Transcript Management Type 1 Diabetes

Inpatient Diabetes Management
Rana Malek M.D.
[email protected]
Objectives
• Inpatient management
– Hyperglycemia
– Hypoglycemia
– Starting insulin on an inpatient
– Adjustment of insulin on inpatient
2
Case: Mr. Smith
• You are on call doing cross cover. You get paged right at
sign out (7 pm) and told that Mr. Smith’s glucose is 400
mg/dL
• The nurse tells you he has a sliding scale. You ask what
the sliding scale dose is and to give that dose. He
receives 10 units of humalog.
• She calls you at 10 pm to let you know his blood sugar is
now 50 mg/dL
• What happened?
– STACKING OF INSULIN
3
Necessary Information
•
•
•
•
What type of diabetes does Mr. Smith have?
When was the last time Mr. Smith ate?
What is his current insulin regimen?
When was his last dose of insulin and what kind of insulin
was it?
• What is he in the hospital for?
4
Necessary Information
• What type of diabetes does Mr. Smith have?
• Type 2
• When was the last time Mr. Smith ate?
• Ate dinner at 5:30 pm when trays came
• What is his current insulin regimen?
• Lantus 40 units qHS and “humalog sliding scale”
• When was his last dose of insulin and what kind of insulin was
it?
• Humalog 10 units at 5 pm (based on his pre-meal blood
sugar of 410 mg/dL)
• What is he in the hospital for?
• ESRD and vascular disease
5
What would you have done differently?
• Given this information—
– He had 10 units of humalog with his dinner and he was
400 at the time
– 2 hours later, he was still 400
– He was dosed an additional 10 units at 7 pm
– What would you expect to have happen?
6
Physiological insulin profile
Insulin
effect
Breakfast
06:00
Lunch
12:00
Dinner Snack
18:00
Time
24:00
Breakfast
06:00
Basal insulin
Onset
(hours)
Peak
action
(hours)
Effective
duration
of action
(hours)
Max
Duration
(hours)
Glargine
3-4
none
18-20
Detemir
3-4
6-8
14
20-24
hours
20
NPH
2-4
4-10
10-16
14-18
Bolus insulin
Lispro
(humalog)
Aspart
(novolog)
Glulisine
(apidra)
Regular
Onset
Peak
Effective
Max
Duration Duration
3-4 hrs 4-6 hrs
15-30
min
30 -90
min
15-30
min
30 -90
min
3-4 hrs
4-6 hrs
15-30
min
30 -90
min
3-4 hrs
4-6 hrs
30-60
min
2-3
3-6 hrs
6-8 hrs
Insulin treatment: 1950- 1980+
Insulin
effect
Insulin
Onset
Peak
Duration
Regular
30-60 min
2-4 hours
5-8 hours
1-2 hours
4-10 hours
NPH
Breakfast
Lunch
06:00
12:00
Dinner
18:00
Time
Snack
24:00
12 - 18
hours
Breakfast
06:00
11
Knowing this—what would you have done?
• He got 10 units at 5 pm
• “Insulin on board”—(rough rule) about 25% of bolus is
used up over each hour (over 4 hours).
• You estimate that by 7 pm, he still had about 5 units of
the first injection still on board
• You then gave another 10 units at 7 pm (so he effectively
had 15 units at this time).
• By 10 pm—he still has about 4 units still on board
12
Case #2
• You are paged in the middle of the night when on cross
cover. You are told that during the 3 am vital check, Ms.
Jones was diaphoretic. The nurse checked her blood
sugar and it was 30 mg/dL. They gave her D50 and called
you.
• You ask them to call you back in 15 minutes with a repeat
blood sugar—it is 70 mg/dL. You thank the nurse
• At 6 am, you hear a code called on the same patient. She
is fortunately revived but her blood sugar was 20 mg/dL
when it was first checked
• What happened?
13
Necessary Information
•
•
•
•
Does Ms. Jones have diabetes? What type?
If so, is she receiving insulin in the hospital?
When was her last dose of insulin?
Is she NPO?
14
Necessary Information
• Does Ms. Jones have diabetes? What type?
– Yes—type 2 diabetes
• If so, is she receiving insulin in the hospital?
– Yes
• When was her last dose of insulin?
– Yes—she received 60 units of lantus at night (about 6
hours prior to her hypoglycemic event) and she said
this was her home dose
• Is she NPO?
– No
15
Basal insulin
Onset
(hours)
Peak
action
(hours)
Effective
duration
of action
(hours)
Max
Duration
(hours)
Glargine
3-4
none
18-20
Detemir
3-4
6-8
14
20-24
hours
20
NPH
2-4
4-10
10-16
14-18
“Home Insulin Dose”
• Verify with your patient not only what they are
prescribed but what they are actually taking
– Do not simply write the dose you see in the EMR
– Ms. Jones says she takes the 60 units of Lantus 3
nights a week because if she took it every day she
would drop very low
17
NPO Status
• Perfect basal dose allows a person to do their normal
daily activities, fast, and not become hypoglycemic
• Hospitalized patients should still have their basal dose
reduced by 15-30% if they are NPO (in case they take less
insulin than their prescription states)
18
Treatment of Hypoglycemia
• 51-70 mg/dL: treat with 10-15 gm rapid acting carbs
• <50 mg/dL: treat with 20-30 gm
– Retest after 15 minutes and treat until bg >70 mg/dL
– Then cover next meal appropriately
• 1 amp D50= 25 gms of carbs (100kcal)
• 4 oz OJ= 15 gms of carbs
• 1 L D5W at 100mL/hr = 5% Dextrose (50 gm/bag) =
5g/100mL x 1L . GETTING 5 gm GLUCOSE/HR
• 1 L D10W at 100mL/hr = 10%D (100 gm/bag)=
10g/100mLx1L= GETTING 10 GM GLUCOSE/HR
Back to Ms. Jones
• Her hypoglycemia was the results of too much lantus
– Lantus is 24 hours
• Once her blood sugar was up with rapid acting carbs,
would recommend feeding patient with close monitoring
of her glucose
20
Starting Insulin on
Inpatients
21
Case 3
• Ms. Patel is a 54 year old woman with a history of type 2
diabetes on oral medications (glipizide and metformin)
with an A1c of 8%. She is admitted to the orthopedic
surgery service after a knee replacement. All oral meds
were held on admission.
• You are Med Con and are called at 8 pm for a glucose of
375 mg/dL. She has some post op pain but no other
acute issues
• How do you treat her blood sugars?
22
What do you know
• She has type 2 diabetes (so unlikely to be in DKA)
• She had poor control on oral meds
• Her oral meds were held and then she underwent a
stressful event (surgery)
• Her goal inpatient glucose should be 140-180 mg/dL
• What does she need now?
–Insulin
23
Starting Patients on Insulin
24
Calculating Insulin Doses
25
How to calculate the Correction Factor
• 1800 RULE: 1800/TDD
• Example: 1800/35= 51.4 mg/dL
• 1 unit will drop glucose 50 points
• Correction scale:
• 150-200: 1 unit
• 201-250: 2 units
• 251-300: 3 units
Med Con Recs
• Ms. Patel weighs 80 kg (BMI 28 kg/m2)—Overweight
• Step 1: Calculate Total Daily Dose (TDD)
– 80 x 0.5=40 units
• Step 2: Calculate Basal Dose
– 0.50 x 40 units= 20 units
• Step 3: Calculate Bolus Dose
– 0.33 x 20 units= 6 units with each meal
• Step 4: Calculate Correction
– 1800/40= 45 mg/dL (1 unit of insulin with lower her
glucose by 45 mg/dL)
27
Now Write the Orders
• Glargine: 20 units qHS (first dose now)
• Aspart: 6 units qAC
• Aspart correction scale: 150-200: 1 unit; 201-250: 2
unit; 251-300: 3 units, 301-350: 4 units; 351-400: 5 units.
– Give her a correction dose now
– 375 mg/dL= Aspart 5 units
• Check blood sugars qAC and bedtime
28
Glucose follow up
• Ms. Patel has a complicated hospital course and remains
an inpatient for several days. You continue to help
manage her blood sugars
• Lantus 20 units qHS
• Novolog 6 with meals + correction (1/50 >150)
Breakfast
Lunch
Dinner
Bedtime
Day 1
220
280
199
205
Day 2
240
310
277
220
29
Glucose adjustments
• What would you do?
• Lantus 20 units qHS
• Novolog 6 with meals + correction (1/50 >150)
Breakfast
Lunch
Dinner
Bedtime
Day 1
220
280
199
205
Day 2
240
310
277
220
30
Information needed to adjust
•
•
•
•
Did she eat all meals (any meals held)?
Where any insulin doses held?
Exactly how much insulin and when.
Correction: 150-200 1; 201-250 2; 251-300 3; 301-350 4
Day 1
Insulin
Day 2
Insulin
Breakfast
Lunch
Dinner
Bedtime
Total
Insulin
220
6+2
240
6+2
280
6+3
310
6+4
199
6+1
277
6+3
205
2
220
2
20 L +
26N =46
20L +
29N=49
31
Glucose adjustment
•
•
•
•
•
•
•
Day 1: 46 units insulin needed
Day 2: 49 units insulin needed
Avg: 48 units did not control glucose
Increase by 10%: 52 units
Redistribute
Lantus 52/2: 26 units
Novolog: 9 units with meals.
32
Insulin Resistant Patient
• Mr. Smith has known type 2 diabetes. Followed at
UMCDE by Dr. Malek. Takes lantus 40 units twice daily.
Takes 25 units with each meal (155 units/day).
Correction scale: 150-200 4 units; 201-250 8 units; 251300 12 units; 301-350 16 units
Breakfast
Lunch
Dinner
Bedtime
Total
Insulin
Day 1
Insulin
220
25+8
280
25+12
199
25+4
205
8
Day 2
Insulin
240
25+8
310
25+16
277
25+12
220
8
80 L +
107 N
=187
80L +
119N=
199
33
Glucose adjustment
•
•
•
•
•
•
•
Day 1: 187 units insulin needed
Day 2: 199 units insulin needed
Avg: 192 units
Increase by 10%: ADD 19 units? Or round to even 200
Redistribute
Lantus 200/2: 50 units BID (previous dose: 40 BID)
Novolog: 33 units with meals. (previous dose 25 TID)
34
Hypoglycemia
• Ms. Park has type 2 diabetes and is on oral meds at
home. She has had vascular surgery and is now on
insulin. She weighs 70 kg. Started on Lantus 17 units
(dosed on admission) and novolog 6 with meals and 1/50
correction scale)
35
Hypoglycemia
Breakfast
Day 0
140
Day 1
Insulin
Day 2
Insulin
160
6+1
89
4
Day 3
55
Lunch
184
6+1
62
0
Dinner
150
6
199
6
Bedtime
Total
Insulin
220
17 L
140
17 L +
20N =37
120
17L +
10N=27
36
Hypoglycemia adjustments
• Must know exactly how much insulin was given (do not
go on insulin orders alone)
• Day 1=37; Day 2=27
• 27 units with tight control and hypoglycemia following
morning
• Reduce by 20%: 27-6=21
• 20/2: lantus 10 units, novolog 3 with meals.
37
Tube Feeds!
• Mr. Ngozi is a 55 yo M T2DM x 5 yrs, S/P surgery and RT
for oral cancer with recent PEG placement. Weights 90
kg
• On continuous tube feeds
• Since starting TF, BS 200-300
• Regular insulin is your friend: duration 6-8 hours!
– Dose every 6 hours for stacking effect (0.5 units/kg)
– Use very low dose glargine (0.15 units/kg)
– Glargine 13 units; Regular 11 units q 6 hours with
REGULAR CORRECTION q 6 hours
38
INSULIN REQUIREMENTS:
CONTINUOUS TUBE FEEDS
Glucose 180 mg/dL
Regular
Glargine
6 am 12 pm 6 pm 12 am
Take Home Points
• For glucose emergencies, always take a few minutes to gather
key information
• Knowing profiles of different insulins will help you predict the
patient’s clinical course
• Use weight based formulas to calculate insulin doses on
inpatients
• Inpatient goal is 140-180 mg/dL
• Take into account all supplemental insulin needed over the
last day to adjust insulin
• Rule of thumb:
– Hyperglycemia: increase total daily insulin by 10%
– Hypoglycemia: reduce total daily insulin by 20%
40
THANK YOU!
41