RUSH INPATIENT DIABETES
MANAGEMENT GUIDELINES
July 2004
2nd.ed
INITIAL ASSESSMENT OF THE
HYPERGLYCEMIC PATIENT
Preexisting Diabetes
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What types of insulin or oral agents?
What are the doses and the dose timing?
How has the blood glucose been at home?
When was diabetic therapy last taken?
New Onset Hyperglycemia
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Is it TYPE 1 or TYPE 2?
Younger age and ketones favor TYPE 1
Older age, FH of DM, overweight sugg. TYPE 2
Is there a provocation: infection or other stress?
Is there glucocorticoid Rx?
Is there hyper-alimentation?
INITIAL EVALUATION
 Check HBA1C on all patients with hyperglycemia
ALWAYS MUST CONSIDER AND R/O DKA
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Nausea and vomiting are important clues for DKA
10% of DKA’s have glucose < 300
Check electrolytes; check serum acetone if HCO3<18
Acetone may initially be negative in DKA
If DKA is a possibility check an ABG
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Check BUN/Cr. Check U/A to look for proteinuria
Best test for proteinuria is urine microalbumin
Clinical estimation of left ventricular function is
important when assessing the suitability of
metformin or a glitazone
What is the IV fluid? Is the patient eating?
How insulin resistant is the patient ie. How much
overweight?
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PREPARED BY THE SECTION OF ENDOCRINOLOGY
INITIAL APPROACH TO NEWLY
DIAGNOSED DIABETIC INPATIENTS
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Check HBA1C and begin QID blood glucose testing
If type 2 with glucose 100-200’s and overweight then
begin metformin as long as serum creat. is normal.
Otherwise start with glyburide 1.25 mg or
glipizide 5 mg or glimiperide 1 mg QAM.
Doses can be increased every 24-48 hours in inpatients.
If the HBA1C > 8% then change to combination therapy:
sulfonylurea / metformin or metformin / glitazone.
If glucoses >300, insulin therapy is required
If noon or midnight give an initial dose of REG 5-10 SQ
At the next AM or PM meal begin mixed NPH and REG
The initial doses of REG insulin are the same BID, while
the AM dose of NPH is twice the PM dose.
Thus begin with the ratios:
N/R in AM = 2X/X and N/R in PM = X/X
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The first X = 5 units unless the pt. is obese or the
glucoses > 400 in which case begin with X = 10.
Dose Change Needed in
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Guided by Glucose at
PM NPH
6 AM
AM REG
NOON
AM NPH
6 PM
PM REG
11 PM
Twice daily at 8 AM and 6 PM review the responses of
the previous doses of NPH and REG and reformulate a
new X to aim all glucoses into the 100-200 range.
If glucose > 200 at noon: repeat the AM dose of REG
If glucose > 200 at 11PM: repeat 1/2 the PM dose of
REG. Double these if glucose > 300.
When recalculating the next dose of NPH, an intervening
dose of REG insulin is added to the preceding dose of
NPH, e.g. NPH 10 units at 8 AM and REG 5 units at 1
PM is counted as though NPH 15 units was given at 8AM
If the pt. is NPO missing breakfast then give NPH = X in
AM and REG = X with lunch. If both meals are missed,
then only give NPH = X in AM.
All diabetics need NPH = X BID when fasting.
INITIAL APPROACH TO PREEXISTING
DIABETIC INPATIENTS
If previously treated with oral agents:
If the initial blood glucose is in 100’s and pt. is eating,
continue the usual doses of agent(s). Exceptions:
ORAL AGENT
SULFONYLUREAS
HOLD IF
NPO
METFORMIN
INCR. SCr, DECR. BP, CHF,
IV CONTRAST
CHF
GLITAZONES
If HBA1C and subsequent glucoses are ok, continue oral(s).
If HBA1C is >7% then increase the dose of 1 drug or increase 1
drug to 2 drugs or 2 drugs to 3 drugs.
In general each oral agent can only lower HBA1C by 1-2%.
Thus a pt. with HBA1C of 12% on 2 agents will require insulin.
If previously treated with insulin:
If the pt. is eating then resume usual doses.
Increase or decrease by 25-50% if glucoses are high or low.
If NPO only give basal insulin = 1/2 NPH BID or all glargine.
SPECIAL SITUATIONS:
To change BID NPH to daily glargine give 80% of the total daily
dose of NPH as glargine QHS.
Glargine may not be mixed with other insulins.
Glargine based regimens will always need aspart/lispro insulin
given TID with meals if the pt. is a Type 1 diabetic.
Glargine is also useful if added to oral agent therapy in type 2
patients who have inadequate control.
QHS glargine is adjusted based on the next AM glucoses.
Insulin lasts much longer in dialysis patients. NPH is usually
given only once daily. Lispro/aspart are preferred over regular.
HIGH DOSE GLUCOCORTICOIDS:
Steroid therapy may create or aggravate hyperglycemia. Oral
agents are ineffective and NPH/REG insulin is usually required
BID, often at high doses.
Unlike methylprednisolone and dexamethasone, prednisone
given QAM only lasts ~20 hours and PM dosing of NPH
requires care to avoid AM hypoglycemia.
PARENTERAL OR ENTERAL NUTRITION:
Insulin is always required.An IV drip may be used. SQ NPH
may be given BID and REG is added BID until the doses of
NPH have been titrated up to goal.
REG insulin may also be added to bags of IV hyperalimentation.
If parenteral/enteral feeds suddenly become discontinued, then
begin IV D10W at twice the preceding rate to balance the
previous dose of NPH and avoid hypoglycemia.
DIABETIC KETOACIDOSIS
MANAGEMENT
CLINICAL SUSPICION: H/O DM, VOMITING
1. Check BMP, acetone, pH,
HBA1C
2. Begin IV fluids: 0.9NS bag #1
@ 1000 ml/hr, bag #2 @
500ml/hr.
3. DKA diagnosed if Ph < 7.30
and 2 out of 3 of the following
are present: HCO3 <18,
glucose > 300,
acetone-positive
TREATMENT PHASE
1. Begin IV insulin drip @ 0.1 unit/Kg/hr
2. Change IV fluids to 0.45NS @ 200ml/ hr for bags # 3,4
then 125ml/hr for bags # 5-8 liters
3. Begin with D5 fluids if initial
glucose level < 300
4. Remember that 10% DKA have
glucose <300
5. Change IV fluids to D5/. 45 when glucose <200
6. Check blood glucose every 1 hr
7. Check potassium every 2-3 hrs
8. Remember that IV insulin will
rapidly lower K+
9. Give KCL Q 3 HRS if serum K < 4.0
10. Check venous pH, BMP,
acetone every 6 HRS
TRANSITION TO SQ INSULIN
Must meet all 5 criteria
1.
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Tolerating PO fluids
Ready to eat breakfast 8 AM or supper 6 PM
Glucose < 300
Serum acetone- negative
Acidosis resolved: pH > 7.30, HCO3 >18
CALCULATE SQ DOSE
1. Stable dose of IV insulin infusion in last 2-3
hours = X units/hr
2. NPH = 8 times X
3. REG = 4 times X
4. Give the SQ insulin first, then stop IV
insulin 90 minutes later.
NON-KETOTIC HYPERGLYCEMIC
HYPEROSMOLAR SYNDROME
CLINICAL SUSPICION: often elderly, h/o DM,
neuro.changes, dehydration, often have infection
or other stress
Check BMP, acetone, ABG, HBA1C
serum osmolarity
Begin IV fluids: bag #1 0.9NS @ 500/hr
Bag #2 0.9NS @ 333/hr, bag #3 0.45NS @ 250/h
HYPEROSMOLAR SYNDROME: diagnosed
If glucose > 500, serum osmols >320,
acetone-neg, elev. Bun/Cr. c/w dehydration,
positive neurological changes.
Only begin IV insulin 0.1 unit/kg/hr after
pt. has received 3000 ml. IV in order to avoid
hypotension or arterial thrombosis.
IV bags # 4-5 @166/hr, bags # 6-8 @ 125/hr
Once glucose < 200, add D5 to IV fluids,
and decr. IV insulin to 0.05 units/kg/hr
Check glucose every 1-2 hrs, BMP Q 6 hours
TRANSITION TO SQ INSULIN:
Must be tolerating PO liquids, glucose < 300
Ready to eat @ 8 AM or 6 PM
NPH = 8 x IV insulin rate
Reg = 4 x IV insulin rate
D/C IV insulin 90 min later.
Continuous IV Insulin Infusion Protocol
Insulin infusion rates will be titrated to maintain glucose
levels between 80-120 mg/dl
Initial Titration Phase
Initial glucose 120-220
10 unit bolus and 2 units/hr.
Initial glucose more than 220
20 units bolus and 4 units/hr.
Subsequent glucose more than 140
Increase by 2 units/hr.
Subsequent glucose 120-140
Increase by 1 unit/hr
Maintenance Phase
Begin once glucose is <120 mg/dl
Glucose less than 60
Stop insulin drip and give 1 amp
D50% and resume insulin at 50% of
the previous rate when glucose is
more than 120
Glucose 60-80
Decrease by 25%/hr.
Glucose 80-120
Maintain or change
depending on trend
Increase by 25%/hr
Increase by 50%/hr.
Glucose 120-160
Glucose more than 160
or
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Glucose checks are q 1 hr until stable, then can be q 2 hrs
once the infusion rate remains unchanged for 2-3 hours
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Once the rate is stable over many hours, the glucose
checks may be decreased to every 3-4 hours as long
as there is no change in caloric intake or overall
condition.
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When patient is ready to transfer to SQ insulin, use
the following formula to calculate the first SQ dose
at 8 am or 6 pm:
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NPH = 8 X rate of IV insulin, and Regular =
4 X rate of IV insulin
Glargine = 20 X rate of IV insulin
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May discontinue IV drip 1-2 hours after SQ insulin
is given.
by 10 %