 units
301 - 350 = 14 units
351 - 400 = 16 units
>400 = 18 units
Umpierrez GE et al. [RABBIT-2 Trial] Diabetes Care 2007;30:2181-2186.
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Mean Blood Glucose Levels During Insulin Tx
Blood Glucose Levels During Insulin Treatment
240
Blood glucose (mg/dL)
220
*
200
*
*
¶
¶
¶
¶
180
Regular ISS
160
140
Lantus + glulisine
120
100
* p<0.01
¶ p<0.05
Admit
1
2
3
4
5
6
7
8
9
10
Days of Therapy
< Day 3: P=0.06
Umpierrez GE et al. [RABBIT-2 Trial] Diabetes Care 2007;30:2181-2186.
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Basal–Bolus Insulin in Non-critically Ill Patients
• Treatment success
• Treatment failure
100%
75%
66%
50%
38%
25%
0%
Basal-Bolus
Sliding-Scale
Insulin
– One out of 5 patients using SSI
remained with BG >240 mg/dL and
switched to Basal-Bolus (Lantus®
+ Apidra®)
Blood Glucose (mg/dL)
with%BG <140
Patients
mg/dL,
– BG target of < 140 mg/dL was
achieved in 66% of patients on
Basal-Bolus (Lantus® + Apidra®)
and 38% regular insulin (SSI)
300
Sliding-Scale
Insulin Delivery
LANTUS® + APIDRA®
280
260
240
220
200
180
160
140
120
100
Admit 1
2
3
4
1
2
3
4
5
6
7
Days of Therapy
Adapted from: Umpierrez GE et al. [RABBIT-2 Trial] Diabetes Care 2007;30:2181-2186.
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Hypoglycemia
• Basal Bolus Group:
– 1,005 BG readings
– Two patients (3%) had BG < 60 mg/dL
– Four BG readings (0.4%) < 60 mg/dL
– No BG < 40 mg/dL
• Regular ISS:
– 1,021 BG readings
– Two patients (3%) had BG < 60 mg/dL
– Two BG readings (0.2%) < 60 mg/dL
– No BG < 40 mg/dL
• None of the episodes of hypoglycemia in either group were associated with
adverse outcomes
Umpierrez GE et al. [RABBIT-2 Trial] Diabetes Care 2007;30:2181-2186.
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Which Insulin Is Best For What Strategy?
Basal:
Analog Insulins:
(Glulisine)
(Lispro)
(Aspart)
GFR<30
-Lantus q24h
q24h
-Levemir q12h
q12h
-NPH q8h
q12h
Nutritional (Bolus):
-Analog qAC
qAC
-Regular qAC
qAC
(Glargine)
Nutritional (Continuous):
-Regular q4h
q6h
-Analog q4h
q6h
Corrective and/or NPO:
-Same as nutritional!
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
NPO (No Nutrition) Treatment




Hold nutritional insulin
Continue basal insulin
Continue corrective insulin
If no other carbohydrate (CHO) source:
 Start D5 (+/- saline) @ minimum 100 mL/h or D10 (+/- saline) @
minimum 50 mL/h
 Equivalent to 17 KCal/h or 408 Kcal/d
 Order prn hypoglycemia therapy
NPO - Hold Nutritional Insulin
Corrective Insulin
Severe Hyperglycemia
Insulin resistance or DM
180
Post-prandial Hyperglycemia
Nutritional Insulin
Insulin, GLP, Incretins
126
Fasting Euglycemia
Basal Insulin
Nutrition, Glycogenolysis, Insulin
80
Hypoglycemia
Hypoglycemia Tx
0
Cortisol, Epinepherine, Glucagon, Glycogenolysis
Inpatient Diabetes Safety
Hypoglycemia:
 Definition <80 :
 Glucose lower than desired treatment goal
 Clinically insignificant: Glucose 60 - 80
 Associated with either mild or no symptoms of hypoglycemia
 This level can be occasionally tolerated
 Clinically significant: <60
 Confirm with serum blood test
 Glucose 40 - 60, usually associated with significant symptoms of
hypoglycemia, including confusion and lethargy; avoid if possible
 Glucose <40, associated with lethargy, coma, possible permanent
parkinsonian dementia with extrapyramidal symptoms, and increased
mortality; goal would be to avoid 100% of the time
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Inpatient Diabetes Safety
Hypoglycemia Treatment:
 Clinically stable:
 Glucose 40 - 80, give meal first, then recheck q15 minutes until >70
 Give D50 IVP or glucagon if unable to take PO, start D5 or D10 until
>70
 Reduce nutritional insulin dose and corrective sliding scale dose by
20+ %
 Clinically significant:




Glucose <40, give D50 IVP and start D5 or D10-IVF
Hold all diabetic medications.
Once >70, use insulin sensitive corrective sliding scale @ >200
If corrective scale needed >2 times/24h, restart basal insulin at lower
dose
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Basal-Bolus (Basal-Nutritional) Strategy
 Remember this!:
 Inpatient goal: glucose 140 - 180
 I, II, rII, 0.3, 0.4, 0.5
(DM I, II, resistant II, use 0.3, 0.4, 0.5 units/Kg/d as TDD)
 GFR <50, adjustment 20-50% reduction of TDD
 50/50 basal to nutritional
(50% TDD = Basal, 50% TDD = nutritional)
 D5 @100 mL/h or D10 @ 50 mL/h if no nutrition source
 Forget this:
 Insulin sliding scale
 Estimating inpatient requirement based on home therapy
 Using last 24h IV insulin dose to estimate SQ insulin dose
Amish A Dangodara, MD, University of California, Irvine School of Medicine, Hospitalist Program
Questions?