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Inpatient Management of Diabetes Mellitus

Inpatient Management of Diabetes Mellitus. William Harper, MD, FRCPC Endocrinology & Metabolism Assistant Professor of Medicine, McMaster University. BS > 11.1 mmol/L. Renal threshold for glycosuria (normal GFR). Decreased WBC function Chemotaxsis Phagocytosis. Decreased Wound Healing.

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Inpatient Management of Diabetes Mellitus

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  1. Inpatient Management of Diabetes Mellitus William Harper, MD, FRCPC Endocrinology & Metabolism Assistant Professor of Medicine, McMaster University

  2. BS > 11.1 mmol/L Renal threshold for glycosuria (normal GFR) Decreased WBC function Chemotaxsis Phagocytosis Decreased Wound Healing

  3. Evidence to support Inpatient BS control? DIGAMI • 620 patients AMI, prior dx DM or BS > 11 mM • IV insulin gtt started @ 5 U/h • Titrated to keep BS 7-10.9 mM • Insulin IV > 24h  MDI > 3 months • No in-hospital mortality benefit. • Rx Increased hospitalization by 1.8d • 0.5% reduction HbA1c @ 3 months • @ 1 year % on Insulin: 72% Rx Group 49% Cntrl Group • 1 year mort: ARR 7.5% NNT 13 • 3.4 y mort: ARR 11% NNT 9

  4. Evidence to support Inpatient BS control? Leuven, Belgium Study • 1548 ICU patients (63% CV Sx) • If BS > 6.1 mM: Rx with IV insulin gtt & TPN +/- tube feeds • Start IV insulin @ 2-4 U/h, titrated to BS 4.4-6.1 mM • Ave insulin dose: Rx group 3.0 U/h Cntrl group 1.4 U/h • Once out of ICU relaxed treatment goal to < 11.1 mM • Mortality in ICU: ARR 3.4% NNT 29 • Mortality in-hospital: ARR 3.7% NNT 27 • Greatest reduction in mortality was sepsis-related. • Insulin Rx reduced: bacteremia, ARF needing HD, need for PRBC, critical illness polyneuropathy, duration of ventilation and length of stay in ICU • To what extent were benefits nutrition related as opposed to insulin related?

  5. Goals of Inpatient DM Management • “Avoid hypoglycemia and marked hyperglycemia” • Target BS: 7.0 - 11.0 mM (5.0 – 10.0 mM) • Avoid Hypoglycemia • Precipitating arrhythmia or other cardiac events • Inducing seizure, focal or cognitive defects periop • Avoid Marked Hyperglycemia (BS > 11.1 mM) • Treat (and avoid) DKA, HONC

  6. DM Inpatient Management • Eating • NPO: temporary (for a test or surgery) • NPO: prolonged

  7. DM Inpatient Management • Eating Diet (T2DM) OHA (T2DM) Insulin (T2DM and T1DM) • NPO: temporary (for a test or surgery) • NPO: prolonged

  8. Pathophysiology of T2DM _ Hepatic glucose output INSULIN + Blood glucose Peripheral Tissue Uptake diet

  9. Sites of Action of Currently Available Therapeutic Options MUSCLE ADIPOSE TISSUE LIVER PANCREAS GLUCOSE PRODUCTION Metformin Thiazolidinediones PERIPHERAL GLUCOSE UPTAKE Thiazolidinediones Metformin INSULIN SECRETION Sulfonylureas: Glyburide, Gliclazide, Glimepiride Non-SU Secretagogues: Repaglinide, Nateglinide INTESTINE GLUCOSE ABSORPTION Alpha-glucosidase inhibitors

  10. OHAs:

  11. TZD adverse effects • Edema • 4-5% of patients get mild-moderate edema • 15% if TZD used in combo with insulin • Mild anemia (dilutional) • Weight gain • Increase in subcutaneous not visceral fat • Myalgia (pioglitazone only) • Myalgia 5.4% pioglitaz. versus 2.7% placebo • Few patients with unexplained CK > 10x ULN • Contraindicated in class II, III and IV CHF • Contraindicated if ALT > 2.5x ULN or active liver disease

  12. Metformin • Contraindications: • Creatinine >133 uM (men), >124 uM (women), CrCl < 1.17 mL/s • CHF symptomatic (> NYHA class III, E.F. < 35-40%) • Liver failure • Alcoholism • Hypoxic respiratory condition • Active moderate to severe infection • Radiocontrast or Surgery with GA: • Hold metformin for 24-48h • Restart after documented preservation of renal function

  13. Metformin • Side effects: • Lactic acidosis (metformin 0.03 cases/1000 patient years) • Phenformin 10-20X higher rates of lactic acidosis • GI: diarrhea, flatulence, abdominal discomfort • Usually disappear within 2 weeks • Dose dependent: avoided by slow titration & in some cases dose reduction • 5% of patients can’t tolerate metformin due to GI S/E’s • Starting dose: 500 mg with largest meal (prevent GI S/E’s) • Increase by 500 mg increments q1-2 wk • Maximal hypoglycemic affect: 1000 mg bid

  14. Insulin

  15. BIDS Therapy • T2DM: “Introduction to insulin” • Keep on OHAs • Start NPH 0.2 U/kg SC qhs • Increase by 2-4 U q4d until FBS 4-7 • If dose > 30-40U or if BS high late in day despite OK FBS than split into 2 injections with 2/3 acB and 1/3 qhs

  16. Starting Insulin Regimen • TDD = 0.5-0.7 U/kg • “2/3, 1/3” Regimens • 2/3 of TDD acB, 1/3 acD • 2/3 of TDD as Long-acting, 1/3 as short acting • Pre-mix: acB 30/70 acD 30/70 • MDI Regimens • 2/3, 1/3 Regimen: move acD long acting to qhs • i.e. acB N, H acD H qhs N • ac meals H qhs N (bolus 60%, basal 40%) • ac meals H UL q12h (bolus 50%, basal 50%)

  17. Insulin Regimens acB acL acD qhs Bedtime NPH (+/-bids) N NPH bid N N 30/70 bid 30/70 30/70 MDI (3 injections) H + N H N MDI (>4 injections) H (+/-N) H H N MDI (>4 injections) H + UL H H UL CSII (Insulin Pump)

  18. NEJM 347:1342-9

  19. Surgeon: ? Internal Medicine: ? Endocrinologist: ?

  20. Surgeon: Give 5 U Regular SC now Internist: ? Endocrine: ?

  21. Surgeon: Give 5 U Regular SC now Internist: Increase qhs N to 12 tonight and acB R to 12 tomorrow Endocrine: ?

  22. Surgeon: Give 5 U Regular SC now Internist: Increase qhs N to 12 tonight and acB R to 12 tomorrow Endocrine: Increase qhs N to 12 start tonight Decrease acB N15 R7 starting tomorrow AM Check 3AM BS tonight

  23. Guideline for Insulin Adjustments • Adjust the insulin that accounts for the high or low reading. • Always compare an abnormal BS reading with the one previous. • If insulin dose is: • Less than 8U, adjust by 1U • 8-20U, adjust by 2U • > 20 U, adjust by 10% (increase), 20% (decrease) • Don’t forget to compensate for a successful adjustment

  24. SC Insulin Supplemental Scale

  25. DM Inpatient Management • Eating • NPO: temporary (for a test) • NPO: prolonged

  26. NPO for a test: T2DM on Diet Rx or OHA • Schedule test for the AM • Hold OHAs on AM of test • CBG @ 7AM: < 3.0 Consider postpone test 3.1-4.0 IV D5W gtt @ 75-100 cc/h 4.1-11.0 Proceed with test, no Rx necessary > 11.1 Insulin R or analogue SC supplemental or IV insulin gtt & IV D5W gtt @ 75-100 cc/h > 20.0 Check urine ketones, consider postpone test

  27. Insulin IV gtt • Add 50 U of Human regular insulin (Humulin R or Novolin Toronto) to 500cc D5W (1U/10cc). • Flush & discard first 50cc. • Infuse insulin solution by IVAC (intravenous infusion pump), piggybacked into D5W running at 100cc/h. • Start insulin @ 0.9 U/h (9cc/h) or start at a rate dependent on patient’s insulin dose: IV insulin gtt rate = ( ½ TDD ) / 24

  28. Insulin IV gtt CPG q1h x 2, then q2h: Adjust Insulin IV infusion rate as per scale below: < 4.0 Call MD 4.1-6.0 0.5 U/h (5cc/h) 6.1-8.0 1.0 U/h (10cc/h) 8.1-10.0 1.5 U/h (15cc/h) 10.1-12.0 2.0 U/h (20cc/h) 12.1-15.0 2.5 U/h (25cc/h) 15.1-18.1 3.0 U/h (30cc/h) 18.1-22.0 3.5 U/h (35cc/h) > 22.1 Call MD

  29. NPO for a test: T1/T2DM on Insulin • Schedule the test for the AM • Hold AM Insulin on day of test • CBG @ 7AM: < 3.0 Consider postpone test 3.1-11.0 Give ½ of total AM insulin dose as NPH SC IV D5W gtt @ 75-100 cc/h > 11.1 IV insulin gtt & IV D5W gtt @ 75-100 cc/h > 20.0 Check urine ketones, consider postpone test

  30. DM Inpatient Management • Eating • NPO: temporary (for a test) • NPO: prolonged • Patient put on D5W if not on feeds or TPN • IV insulin gtt • SC NPH or UL q12h (+/- supplemental scale) • Starting dose 0.2 U/Kg q12h

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