Canadian Diabetes Association Clinical Practice Guidelines In-Hospital Management of Diabetes

1. Canadian Diabetes Association Clinical Practice GuidelinesIn-Hospital Management of Diabetes Chapter 16 Robyn Houlden, Sara Capes, Maureen Clement, David Miller

2. In-hospital Management Checklist 2013 • CONTINUE pre-hospital diabetes regimen if appropriate, otherwise … • USEinsulin as the treatment of choice • DO NOT use sliding scale insulin alone • DO use BASAL + BOLUS + CORRECTION insulin regimen • AVOID hypoglycemia

3. In-hospital Hyperglycemia is Common Hyperglycemia Approximately 1/3 of in-patients have been found to have hyperglycemia Many have pre-existing diabetes prior to admission

4. Hyperglycemia and Acute Ilness Inzucchi SE. NEJM2006;355;1903

5. Adverse Effects of Hyperglycemia Hyperglycemia Increases risks of postoperative infections and delirium Prolonged hospital stay, resource utilization Increased renal dysfunction and renal allograft rejection in transplant

6. In-hospital Glycemic Targets CABG = coronary artery bypass graft; IV = intravenous; Intraop = intraoperative; periop = perioperative

7. Sliding Scale Alone is Inefficient In the absence of routine insulin, sliding scale insulin regimen (bolus insulin on a prn basis) is purely reactive rather than proactive and allows for hyperglycemia to occur before responding QuealeWS. et al. Arch Int Med1997;157

8. 6.0 Sliding Scale Insulin Alone Results in Variable Glucose Control 16.5 What do you do? BG (mmol/L) What do you do? +6 U +4 U 14.0 Sliding Scale alone 10.0 6.0 4.0 What do you do? What do you do? 0 U 0 U 3.0 Breakfast Lunch Dinner Bedtime Bolus insulin QID QID: four times daily; SSI: sliding-scale insulin; BG: blood glucose

9. Use BASAL + BOLUS + CORRECTION In-hospital circumstances may warrant temporarily holding other antihyperglycemic medications (eg. renal or hepatic impairment) Insulin = treatment of choice BASAL + BOLUS + CORRECTION BOLUS + CORRECTION Insulin BASAL Breakfast Lunch Dinner

10. 6.0 BASAL + BOLUS + CORRECTION Results in Smoother Glycemic Control 6+2 U Correctional Insulin AC meals What do you do? 12.0 10.0 6+0 U What do you do? What do you do? 6.0 6.0 What do you do? 4.0 18U 6+0 U Breakfast Lunch Dinner Bedtime Basal insulin 6U 6U 6U ROUTINE Bolus insulin Routine Basal

11. Basal-Bolus (BBI) Regimen Achieves Better Control than Sliding Scale (SSI) Alone RABBIT 2 RABBIT 2 Surgery 13.3 13.3 * 12.2 11.1 * 11.1 * SSI SSI * * ¶ 10.0 ¶ ¶ 10.0 ŧ ¶ ŧ † Blood glucose (mmol/L) 8.9 † 8.9 7.8 7.8 6.7 *p < 0.01; ¶p < 0.05. BBI *p < 0.001, ŧp = 0.02, †p = 0.01 BBI 6.7 5.6 Admit 1 2 3 4 5 6 7 8 9 10 Randomi-zation 1 2 3 4 5 6 7 8 9 Duration of treatment (days) Duration of treatment (days) Adapted from: Umpierrez GE, et al. Diabetes Care 2007;30:2181-86. Adapted from: Umpierrez GE, et al. Diabetes Care 2011;34:256-61.

12. Avoid Hypoglycemia • Protocols for hypoglycemia avoidance, recognition and management should be implemented with nursing-initiated treatment • Patients at risk of hypoglycemia should have ready access to an appropriate source of glucose at all times • Insulin protocols and order sets may be used to improve adherence to optimal insulin use and glycemic control

13. Recommendation 1 • Provided that their medical conditions, dietary intake, and glycemic control are acceptable, people with diabetes should be maintained on their pre-hospitalization oral anti-hyperglycemic agents or insulin regimens[Grade D, Consensus]

14. Recommendation 2 • For hospitalized patients with diabetes treated with insulin, a proactive approach that includes basal, bolus, and correction (supplemental) insulin, along with pattern management, should be used to reduce adverse events and improve glycemic control, instead of the reactive sliding-scale insulin approach that uses only short- or rapid-acting insulin [Grade B, Level 2]

15. Recommendations 3 and 4 • For the majority of non critically ill patients treated with insulin, pre-meal BG targets should be 5.0 to 8.0 mmol/L in conjunction with random BG values <10.0 mmol/L, as long as these targets can be safely achieved [Grade D, consensus] • For most medical/surgical critically ill patients with hyperglycemia, a continuous IV insulin infusion should be used to maintain glucose levels between 8.0-10.0 mmol/L [Grade D, consensus] 2013 2013

16. Recommendations 5 and 6 • To maintain intraoperative glycemic levels between 5.5-10.0 mmol/L for patients with diabetes undergoing CABG, a continuous IV insulin infusion protocol administered by trained staff, [Grade C, Level 3]should be used • Perioperativeglycemic levels should be maintained between 5.0-10.0 mmol/L for most other surgical situations, with appropriate protocol and trained staff to ensure safe and effective implementation of therapy and to minimize the likelihood of hypoglycemia [Grade D, Consensus] 2013

17. Recommendation 7 2013 • In hospitalized patients, hypoglycemia should be avoided: • Protocolsfor hypoglycemia avoidance, recognition and management should be implemented with nurse –initiated treatment, including glucagon for severe hypoglycemia when IV access is not readily available [Grade D, consensus] • Patients at risk of hypoglycemia should have ready access to an appropriate source of glucose (oral or IV) at all times, particularly when NPO or during diagnostic procedures [Grade D, Consensus]

18. Recommendation 8 and 9 2013 • Healthcare professional education, insulin protocols and order sets may be used to improve adherence to optimal insulin use and glycemic control [Grade C, Level 3] • Measuresto assess, monitor, and improve glycemic control within the inpatient setting should be implemented, as well as diabetes-specific discharge planning [Grade D, Consensus]

19. CDA Clinical Practice Guidelines http://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca – for patients