Transcript Document

Thursday School
2013
Management of Inpatient Diabetes
and Hyperglycemia
Kendall Rogers MD CPE FACP SFHM
Associate Professor
Chief – Division of Hospital Medicine
Objectives For This Lecture
 Recognize the importance of good glycemic control for
hospital inpatients
 Appreciate the obstacles to achieving good glycemic
control in hospital patients
 Understand and apply the best practice of inpatient
hyperglycemia/diabetes management using
subcutaneous insulin, including the use of
anticipatory, physiologic insulin dosing in a variety of
clinical situations
 Review special cases including steroids and discharge
Case 1
56 year old woman with DM2 admitted with a diabetes-related
foot infection which may require surgical debridement in the
near future, eating regular meals.
- Weight: 100 kg
- Home medical regimen: Glipizide 10 mg po qd, Metformin
1000 mg po bid, and 20 units of NPH q HS
- Control: A recent HbA1c is 10%, POC glucose in ED 240
mg/dL
What are your initial orders?
 You put the patient on the ‘Insulin Order Set’ with the
reg diet checked, ‘moderate dose’ option with
nutritional and basal insulin ordered
 Write down:
 When will the CBGs be checked?
 Exactly what insulin is scheduled and at what times?
 If the patient is hypoglycemic, what will happen?
Managing Diabetes in the Hospital Presents Different
Challenges than Managing Diabetes in the Outpatient
Arena!
The hospital is associated with:
- Nutritional and clinical instability
- The need for changes from the home diabetes medical regimen
- Acute illness, “stress-related” hyperglycemia
- Use of medications that impact glycemic control
Why Should We Care?
 Hyperglycemia occurs frequently in hospital patients, and is
associated with poor outcomes
 Hypoglycemia occurs frequently in hospital patients, and is
unpleasant and dangerous
 Adequate metabolic control is an attainable goal for hospital
patients
Inpatient Glycemic Goals
GOOD
BAD
Hypoglycemia
<40
70
BAD
Somewhere in the Middle
110
140
170
Hyperglycemia
>200
Recommended Inpatient
Glycemic Targets
 Maintain fasting and preprandial BG <180 mg/dL
(ideal <140 preprandial, acceptable <180)
 Modify therapy for BG < 100 mg/dl to avoid risk for
hypoglycemia
 More stringent targets may be appropriate in stable
patients with previous tight glycemic control.
 Less stringent targets may be appropriate in terminally
ill patients or in patients with severe co-morbidities.
UNM Glycemic Goals
 If 2 readings >180 in 24 hours, diabetes is uncontrolled
and a change should be made to scheduled insulin
 Our definitions:
 >300 Severe Hyperglycemia
 180-299 Hyperglycemia
 100-180 Controlled
 <70 Hypoglycmia
 <40 Severe Hypoglycemia
Recommendations for Managing Patients
With Diabetes in the Hospital Setting
Antihyperglycemic Therapy
Insulin
Recommended
OADs
Not Generally
Recommended
IV Insulin
SC Insulin
Critically ill patients
in the ICU
Non-critically ill
patients
1. ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care. 2006 & 2009
2. Diabetes Care. 2009;31(suppl 1):S1-S110.
Considerations with non-insulin
therapies in the hospital
 Sulfonylureas are a major cause of prolonged hypoglycemia
 Metformin is contraindicated in patients with decrease




renal function, use of iodinated contrast dye, and any state
associated with poor tissue perfusion (CHF, sepsis)
Thiazolidinediones associated with edema and CHF
α glucosidase inhibitors are weak glucose lowering agents
Amylin and GLP1 agonists can cause nausea and exert a
greater effect on postprandial glucose
Time action profiles of oral agents can result in delayed
achievement of target glucose ranges in hospitalized
patients
What is the “Best Practice” for Managing Diabetes and
Hyperglycemia in the Hospital?
 Anticipatory, physiologic insulin dosing, prescribed as a
basal/bolus insulin regimen
 Giving the right type of insulin, in the right amount, at the
right time, to meet the insulin needs of the patient
 Not ‘Sliding Scale Insulin’
The Components of a
Physiologic Insulin Regimen
 Basal insulin
 Nutritional insulin
 Correctional insulin
The Components of a
Physiologic Insulin Regimen
 Basal insulin
 long-acting insulin required in all Type 1 (and most Type 2) patients to
maintain euglycemia by preventing gluconeogenesis
 Nutritional insulin
 scheduled short-acting insulin given just before a meal, in anticipation
of the glycemic spike that occurs due to carbohydrate ingestion (this
dose is given even when the blood sugar is in the normal range).
 Correctional insulin
 short-acting insulin that is given in addition to scheduled nutritional
insulin (or given at other times of the day) as a response to preexisting
high blood glucose levels
Physiologic Insulin Secretion:
Basal/Bolus Concept
Nutritional (Prandial) Insulin
Insulin
(µU/mL)
50
25
Basal Insulin
0
Breakfast
Glucose
(mg/dL)
150
Lunch
Supper
Nutritional Glucose
100
50
0
Suppresses Glucose
Production Between
Meals & Overnight
Basal Glucose
7 8 9 101112 1 2 3 4 5 6 7 8 9
A.M.
P.M.
Time of Day
The 50/50 Rule
Providing Exogenous Basal Insulin
 Long-acting, non-peaking insulin is preferred as it provides
continuous insulin action, even when the patient is fasting
 Required in ALL patients with type 1 diabetes
 Many patients with type 2 diabetes will require basal insulin in
the hospital
 Can be estimated to be about 1/2 of the total daily dose of
insulin (TDD)
Which Insulins are Best for
Basal Coverage?
Insulin Effect
NPH
Detemir (Levemir)
Glargine (Lantus)
Regular
Lispro (Humalog)
Aspart (Novolog)
Glulisine (Apidra)
0
6
12
Time (hours)
18
24
Providing Exogenous Nutritional Insulin
 Usually given as rapid-acting analogue (preferred in most
cases) or regular insulin, for those patients who are eating
meals
 Must be matched to the patient’s nutrition
 Should not be given to patients who are not receiving nutrition
(e.g. NPO)
 Can be estimated to be about ½ of the total daily dose of
insulin (TDD)
Which Insulins are Best for
Basal Coverage?
Insulin Effect
NPH
Detemir (Levemir)
Glargine (Lantus)
Regular
Lispro (Humalog)
Aspart (Novolog)
Glulisine (Apidra)
0
6
12
Time (hours)
18
24
Providing Exogenous Correctional Insulin
 Correctional insulin is extra insulin that is given to correct pre-
existing hyperglycemia
 Usually rapid-acting or regular insulin (usually the same as the
nutritional insulin)
 Often written in a “stepped” format that is used in addition to basal
and nutritional insulin
 Customized to the patient using an estimate of the patient’s insulin
sensitivity
 If correctional insulin is required consistently, or in high doses, it
suggests a need to modify the basal and/or nutritional insulin doses
A Stepwise Approach to Physiologic Insulin Dosing in
the Hospital
1.
Decide if patient is appropriate for the subcutaneous insulin
and discontinue oral anti-diabetic agents
2.
Calculate the estimated total daily dose (TDD) of insulin
3.
Determine the distribution of the TDD between basal and
nutritional insulin based on nutrition regimen.
4.
Re-evaluate & adjust the TDD daily based on the glycemic
control of the previous 24h
Step 1: Which Patients Should be Treated with a
Physiologic Insulin Regimen?
During hospitalization
 Any patient with blood glucose levels consistently above the target
range
Immediately at the time of admission
 All patients with type 1 diabetes
 Patients with type 2 diabetes if…
 They are known to be insulin-requiring
 They are known to be poorly controlled despite treatment with
significant doses of oral agents
 They are known to require high doses of oral agents that will be
held in the hospital
Indications for IV Insulin Therapy
 Prolonged fasting (>12 h)
in type 1 DM
 Critical illness
 Before major surgical
procedures
 After organ
transplantation
 DKA
 Labor and delivery
 Acute MI
 Other illnesses
requiring prompt
glucose control
ACE Position statement on inpatient diabetes 2004
Step 2: Estimate the Amount of Insulin the Patient Would
Need Over One Day, If Getting Adequate Nutrition = Total
Daily Dose (TDD)
 For patients already treated with insulin, consider the patient’s
preadmission subcutaneous regimen and glycemic control on that
regimen
 Weight-based estimate:
 TDD = 0.4 units x Wt in Kg
 Adjust down to 0.3 units x Wt in Kg for those with hypoglycemia risk factors,
including kidney failure, type 1 diabetes (especially if lean), frail/low body
weight/ malnourished elderly, or insulin naïve patients
 Adjust up to 0.5-0.6 units (or more) x Wt in Kg for those with hyperglycemia
risk factors, including obesity and high-dose glucocorticoid treatment
 Insulin drip-based estimate
Step 3: Decide Which Components of Insulin the Patient
Will Require, and Which Percentage of the TDD Each
Should Represent
 Basal insulin can generally be estimated to be 1/2 of the TDD
 Nutritional insulin makes up the remaining 1/2 of the TDD
STEP 3: Decide Which Components of
Insulin the Patient Will Require, and Which Percentage
of the TDD Each Should Represent
 In most cases, basal insulin should be provided
 In most cases, well-designed corrective insulin
regimens should be provided
 When a patient is not receiving nutrition, nutritional
insulin should not be given
 Nutritional insulin needs must be matched to the
actual nutritional intake
STEP 3: Assess the Patient’s Nutritional Situation
 Eating meals or receiving bolus tube feeds
 Eating meals but with unpredictable intake
 Getting continuous tube feeds
 Getting tube feeds for only part of the day
 Getting parenteral nutrition
 NPO
Examples for Initial Orders
 55 yo male presents with CBG 250, HgA1c of 9.5 on 30
lantus and metformin
 65 yo female with renal insufficiency presents on only
glipizide, HgA1c 7.9 with CBG of 145
 45 yo female presents with CBG of 320, HgA1c of 13.5
prescribed 85 units of lantus and 15 lispro each meal
 47 yo male no known history of DM with CBG of 240
in ER
Back to our patient
56 year old woman with DM2 admitted with a diabetesrelated foot infection which may require surgical
debridement in the near future, eating regular meals.
- Weight: 100 kg
- Home medical regimen: Glipizide 10 mg po qd,
Metformin 1000 mg po bid, and 20 units of NPH q HS
- Control: A recent HbA1c is 10%, POC glucose in ED 240
mg/dL
Initial Orders
 Stop orals
 Basal Insulin: 20-30 units
 Nutritional Insulin: 21-30 units (7-10 units each meal)
 Moderate dose correction scale
 Monitor for 24 hours and begin adjusting
Other answers
 When will the CBGs be checked?

Before each meal and at 9PM
 Exactly what insulin is scheduled and at what times?

Before each meal and at 9PM
 If the patient is hypoglycemic, what will happen?
STEP 4: Assess Blood Glucoses at Least Daily, Adjusting
Insulin Doses as Appropriate
 2 readings above 180 are consider uncontrolled
 Get your data
 Review current orders for insulin
 Check MAR for insulin administration for previous day
 Investigate meals and snacks
 Calculate correction scale usage
 There is no “autopilot” insulin regimen for a
hospitalized patient! Make a change.
STEP 4: Assess Blood Glucoses at Least Daily, Adjusting
Insulin Doses as Appropriate
 Hyperglycemia
 Use previous correction day scale and redistribute
 10/20/30/40 rule
 Adjust based on which values are elevated
 Hypoglycemia
 If hypoglycemic event, evaluate cause and adjust
 If under 100 back off insulin by 10%
Issues- It is not just about glycemic target
 Choice of initial regimen in the hospital.
 Poor glycemic control ignored/accepted.
 Reliance on sliding scale insulin.
 Inappropriate follow up of hypoglycemia.
 “Stacking” of insulin dosing.
 Communication between services.
 Inconsistent approach to insulin ordering
 Nurse to physician communication.
 Poor coordination of tray delivery, monitoring, and insulin
“Basal Plus”
“Basal Plus”
 New regimen proposed by Umpierrez
 If using less than .4 u/kg/day can consider .2 u/kg
basal without nutritional
 Must select the right patients:
 Known type 2 DM
 Diet controlled, on orals only or using <.4 u/kg at home
 No hepatic or renal impairment
 CBG <400 in hospital
 2 consecutive readings >240 or daily mean BG >240 were
switched to basal bolus
Dangers with Basal Plus
 Validating inappropriate use of only basal and
escalation into covering nutritional
 Risk of hypoglycemia
Special Situations
 Insulin Pump
 Steroids
 Discharge
Insulin Pump
 Some patients may remain on pump if self-managed
 Always consult endocrine
 If stopping pump, must be on subcutaneous or
intravenous insulin within 30 minutes
 Insulin pumps must be discontinued for an MRI. If the
pump is interrupted for more than one hour, another
insulin source needs to be ordered.
Steroids
 The majority of patients receiving > 2 days of
glucocorticoid therapy at a dose equivalent of at least
40 mg per day of Prednisone developed hyperglycemia
 No glucose monitoring was performed in 24% of
patients receiving high dose glucocorticoid therapy
Treatment on Steroids
 For patients without prior DM or hyperglycemia or
those with diabetes controlled with oral agents:
 Initiate glucose monitoring with low dose correction
insulin scale administered prior to meals
 For patients previously treated with insulin
 Increase total daily dose by 20 to 40% with start of
high dose steroid therapy
 Increase correctional insulin by one step
(low to moderate dose)
 Adjust insulin as needed to maintain glycemic control
Covering once daily prednisone
 If patient is taking basal/bolus already
 Continue same regimen
 Order prednisone as single AM dose daily
 Day 1 of prednisone: establish that prednisone
hyperglycemia occurs (cover with correction)
 Day 2: add AM dose of NPH and titrate up to cover
daytime hyperglycemia
 Use NPH does equal to ½ sum of correction for day 1
What to do at discharge?
 Transition to home begins at admission
 Identify, monitor, and treat all pts with hyperglycemia
 Draw HgA1c on all hyperglycemic pts
 Identify financial/social barriers to outpt management
 Involve DM educator (Cauleen) and SW early
 Do not automatically continue a hospital regimen as a
home discharge regimen
Use Admission HgA1c for DC
Identify barriers to DM
 Common social issues
 Poor home support
 Transportation issues
 Drug of etoh
 Common financial barriers
 No insurance
 High deductibles
Outpatient Meds
Discharge Summary
 Use HgA1c to predict needs
 Choose affordable treatment regimens
 Involve Cauleen for DC education
 Arrange follow-up for all uncontrolled pts
 Utilize DC3
DM Resources at UNM
 Cauleen Svanda, Inpatient DM educator
 Diabetes Comprehensive Care Center (DC3)
 Glycemic Control Nurse Practitioner
 UNM Hospitalist Wiki Site – type ‘glycemic control’
Powerchart
 Order Set
 Cache List
 Insulin Dynamic Dashboard
Glycemic Control Points
 Above 180 twice is ‘uncontrolled DM’ and a change
needs to be made in insulin management
 Use of correction scale is sign of a treatment failure
 Uncontrolled DM should be on all 3 insulins
 Avoid clinical inertia, make changes to insulin
 Check MAR and administration times
Hypoglycemia
Severe Hyperglycemia
Kendall Rogers, MD
Case 1
56 year old woman with DM2 admitted with a diabetes-related
foot infection which may require surgical debridement in the
near future, eating regular meals.
- Weight: 100 kg
- Home medical regimen: Glipizide 10 mg po qd, Metformin
1000 mg po bid, and 20 units of NPH q HS
- Control: A recent HbA1c is 10%, POC glucose in ED 240
mg/dL
What are your initial orders?
Case 1: Solution
 Bedside glucose testing AC and HS
 Discontinue oral agents
 Total daily dose 100 kg x 0.6 units/kg/day = 60
 Basal: Glargine 30 units q HS
 Nutritional: Rapid-acting analogue 10 units q ac at the first bite of
each meal
 Correction: Rapid-acting analogue per scale q ac and HS (Note: Use
correctional insulin with caution at HS, reduce the daytime
correction by up to 50% to avoid nocturnal hypoglycemia)
 How would you alter this if the patient had renal failure?
Prior Day
Glucose
8 AM
Noon
Supper
Bedtime
254
295
238
291
Insulin
Lispro
Glargine
TDD
Total
18 u
18 u
16 u
8u
60 u
30 u
30 u
90 u
What is your next step?
 A. Continue the current regimen
 B. Increase the Basal insulin by 20 units
 C. Increase the Nutritional Insulin by 5 units/meal
 D. Increase the Basal by 15 units and the Nutritional by
15 units (5 with each meal)
 E. Increase the Basal by 10 units and the Nutritional by
6 units (2 with each meal)
Prior Day
Glucose
8 AM
Noon
Supper
Bedtime
254
295
238
291
Insulin
Total
Lispro
Mealtime
10 u
10 u
10 u
Lispro
Correctional
8u
8u
6u
Glargine
TDD
30 u
8u
30 u
30 u
30 u
90
Case 1 Continued…
The patient is made NPO after midnight for a bone biopsy, but is
expected to be able to resume her diet at lunch or dinner the next
day.
What changes would you make to her management program
regarding glucose monitoring and her insulin program?
Case 1 continued: Solution
 Change bedside glucose checks to q 4 hours, as the patient will not
be eating meals
 Continue basal insulin: If using glargine, continue as is. If using
NPH, continue in equal twice daily doses with a dose reduction of
1/3-1/2 while NPO.
 Hold nutritional insulin while NPO
 Continue appropriate correctional insulin for hyperglycemia
Case 2
 58 yo M admitted to Vascular surgery team for amputation
of RLE for dry gangrene. Medicine consulted on POD #3
for diabetic management. At home he is on max doses of
metformin and glyburide and glargine 15 units at bedtime.
His HgA1c this admission is 9.2 and there is a question
about his compliance in PCP notes. He is on regular SSI
and glargine 15 units at bedtime
Case 2 Continued
POD 1:
POD 2
 AM CBG: 85
 AM CBG: 182
 Noon CBG: 248
 Noon CBG: 255
 Dinner CBG: 166
 Dinner CBG: 72
 Bedtime CBG: 287
 Dinner CBG: 207
 SSI given 12 units
 SSI given 12 units
Case 2 Continued
 What would you do next?
A) Divide total daily dose into 50/50 basal and bolus
B) Yell at Vascular surgery for using SSI
C) Gather more information on meal intake, time of
CBG measurements and insulin administration
D) Continue with current regimen one more day to
gather more data
Case 2 Explanation
 Answer is C
 Gather more information on meal intake, time of CBG
measurements and insulin administration
 Patient with labile CBGs, but good response to insulin.
With history of non-compliance he maybe not eating
or snacking in between meals. CBG time and insulin
administration may also play an effect. Before dividing
CBG 50/50 you need to gather more data. You can
make changes to insulin regime after you gather more
data.
Case 2 Continued
 His CBGs in POD #1 and 2 are the following
 POD 1:
 AM CBG: 85, no insulin given, day prior glargine was given
 Noon CBG: 248, 4 units
 Dinner CBG: 166, 2 units
 Bedtime CBG: 287, 6 units given, glargine held
 POD 2
 AM CBG: 182, 2 units given
 Noon CBG: 255, 6 units given
 Dinner CBG: 72, no insulin given
 Dinner CBG: 207, 4 units insulin and 15 units glargine given
Case 3
56 year old woman with type 1 diabetes admitted with a diabetesrelated foot infection. The wound is an infected ulcer on the fifth digit
with necrosis. The plan is for amputation first thing in the morning, so
the patient will be NPO after midnight. However, she is expected to
resume a regular diet at lunch the following day after surgery.
- Weight: 70 kg
- Home medical regimen: 70/30 insulin 14 units BID
- Control: A recent HbA1c is 9%, POC glucose in ED is 240 mg/dL
It is now dinner time, and the patient took her last dose of insulin
before breakfast. What insulin would you give her now (before dinner)
and how would you modify her regimen given the plan for NPO after
midnight?
Case 3: Solution
 Bedside glucose testing AC and HS while eating, and q 4 hours when NPO
 TDD by weight = 70 kg x 0.4 units/kg/day = 28 units
 Her home TDD is 28, but patient has very poor control on this regimen, so
increase (arbitrarily) by 20% = 34 units
 IV dextrose infusion while NPO (e.g. D5 at 75-150 cc/hr)
 Basal: Glargine 17 units q HS
 Nutritional: Rapid-acting insulin 6 units q ac at the first bite of each meal
 Correction: Rapid-acting insulin per scale q ac and HS
Case 4
 77 yo 100kg M with COPD and T2DM is admitted for
syncopal episode and pyelonephritis. He reports being
clammy and shaky prior to passing. Per EMS CBG was
50. He is from Alabama and uses 70/30 80 units in am
and 20 units at bedtime. He takes his meds as
prescribed, but has had poor appetite during the past
several days. Does not remember his HgA1C. What
insulin regimen would you place him on?
Case 4
A) Continue home dose of insulin
B) Calculate TDD based on weight and place patient on
glargine and short acting insulin
C) Place on SSI and monitor CBGs for 24 hours
D) Call Kendall or Pejvak
E) None of the above
Case 4 Explanation
 Answer: none of the above
 First correct hypoglycemia
 Once normalized, consider 20u of basal with
correction scale, no nutritional until eating well. Then
you can place on nutritional and correctional insulin.
Basal glargine insulin has much lower incidence of
hypoglycemia than NPH
Case 5
You are consulted by the neurology service for diabetes management
on a 79 y/o M who suffered a large stroke, leaving him with severe
dysphagia. He has type 2 diabetes, on maximum doses of metformin,
glipizide, and rosiglitazone at home. A PEG was placed and he is up to
his goal of 60 cc/hr on continuous tube feeds, but is now
hyperglycemic (see next slide).
- Weight: 100 kg (BMI 35)
- Current medical regimen: “High” sliding-scale (orals all held)
- Control: Glucoses consistently in the mid to high 200’s, a recent HbA1c
is 9.6%
What insulin regimen will you choose? Does the distinction between
basal and nutritional insulin still make sense with continuous feeding?
Case 5: Solution
 TDD = 100 x 0.6 units/kg/day = 60 units
 Provide this TDD to meet basal and continuous nutritional
insulin requirements
 There is no scientific evidence suggesting one way is better than
another
 Examples:







Glargine 60 units daily
Glargine 24 units daily (basal) + rapid-acting insulin 6 units q4 hrs (nutritional)
Glargine 24 units daily (basal) + regular 9 units q6 hrs (nutritional)
70/30 20 units q8 hrs
Regular insulin 15 units q6 hrs
Rapid-acting insulin 10 units q 4 hrs
Other combinations
How would you manipulate this
patient’s insulin as you initiate tube
feeds?
 Bolus feeds TID
 Nocturnal Tube Feeds
Case 6
 62 yo M with COPD is admitted with increased cough,
sputum production and green/thick sputum. CXR
consistent with pneumonia. He is started on
ceftraixone, doxy, duonebs and prednisone 60mg/day.
He does not have diabetes, but he reports that during
prior hospitalizations and with steroid use he has
“needed insulin injections.” What would you do next?
Case 6 Answers
A) Calculate TDD insulin and place on Glargine and
Aspart
B) Place on SSI and monitor CBGs for 24 hours and
change to basal/bolus after 24 hours
C) Given infection and taper of steroids, monitor CBGs
and put on correction insulin
D) Do nothing
Case 6 Explanation
 Answer C then maybe B
 Patient has an acute infection and is on steroids. This
combination leads to increased CBGs. However, as
infection is treated and steroids tapered, his insulin
requirement will decrease. This could lead to
unpredictable CBGs and increased risk of
hypoglycemia on basal/bolus protocol. Treating
increased CBGs shortens hospital stay. If 2 CBGs are
above 180 daily, consider using basal/bolus protocol
Case 6 Part 2
 Patient did well and after 3 days of treatment is ready
to be discharged on 14 day taper of steroids. Currently
he is on 40mg prednisone and required 4 units of
insulin yesterday. Would you discharge this patient in
insulin?
A) Yes
B) No
Case 6 Part 2 Explanation
 Answer is B) NO
 Patient is not used to using injectable insulin and
there is no indication to start him on oral glycemic
meds as he has not have a diagnosis of DM. In
addition, as mentioned previously, as prednisone is
tapers his CBGs will decrease to more normal range
and he is at increased risk for hypoglycemia.
Case 7
 52 yo male, no previous history of dm, admitted for
CAP with an O2 requirement, his admission cbg is 210
 Wt 60kg
 What orders would you write?
 What if the patient had known DM was on 1 oral agent
with relatively good control?
Case 8
 53 yo M with DM, HTN and CAD is admitted for
unstable angina to the VAMC. At home he takes NPH
30 units QAM and 30 units QPM, in addition to sliding
scale regular insulin. He reports good CBG control at
home and uses 7-10units of insulin prior to meals. His
last HgA1c is 6.8. He is NPO for possible cardiac cath
in the morning. What regimen would you place him
on?
Case 8 Answers
A) Calculate TDD and place on 50/50 basal bolus
insulin and correctional insulin
B) Decrease NPH by 50% and place on correctional
insulin while NPO
C) Continue home NPH and correctional insulin
D) Convert total home insulin use to glargine and aspart
insulin premeal and correctional insulin
Case 8 Explanation
 Answer is B
 Patient has good control with NPH at home with
HgA1c at goal. Due to increased ease of transition from
inpatient to outpatient diabetes management, NPH
should be continued. However, NPH has increased
risk of hypoglycemia if patient is NPO. Dose should be
decreased by 1/3 to 1/2 if patient is NPO. Since patient
is not eating, his CBGs can be monitored per protocol
and treated with correctional insulin while NPO. Once
patient is eating, he can be placed on home NPH dose,
premeal and correctional insulin
Case 9
 42 yo on 160 u with HgA1c of 14.3 admitted with
pneumonia and current CBG is 260. What are your
admit insulin orders?
Case 10
 39 yo F with obesity, DM and HTN is admitted to the
VAMC with hypertensive urgency. She takes
metformin and glyburide with last HGA1c 8.3. He
weight is 120kg and BMI 33. She is able to eat. What
regime would you place her on at the VA and at the UH
respectively.
Insulin Order Sets
 UNM Order Set
 VA Order Set
Summary
Understanding these basic principles of physiologic, anticipatory
insulin will allow clinicians to formulate rational insulin
regimens in virtually any clinical situation!
Key Review Articles
 Inzucchi. Management of Hyperglycemia in the Hospital
Setting. N Engl J Med 2006;355:1903-11.
 Clement and colleagues. Diabetes Care 2004; 27: 553-91.
 American College of Endocrinology Position Statement on
Inpatient Diabetes and Metabolic Control. Endocrine
Practice 2004; 10: 77-82.
 American College of Endocrinology and American Diabetes
Association Consensus Statement on Inpatient Diabetes and
Glycemic Control. Diabetes Care 2006; 29: 1955-62.