Transcript Pharmacy 515 Acute/Critical Care Pharmacology

Glycemic Control in Acute Care
Janet L. Kelly Pharm.D.
October 22, 2013
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Understand the differences between basal, prandial,
and correction insulin and the options for delivering
each
Determine glycemic targets for specific patients and
situations
Know when IV insulin therapy is indicated
Be able to recommend glycemic control strategies for
the following situations:
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Enteral/Parenteral Nutrition
Steroids
Transitioning from IV to Subcutaneous Insulin
DKA/HHS
Recognize the signs/symptoms of hypoglycemia and
recommend appropriate treatment
Control blood glucose in fasting state
NPH
Glargine
Detemir
Degludec
Recombinant
DNA
Technology
PRANDIAL
 Lispro (Humalog)
 Aspart (Novolog)
 Glulisine (Apidra)
Altered
Absorption
Characteristics
BASAL
 Glargine (Lantus)
Detemir (Levemir)
Degludec (Tresiba®)
Prevent post-prandial spike in BG
Regular
Lispro
Aspart
Glulisine
Insulin Type
Onset
Peak
Duration
Regular
30-60 min
3-4 hr
6-8 hr
Lispro
5-15 min
1 hr
4 hr
Aspart
5-15 min
1 hr
4 hr
Glulisine
20 min
1.5 hr
5 hrs
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Use rapid acting insulin analogs ONLY
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Do NOT replace prandial or basal insulin
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Based on patient’s insulin sensitivity
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Typically bedtime dosing is less aggressive
Lispro
Aspart
Low-Dose Algorithm
Medium-Dose Algorithm
(For pts requiring<40 units of insulin/day)
(For pts requiring 40–80 units of insulin/day)
Premeal BG
200-249
250-299
300-349
>350
Bedtime BG
200-249
250-299
300-349
>349
Add Insulin
2 units
3 units
4 units
5 unit
Add Insulin
1 unit
2 units
3 units
4 units
Premeal BG
200-249
250-299
300-349
>350
Bedtime BG
200-249
250-299
300-349
>349
Add Insulin
3 units
5 units
7 units
8 unit
Add Insulin
2 units
3 units
5 units
7 units
-Cell Function (% )
100
Non-physiologic
Replacement
Early Type 2
80
60
40
Physiologic
Replacement:
Basal/Prandial
20
0
10
9
8
7
6
5
4
3
2
1
0
1
2
3
4
5
6
Years
Adapted from UK Prospective Diabetes Study (UKPDS) Group. Diabetes. 1995; 44:1249-1258.
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TR is a 58 year old male with Type 2 DM
admitted to the CCU following a cardiac arrest.
His home diabetes regimen is:
• Metformin 1 gram twice daily
• Glipizide 20 mg twice daily
• Pioglitazone 30 mg daily
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His HbA1c is 7.8 and current BG=212 mg/dL
What should we do?
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Discontinue all oral medications
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Do not provide the necessary flexibility
Metformin – lactic acidosis
Glipizide – augment reperfusion injury?
Pioglitazone – edema and CHF
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Diabetic ketoacidosis
Hyperglycemic
hyperosmolar state
Critical care illness
(surgical, medical)
Postcardiac surgery
Myocardial infarction or
cardiogenic shock
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NPO status in type 1
diabetes
Labor and delivery
Hyperglycemia
exacerbated by highdose glucocorticoid
therapy
Perioperative period
After organ transplant
Total parenteral nutrition
therapy
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Treatment threshold >180 mg/dL
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Goal 140-180 mg/dL for most patients
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Lower goal of 110-140 in select patients
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To avoid hypoglycemia, reassess and modify
diabetes therapy when BG is ≤100 mg/dL
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Start insulin infusion
 Lots of protocols in the literature
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Goal BG range 140-180mg/dL
Must have a dextrose source
 5-10gm/hour (e.g. D5W 100-200 mL/hr)
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Hourly BG monitoring until within goal range
 Once stable in goal range for several hours can decrease
frequency to every 2 hours.
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Hypoglycemia protocol should be embedded in
insulin infusion protocol
TR has been stable in target range on 3 units/hr
for nearly 8 hours. He will be starting an oral diet
and transferring to a floor unit in the next few
hours.
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Is now the right time to transition?
Will he need subcutaneous insulin?
Which patients on IV insulin will need a transition
to scheduled subcutaneous insulin?
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Patients with Type 1 DM
Patients with Type 2 DM (on insulin PTA)
Patients with Type 2 DM (on ≥2 units/hr)
If patient is on insulin PTA
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Use home dose as a guide
If not on insulin PTA
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Calculate daily insulin requirement
(3 units/hr) X 24 hr = 72 units/day
Use 50-100% of calculated daily insulin requirement
(36-72 units)
Divide 50% basal and 50% prandial
e.g. 18 units of glargine and 6 units lispro with each
meal
CK is a 72 year old female admitted for community
acquired pneumonia.
PMH: Type 2 DM ( HbA1c = 8.7)
COPD with multiple exacerbations
Weight = 90 kg
Meds: Glimepiride 8 mg daily
Prednisone 10 mg daily
Pioglitazone 30 mg daily
Hospital Course: Started on antibiotics, pulse steroids
and oxygen via a face mask. Her current BG is
254 mg/dL
How should her diabetes be managed?
Yes
A Little
SubQ Insulin
Basal & Prandial
SubQ Basal & Correction
OR
IV Insulin Infusion
No
IV Insulin Infusion
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Oral DM therapies are not ideal
 Difficult to titrate to changing needs
 Toxicity
Subcutaneous Insulin
 Basal + Prandial
Total daily insulin requirement = 0.5
units/kg/day
 Correction based on total daily insulin
requirement
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CK weighs 90 kg
 Total Daily Insulin Requirement = 45 units
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Divide Total Daily Insulin
(40% basal/60% prandial)
 18 units of basal (glargine/detemir)
 27 units prandial = 9 units before each meal
(lispro/aspart/regular)
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Correction Algorithm
 Total daily insulin dose 40-80 units = MEDIUM DOSE
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Most patients receiving steroids will experience
elevations in blood glucose
Initiate bedside glucose monitoring ALL
patients receiving high dose steroids
Patients on steroids will likely need a larger
component of their daily insulin requirement as
prandial
During initiation and taper of steroid therapy,
proactive adjustment of insulin therapy is
necessary
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TJ is a 42 year old female with inflammatory
bowel disease s/p extensive surgical resection
She is transferring to a floor bed and will be
starting TPN tonight
She is on an insulin infusion receiving low doses
(0.5 -1 unit per hour)
Can we discontinue the insulin infusion?
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Stop the insulin infusion and monitor?
Stop the insulin infusion and give correction
insulin PRN?
 How much?
 How often?
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Stop the insulin infusion and add insulin to
TPN bag?
 How much?
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Continue the insulin infusion?
Insulin Requirement Increases with TPN
(large dextrose load)
Unacceptable Hyperglycemia
Correction Insulin?
Positives:
 Simplifies number of infusions/lines
 Easier if patient will be discharged on TPN
Negatives:
 Hard to predict insulin requirement
 Once in the bag you are stuck
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Allows for easy titration and determination of
insulin requirement.
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Once the insulin requirement is determine then it
can be added to the TPN bag
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ES is an 63 year old male s/p curative surgery
for colon cancer admitted for failure to thrive
with malnutrition and dehydration
Continuous enteral feeds currently but goal of
nighttime feeds only
Weight =66 kg
His home diabetes regimen:
Glyburide 5 mg daily (HbA1c = 9.2)
What do you recommend for his DM?
► Discontinue
glyburide and start correction insulin
► Discontinue
glyburide and start scheduled
subcutaneous insulin
 What type of insulin?
 What dose and frequency?
► Discontinue
glyburide and start insulin infusion
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What Type of Insulin?
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What Dose?
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What frequency?
 Intermediate vs. Long Acting
 Calculate weight based insulin requirement
 0.5unit/kg/day or 33 units per day
 Intermediate every 6-12 hours
 Long acting every 12-24 hours
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Initiate bedside BG monitoring for all patients
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Initiate correction insulin for BG >140
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Initiate scheduled insulin for BG >180
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Titrate insulin dose at least daily as needed
Diabetic Ketoacidosis (DKA)
Hyperglycemic Hyperosmolar
State (HHS)
Plasma glucose >250 mg/dL
Plasma glucose >600 mg/dL
Arterial pH <7.3
Arterial pH >7.3
Bicarbonate <15 mEq/L
Bicarbonate >15 mEq/L
Moderate ketonuria or ketonemia
Minimal ketonuria and ketonemia
Anion gap >12 mEq/L
Serum osmolality >320 mosm/L
Treatment: Fluids, electrolyte management and IV insulin
Diabetic Ketoacidosis (DKA)
Hyperglycemic Hyperosmolar
State (HHS)
Absolute (or near-absolute) insulin
deficiency, resulting in
• Severe hyperglycemia
• Ketone body production
• Systemic acidosis
Severe relative insulin deficiency,
resulting in
• Profound hyperglycemia and
hyperosmolality (from urinary free
water losses)
• No significant ketone production or
acidosis
Develops over hours to 1-2 days
Develops over days to weeks
Most common in type 1 diabetes, but
increasingly seen in type 2 diabetes
Typically presents in type 2 or
previously unrecognized diabetes
Higher mortality rate
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Initiate the correction of hypovolemic shock with
fluids, and correct hypokalemia if present,
before starting insulin
When starting insulin, initially infuse 0.1 to 0.14
units/kg/h
If plasma glucose does not decrease by 50-75
mg in the first hour, increase the infusion rate of
insulin
Continue insulin infusion until anion gap closes
Initiate subcutaneous insulin at least 2 h before
interruption of insulin infusion
Kitabchi AE, et al. Diabetes Care. 2009;32:1335-1343.
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Withhold oral agents & GLP-1 receptor
agonists the morning of surgery
Insulin is necessary to control blood glucose in
patients with BG > 180mg/dL during surgery
Oral agents and GLP-1 receptor agonists can
be resumed postoperatively when
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Patient is reliably taking oral
Risk of liver, kidney and heart failure are
minimized
Morning of Surgery
►Give
50-75% of home basal insulin dose
(NPH/glargine/detemir)
►Do NOT give prandial insulin
►Give correction for hyperglycemia
►For prolonged procedures initiate insulin
infusion
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Shaky and/or sweaty
Nausea
Extreme hunger
Heart pounding/racing
Blurred vision
Confusion/inability to concentrate
Vague & Non Specific
Treat any BG≤70 mg/dL
Hypoglycemia
BG =50-70 mg/dL
4 ounces juice
OR
25 mL IV 50% dextrose
OR
Glucagon 0.5 mg SubQ
BG <50 mg/dL
8 ounces juice
OR
50 mL IV 50% dextrose
OR
Glucagon 1 mg SubQ
Do NOT use fat containing food/beverages
delays absorption of carbohydrate
JC is a 70 yo female s/p Whipple procedure
PMH: Type 2 DM treated with insulin
Home diabetes regimen was:
Glargine 18 units at 1800
Aspart with meal per “sliding scale”
Home dose of glargine was re-started with oral diet
and tube feeds
Next day feeding tube was inadvertently Dc’d
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Order written to decrease glargine to 12
units and move it to 2100.
RN didn’t see new order and administered
18 units at 1800.
Evening RN saw the new order an
administered 12 units at 2100
Time
BG
Reading
18:09
184
23:37
83
01:48
46
02:29
183
03:02
143
05:27
85
09:38
48
10:11
73
Intervention
D50 & notified MD of double dose
D50
Long Acting Insulin
Long Acting Glucose Source