Transcript Managing Inpatient Glycaemia

Managing Inpatient Glycaemia
Dr Sue Lynn Lau
Diabetes Clinical Workshop
Newcastle
October 2011
Case 1 - Doug
• 55 year old overweight male
• Admitted overnight with chest pain, ST changes on ECG
• Background history
• Hypertension
• Hypercholesterolaemia
• Benign prostatic hypertrophy
• Medications
• Irbesartan 150mg
• Atorvastatin 40mg
Case 1 - Doug
• No previous history of diabetes
• Random BGL in ED was 14 mmol/L, no treatment
• Next morning the formal fasting BGL is 8.4 mmol/L.
Case 1 - Doug
• Does Doug have diabetes?
• What is your management plan • acutely?
• on discharge?
Case 2 - June
• 72 year old female presents with fever, productive
cough, dyspnoea.
• Sats 91%, WCC 16, Creat 140, CXR – RLL consolidation
• Commenced on intravenous antibiotics
• Background
• Type 2 DM for 7 years
• Smoker
• Hypertension
• Osteoarthritis
Case 2 - June
• Lives alone, but independent and active.
• Medications
• Metformin 1g bd
• Gliclazide MR 60mg daily
• Amlodipine 5mg
• Anti-inflammatories
Case 2 - June
BGLs on the ward after 1 day
• 6 am – 10.3 mmol/L
• 11.30 am – 16 mmol/L
• 5.30 pm – 12. 4 mmol/L
• 9 pm – 15.1 mmol/L
• What do you advise?
- stat dose of 4 units NR
Case 3 - Mike
• 25 year old male with Type 1 diabetes since age 13.
• Fractured ankle after MVA, on ortho ward following
operation fixation.
• Novorapid 6 units tds, Levemir 24 units nocte
• 4 days post-op, he is found sweaty, pale and confused
in bed at 3pm. BGL 1.5 mmol/L.
• What next?
Inpatient glycaemia
1. Stress hyperglycaemia
2. Why treat hyperglycaemia in hospital?
3. What are the glycaemic targets of a hospitalised
patient?
4. Management strategies for inpatient hyperglycaemia
• how to use insulin
• what to do with oral hypoglycaemics
5. Management of inpatient hypoglycaemia
Stress Hyperglycaemia
physiological stress
infection, myocardial infarction, stroke, trauma
Hormones
‘counterregulatory’ factors
catecholamines, cortisol, glucagon
β-cell stress
Inflammatory cytokines
TNF-α
Insulin-resistance
hyperglycemia
Stress Hyperglycaemia
•
‘Stress Hyperglycaemia’
- elevated BGL (eg >11.1 mmol/l or >7 mmol/L)
- in the context of systemic illness
- without pre-existing diabetes.
• Difficult to define
Stress Hyperglycaemia
•
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Some use HbA1c > 6.1% or >6.5% to define preexisting but undiagnosed diabetes
HbA1c doesn’t capture all pre-existing diabetes
Recent high BGL related to stress may contribute to
elevated HbA1c.
HbA1c pitfalls in hospitalised patients
Stress Hyperglycaemia
•
Very Common
−
Levetan et al. Diabetes Care 1998
• Survey of 1034 hospitalised patients
• >1/3 had BGL documented > 11.1 mmol/L
• only 7% had diabetes as a diagnosis in notes.
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Umpierrez et al. JCEM 2002
• 2000 patients admitted to general medical ward.
• 7% had no BGL measured at any stage
• Of the rest, 26% had previous history of diabetes
• 12% had newly diagnosed hyperglycaemia
Stress Hyperglycaemia
•
Does it matter?
IN HOSPITAL MORTALITY
known diabetes
3%
new hyperglycaemia
16%
p<0.01
•
normoglycaemia
1.7%
p<0.01
Cause or Association?
•
•
•
Does high BGL have detrimental effect?
Is high BGL just a marker of more severe illness?
42% received insulin, mostly sliding scale vs 77% in diabetic
group.
Stress Hyperglycaemia
•
Does it matter?
-
More like to die if your admission BGL is high
• AMI, CVA (3-4 times risk of death) *
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Cheung et al, Diabetologia 2008
•
6187 consecutive ED patients
•
Admission BGL correlated to mortality
* Capes et al. Lancet 2000
Capes et al. Stroke 2001
Stress Hyperglycaemia
•
Does treating hyperglycaemia improve outcomes?
-
Theoretical benefit
• Hyperglycaemia alters immune function, cell death,
oxidative stress, endothelial dysfunction, thrombosis,
inflammation
⇒ increased infections
⇒ poor healing
⇒ increased infarct size after AMI
Stress Hyperglycaemia
•
Does treating hyperglycaemia improve outcomes?
-
Several trials in different situations – ICU, AMI, Stroke
Some positive results
• decreased deep wound infection
• decreased mortality
• decreased length of stay
Stress Hyperglycaemia
•
Does treating hyperglycaemia improve outcomes?
-
Others find no benefit
• May depend on the target BGL set
• How well they achieved target vs control group
• Rates of hypoglycaemia
• Suggestions of detriment if target BGL is too low.
Stress Hyperglycaemia
•
What are our treatment targets?
-
American College of Endocrinologists and Australian
Diabetes Society
• Critically ill – infusion target 7.8 - 10 mmol/L
• Non-critically ill – target <7.8 fasting, <10 random
• not less than 5 mmol/L
Doug
•
•
•
55 yo male with chest pain
BGL 8.4 mmol/L fasting, 14.0 mmol/L random.
No previous history of diabetes
•
SUGGESTIONS?
Doug- Scenario 1
•
•
•
Ring pathology lab for previous results – fasting BGL
of 6.8 mmol/L in 2006.
HbA1c 7.8%
Doug’s chest pain resolves, ECG remains unchanged
and his serial cardiac enzymes are not elevated,
planned for discharge and outpatient follow-up.
Doug – Scenario 1
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•
•
•
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Referred to the diabetes educator and dietician.
Commences home blood glucose monitoring.
Metformin 500mg bd initiated, increased to 1g bd
after 1 week.
With increased physical activity and attention to diet,
he loses 3kg over the next 3 months.
Fasting BGLs are down to 5 mmol/L and post-prandial
readings all <10 mmol/L.
An HbA1c 3 months later is 6.5%, he continues
metformin and stops home BGL monitoring.
Doug – Scenario 2
•
•
•
•
Ring Path lab – fasting BGL was 5.2 mmol/L in 2006.
HbA1c is 5.9%
He has a further episode of chest pain with ST
depression in the anterior leads and his troponin
levels rise.
He is planned for angiography as an inpatient.
•
SUGGESTIONS?
Managing Inpatient Hyperglycaemia
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Options for treatment of hyperglycaemia
-
-
Intravenous Insulin infusion
Subcutaneous insulin
 Sliding scale insulin (short acting given on PRN
basis when BGL rises, dose titrated according to
BGL)
 basal bolus (long-acting daily, short-acting with
meals)
 pre-mixed short+long acting, twice a day.
Oral hypoglycaemic agents
Managing Inpatient Hyperglycaemia
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Intravenous insulin infusions
Achieves glycaemic control quickly
Can adapt to changes in patient’s
condition.
Requires minimal endocrinological
expertise as long as protocol is clear
and strictly followed.
Insulin absorption not an issue
Good in fasting patients, less easy if
eating.
x
x
x
x
Frequent BGL
testing for patient
IV access issue.
High use of nursing
resources
Some experience
required
Appropriate in critically ill patients managed in ICU/HDU
setting, surgical patients, Type 1, difficult/unstable BGL.
Managing Inpatient Hyperglycaemia
•
Sliding Scale Insulin – short-acting insulin
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•
Eg, BGL 8 – 12
BGL 12.1 – 16
BGL 16.1 – 20
BGL >20.1
=
=
=
=
Give 2 units
Give 4 units
Give 8 units
Give 10 units, call M.O.
Issues
- Which short-acting to use?
- How often to administer, pre-meals/post-meals/overnight?
- Adjusting scale for different levels of insulin resistance
Managing Inpatient Hyperglycaemia
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Sliding Scale Insulin
-
Easy to use and to chart
Easily ignored and unused, even if charted
Responds to high BGL but does not prevent them
“reactionary” vs “proactive”
Greater swings, BGL instability
Hypos, especially with insulin stacking
Rebound phenomena
GENERALLY AVOIDED IF POSSIBLE
Managing Inpatient Hyperglycaemia
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Regular subcutaneous insulin
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Basal Bolus + supplemental, eg Lantus nocte, Humalog TDS
with meals + extra Humalog if BGL high.
Managing Inpatient Hyperglycaemia
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Regular subcutaneous insulin
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Pre-emptive
Dose titrated based on previous days readings
Flexible, can be used in patient with minimal or variable
oral intake.
Can be taught to staff with minimal endocrine experience
Achieves better glycaemic control and stability than SSI.
Takes about 3 days to achieve target of 7-8 mmol/L
Managing Inpatient Hyperglycaemia
Calculate a total daily dose (TDD) based on body weight and patient
characteristics ( table below for insulin-naïve patients), then split
the TDD into 50% basal and 50% bolus (divided into 3 meals)
TDD Estimation
Patient Characteristics
0.3 units/kg body weight
Underweight
Older age
Hemodialysis
0.4 units/kg body weight
Normal weight
0.5 units/kg body weight
Overweight
>0.6 units/kg body weight
Obese
Insulin resistant
Glucocorticoids
Managing Inpatient Hyperglycaemia
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Tailor to patient’s glycaemic pattern.
Assess and titrate the doses daily
Adjust long-acting dose to target fasting BGL
Adjust short-acting dose to target the increment in
BGL from pre to post-meal.
Consider how much supplemental dose was required
on the previous day.
Dose adjustments of 10-20%, depending on how far
off target.
Does not commit patient to long term insulin therapy
Managing Inpatient Hyperglycaemia
•
BD mixed insulin
- Less flexibility, patient committed to eat certain
amounts at certain times.
- Inappropriate in ill, unstable patient.
- Useful in relatively well patient, normal diet, soon
to be discharged, not planning basal bolus use in
community.
Managing Inpatient Hyperglycaemia
•
Oral hypoglycaemics
- Metformin unsuitable in seriously ill with poor
perfusion, renal impairment, IV contrast
- Sulphonylureas unsuitable if poor oral intake,
other risk factors for hypoglycaemia
- Glitazones risky in fluid overload/CCF
- Delayed onset and offset of action
- May be used/continued in stable patient, normal
appetite, soon to be discharged, not planning
insulin therapy in community.
June
• 72 yo female with pneumonia, renal impairment, sepsis
• Known Type 2 DM on max. dual oral hypoglycaemics
• BGL profile
• 6 am – 10.3 mmol/L
• 11.30 am – 16 mmol/L - stat 4 units NR
• 5.30 pm – 12. 4 mmol/L
• 9 pm – 15.1 mmol/L
QUESTIONS/SUGGESTIONS?
June – Scenario 1
• Weight 56kg, Height 160cm
• Feels nauseous, but eating
• Home BGL monitoring, fasting BGLs 6 - 8 mmol/L
• No hypos
• HbA1c 7.5%
• Normal renal function 3 months ago
• Urine albumin/creatinine ratio 1.3 mg/mmol (normal)
• No evidence of retinopathy, neuropathy
June – Scenario 1
• Ceased metformin and glicazide
• Commence Glargine 12 units nocte, Lispro 4 units
immediately after eating if tolerates meal.
• Supplemental scale tds before meals and before bed
- BGL 10 – 12 mmol/L
 2 units
12.1 – 16 mmol/L  4 units
16.1 – 20 mmol/L  8 units
• Discharge planning - diabetes educator review,
discussed short-term use of insulin, taught insulin
administration.
June – Scenario 1
• June improves with IV antibiotics
• Creatinine returns to baseline
• After 3 days, the oral hypoglycaemics are restarted
• The insulin dose is initially up-titrated, then downtitrated with the reintroduction of OHG, able to cease
bolus (meal-time) insulin.
• Discharged on Glargine + metformin + gliclazide with
outpatient follow-up.
• Plan for self-titration of Glargine depending on fasting
BGL.
June – Scenario 2
• Weight 56kg, Height 160cm
• Feels nauseous, but eating
• Home BGL monitoring, fasting BGLs 9 - 10 mmol/L
• No hypos
• HbA1c 8.5%
• Hasn’t seen a regular LMO for some years
• Not screened for complications
June – Scenario 2
• Oral hypoglycaemic agents ceased
• Commenced on basal bolus insulin + supplemental
dosing, doses titrated daily.
• Creatinine stabilises at 90 umol/L
• Discussed use of long-term insulin therapy on discharge
• Metformin cautiously re-introduced at 500mg bd
• Once eating reliably, basal bolus switched to pre-mixed
bd regimen.
• Education re: home BGL monitoring, complication
screening, hypoglycaemia management, dietary needs.
Case 3 - Mike
• 25 yo male, long-standing Type 1 diabetes.
• 4 days post orthopaedic surgery
• Novorapid 6 units tds, Levemir 24 units nocte
• He is found sweaty, pale and confused in bed at 3pm.
BGL 1.5 mmol/L.
• What next?
Hypoglycaemia in hospital
• Factors contributing to hypoglycaemia in hospital
- poor appetite and intake, vomiting
- fasting for procedures
- delay in meal-times
- breaks in enteral feeding
- renal dysfunction
- reintroduction of physical activity – physio/OT
- overzealous insulin administration
-corticosteroid use
- patient unable to self-report symptoms
Hypoglycaemia in hospital
• Does it matter?
- Critically ill patients
• increased risk of death, seizures
• NICE-SUGAR – do not target normoglycaemia
when using insulin infusion in ICU.
• Excess deaths appear to be cardiovascular
Hypoglycaemia in hospital
• Does it matter?
- Non-critically ill patients
• Turchin et al, Diab Care 2009
• Hypoglycaemia in 7% of diabetic admissions
• Hypoglycaemia associated with increased length
of stay (2-3 days), inpatient mortality, mortality at
1 year.
- Associational, is it a marker of more severe illness?
Management of hypoglycaemia
• Acute management – recommended clinical cut-off for
hypoglycaemia is <4 mmol/L, individual symptoms vary.
•Conscious patient
• 15g carbohydrate orally
•5-7 jelly beans
•150 mls soft drink or juice (not diet)
•100mls Lucozade
•Glucose tablets (equivalent to 15g)
•3 teaspoons of sugar
• Recheck in 15 minutes, if BGL not rising, repeat
Management of hypoglycaemia
• Acute management
•Conscious patient
• If next meal is >20 min away, add longer-acting
carbohydrate
• Sandwich, glass of milk, piece of fruit, 1 tub of
yoghurt, 6 small dry biscuits and cheese
Management of hypoglycaemia
• Acute management
• Patient with impaired consciousness
• If IV access available, quickly achievable
• 50 ml of 50% dextrose (25g glucose)
• or 25 ml of 50% dextrose (12.5g glucose)
• trials looking at 10% dextrose in 50 ml (5g)
increments.
• No IV access achievable, glucagon 1mg s/c or IM
Management of hypoglycaemia
• Subsequent management
- what precipitated the episode?
- subsequent risk of hypoglycaemia in next 24 hours
- adjust insulin dosing appropriately
- never withhold long-acting insulin because of hypoglycaemic
episode.
Mike
• Resuscitated with intravenous 50% glucose, followed by
a sandwich once he regains consciousness.
• Chart review – BGL has been dipping in the afternoons
over last few days.
• Patient history – Mike wasn’t keen on today’s lunch,
mobilising more with crutches this afternoon.
• BGL at home – erratic. Has noticed BGL of 2.0 mmol/L
without symptoms.
• Examination – some areas of lipohypertrophy on
abdomen and upper thighs.
Mike
• Mike’s insulin doses are reviewed and decreased
appropriately.
• More frequent BGL monitoring overnight.
• Sees diabetic educator – revises hypo management,
insulin administration.
• Dietician, refresher on carbohydrate counting.
• Advised to maintain BGL > 6 mmol/L
• Advice about driving
• Mike’s partner shown how to use glucagon kit
Take Home Messages
• Hyperglycaemia is common in hospitalised patients,
many without previous knowledge of diabetes.
• HbA1c may help to distinguish those with undiagnosed
diabetes, likely to require long-term therapy. But beware
pitfalls.
• New hyperglycaemia is a marker for worse outcome
and should be treated as for diabetic patients.
Take Home Messages
• Insulin is the most appropriate therapy in acutely ill
patients, consider temporary cessation of OHG
• Target BGL <10 mmol/L and not less than 5 mmol/L
• Insulin infusions useful in the critically ill and fasting.
• Regular sc insulin (Basal+bolus+supplemental) better
than sliding scale, low risk of hypoglycaemia if targets
appropriate.
Take Home Messages
• Be aware of increased risks for hypoglycaemia in
hospital, avoid overzealous glycaemic targets.
• Follow hospital protocol for hypoglycaemia
management, do not overtreat, do not withhold longacting insulin.
• Look for precipitating factors in your individual patient.
Take Home Messages
• Hospitalisation is a good opportunity to (re)educate
and (re)motivate patients towards better diabetes
management.
• Discharge planning should begin early and involve the
endocrine team, dietician and diabetes educator.
• Requirements may change quickly after discharge,
outpatient follow-up and liaison with GP is essential.