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Diabetes Management in the Hospital
Bruce W. Bode, MD, FACE Atlanta Diabetes
Associates Atlanta, Georgia
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Diabetes in Hospitalized Patients1997

• 3.5 Million US Hospitalizations
• 15 of Admissions
• 14 Million Hospital Days
• 20 of All Hospital Days
• 36 First Diagnosed in Hospital
  66 No Documentation by Physician
  27 Labeled Hyperglycemia
  2 Diagnosed on Chart

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Diabetes in Hospitalized Patients1997 Costs

• 23,500 Each vs. 12,200 for Non-
• diabetics
• 60 of All Diabetes-Related Costs
• Only 5 DKA, HHNKC
• 48 Diabetes Complications
• 52 Other Conditions

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Diabetes in Hospitalized Patients

• High-risk for Bacterial Infection
• Surgery
• Catheters
• Intravenous Access
• Anaesthesia

• Problems with wound healing

• Problems with tissue and organ perfusion

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Infections in Diabetes

• One BG gt220 mg/dl results in 5.8 times increase
  in nosocomial infection rate
• Two hours hyperglycemia results in impaired WBC
  function for weeks
• Pomposelli, New England Deaconess,
• J Parenteral and Enteral Nutrition
  2277-81,1998

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Causes for High Risk for Infection

• Short Term Effect of Hyperglycemia
• Immune Function
• Pathogen Growth
• Vascular Permeability
• Long Term Effect of Hyperglycemia
• Vascular Disease
• Neurologic Disease

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Evidence for Immediate Benefit of Normoglycemia
in Hospitalized Patients

• Numerous Publications on in Vitro Evidence
• Neutrophil Dysfunction
• Complement Inhibition
• Altered Redox State (Pseudohypoxia)
• Glucose Rich Edema as Culture Media
• Six Recent Clinical Publications supporting good
  glucose control in the hospital setting

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Perioperative Glycemic Control Hill,
Peart-Vigilance, Kao, Brancati (Johns Hopkins)
Diabetes Care (22)91408-1414, 1999

• 411 CABG 1990-1995
• Mean of BG in First 36-h Post-op
• Quartiles of BG Results
• 24.3 Infection Rate
• Relative Risk vs. Quartile 1 (BG 121-206 mg/dl)
• Quartiles 2,3,4 1.17, 1.86, 1.72
• Case-Control Analysis
• Patients Subsequently Infected Had Significantly
  Higher BGs Throughout Pre-Infection Course

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Open Heart Surgery in DiabetesPortland St.
Vincent Medical CenterProtocol Ordered by
SurgeonAdministered by Nursing StaffNo Change
Except Insulin Administration

• Control Group
• N968
• 1987-1991
• SubQ Insulin q 4 h
• Goal 200 mg/dl
• Standard Deviation 36
• All Mean BGs lt200 47

• Study Group
• N1499
• 1991-1997
• IV Insulin
• Goal 150-200 mg/dl
• Standard Deviation 26
• All Mean BGs lt200 84

Furnary et al, The 34th Meeting of The Society of
Thoracic Surgeons New Orleans, LA January 26, 1998
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Open Heart Surgery in DiabetesPortland St.
Vincent Medical Center Perioperative Blood
Glucose
Furnary et al, The 34th Meeting of The Society of
Thoracic Surgeons New Orleans, LA January 26, 1998
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Incidence of DSWI 1987-1997
CII
Furnary, et al, The 34th
Meeting of The Society of Thoracic Surgeons New
Orleans, LA January 26, 1998
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Open Heart Surgery in DiabetesPortland St.
Vincent Medical CenterMortality

• All (99/2467) 4.0
• SQI 6.1
• CII 3.0
• Recent Experience
• 1994-1997 DSWI as in non-diabetics
• 1996-7 No DSWI in last 15 mo.

Furnary et al, The 34th Meeting of The Society of
Thoracic Surgeons New Orleans, LA January 26, 1998
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Benefit of CII and Normoglycemia

• Avoids Accelerated Glycosylation
• Immunoglobulins C3 Component
• New Collagen
• Preventing Granulocyte Dysfunction
• Abnormal Adherence
• Impaired Phagocytosis
• Delayed Chemotaxis
• Depressed Bactericidal Capacity
• Reverses Phagocyte Impairment

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LOS and Charge comparison

• Socioeconomic Costs of DSWI
• 16 Hosp Days
• 26,000

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Estimated USA Socioeconomic Savings
Assumes 742K cases, 20 prevalence of DM 2
DSWI with SQI

Variable SQI CII Savings DSWI 2,968 1009 1,959
Additional LOS 47,488 16,416 31,342 Additional
78.4M 26.6M 51.7M Deaths 564 192 372
1998 Heart Stroke Statistical update, AHA
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DIGAMI StudyDiabetes, Insulin Glucose Infusion
in Acute Myocardial Infarction(1997)

• Acute MI With BG gt 200 mg/dl
• Intensive Insulin Treatment
• IV Insulin For gt 24 Hours
• Four Insulin Injections/Day For gt 3 Months
• Reduced Risk of Mortality By
• 28 Over 3.4 Years
• 51 in Those Not Previous Diagnosed

Malmberg BMJ 19973141512
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Cardiovascular RiskMortality After MI Reduced
by Insulin Therapy in the DIGAMI Study
IV Insulin 48 hours, then
4 injections daily
All Subjects
Low-risk and Not Previously on Insulin
.7
.7
(N 620)
(N 272)
.6
.6
Risk reduction (51)
Risk reduction (28)
.5
.5
P .011
P .0004
.4
.4
.3
.3
.2
.2
.1
.1
0
0
0
1
2
3
4
5
0
1
2
3
4
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Years of Follow-up
Years of Follow-up
Malmberg, et al. BMJ. 19973141512-1515.
6-11
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ICU Survival

• 1548 Patients
• All with BG gt200 mg/dl
• Randomized into two groups
• Maintained on IV insulin
• Conventional group (BG 180-200)
• Intensive group (BG 80-110)
• Conventional Group had 1.74 X mortality

Van den Berghe et al, NEJM 2001345(19)1359
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ICU Survival

• Intensive Therapy (80 to 110 mg/dL) resulted in
• 34 reduction in mortality
• 46 reduction in sepsis
• 41 reduction in dialysis
• 50 reduction in blood transfusion
• 44 reduction in polyneuropathy

Van den Berghe et al, NEJM 2001345(19)1359
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Conclusion

• All hospital patients should have normal glucose

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Insulin

• only

powerful
powerful

• The agent we haveto
  control glucose

most
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Comparison of Human Insulins / Analogues

• Insulin Onset of Duration ofpreparations
  action Peak action

Regular 3060 min 24 h 610 h
NPH/Lente 12 h 48 h 1020 h
Ultralente 24 h Unpredictable 1620 h
Lispro/aspart 515 min 12 h 46 h
Glargine 12 h Flat 24 h
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Methods For Managing Hospitalized Persons with
Diabetes

• Continuous Variable Rate IV Insulin Drip
• Major Surgery, NPO, Unstable, MI, DKA,
  Hyperglycemia, Steroids, Gastroparesis, Delivery,
  etc
• Basal / Bolus Therapy (MDI) when eating

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Continuous Variable Rate IV Insulin Drip

• Mix Drip with 125 units Regular Insulin into
• 250 cc NS
• Starting Rate Units / hour (BG 60) x 0.02
• where BG is current Blood Glucose
• and 0.02 is the multiplier
• Check glucose every hour and adjust drip
• Adjust Multiplier to keep in desired glucose
• target range (100 to 140 mg/dl)

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Continuous Variable Rate IV Insulin Drip

• Adjust Multiplier (initially 0.02) to obtain
  glucose in target range 100 to 140 mg/dL
• If BG gt 140 mg/dL, increase by 0.01
• If BG lt 100 mg/dL, decrease by 0.01
• If BG 100 to 140 mg/dL, no change in
  Multiplier
• If BG is lt 80 mg/dL, Give D50 cc (100 BG) x
  0.3
• Give continuous rate of Glucose in IVFs
• Once eating, continue drip till 1 hour post SQ
  insulin

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Glucose Management System
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Glucommander

• Based on 15 Year Experience with a Computer Based
  Algorithm for the Administration of IV Insulin
• Developed for Marketing by MiniMed and Roche
• GMS System
• Shelved Pending FDA Approval of IV Use of Insulin
• Useful and Safe for Any Application of IV Insulin

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Glucommander Effectiveness

• Initial blood glucose
• Median 292 mg/dl
• Range 181-1,568
• Time to achieve glucose lt 180 mg/dl
• Median 3 hours
• Range 0.3 - 19.7
• Time to achieve three consecutive glucose results
  between 60 - 180 mg/dL
• Median 3. 1 hours
• Range 0.3 - 22.5

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Glucommander

• Final Patient Data Set 3,473
• Median patients per month 27
• Median glucose tests per patient 20

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Glucommander Safety and Effectiveness

• Time to end of treatment with the algorithm
• Median 20 hours
• Range 0.4 - 298
• Percentage of blood glucose lt 60 mg/dL
• 1.5 of all data

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Converting to SQ insulin

• Establish Daily Insulin Requirement
• IV Insulin First Night
• (BG - 60) x Multiplier Ins/hr Targeted to 120
• 60 x Multiplier x 24 Daily Insulin Requirement
• Give One-Half Amount As Basal
• Give p.c. Boluses Based on CHO Intake
• Start at CHO/Ins 1 CHO 1.5 units Short-acting
• Monitor a.c. tid, hs, and 3 am
• Supplement All BG gt150
• (BG-100)/(1500/Daily Insulin Requirement)

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Protocol for SQ Insulin in Hospitalized Patient

• Bedtime Wt (kg) x 0.2 Units of Glargine
• Meals Eaten 1.5 units per 15 Gm CHO eaten
• BG gt150 (BG-100) / SF
• SF 3000 / Wt (kg)
• Do Not Use Sliding Scale Only
• Any BG lt80 D50 (100-BG) x 0.3 ml
• Maintain INT
• Do Not Hold Insulin When BG Normal

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GEMS--Glargine Evening
Mealtime Secretagogue

• Basal Dosing
• (Weight in kg x 0..2)
• Glargine bedtime or anytime
• Prior to Meals
• Short Acting Secretagogue
• Rapaglinide 2 mg
• Nateglinide 120 mg

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Conclusion

• Intensive therapy is
• the best way to treat
• patients with diabetes

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QUESTIONS

• For a copy or viewing of these slides, contact
• WWW.adaendo.com

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Clinical Experience with Glucommander

• Summary
• Glucommander provides a safe and effective method
  of treatment for achieving and maintaining
  glycemic control.
• Glucommander provides a standardized treatment
  method, yet is applicable for controlling
  glycemia in a wide variety of medical conditions.

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Enterally Fed Diabetics

• Uncontrolled with Sliding Scale
• Erratically Controlled with Intermittent
  Intermediate Acting or Mixed Insulin

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Diabetes ManagementTube Feeding, On Steroids
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Reversing Glucose Toxicity

• Import in Controlling Type 2 Diabetes
• Well Established Practice of Using IV Insulin
  Under Close Supervision
• Expense and Restriction of Hospitalization

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GEMS--Glargine Evening
Mealtime Secretagogue

• Basal Dosing
• (Weight in s x 0.1)
• Glargine hs
• Prior to Meals
• Short Acting Secretagogue
• Rapaglinide 2 mg
• Nateglinide 120 mg

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The Case for GEMSRoutine Hospital Care for Type
2 Diabetes

• Usually metformin contra-indicated
• Insulin required for normal am glucose
• Stress or steroids
• Interrupted and/or unreliable food intake
• Nursing routine problems
• Lispro insulin at time of tray
• Reluctance to give lispro with normoglycemia
• Supplemental lispro with elevated glucose
• Short-acting secretagogue in half hour before
  tray
• Little risk of hypoglycemia if limited intake

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How to Initiate MDI

• Starting dose 0.4 to 0.5 x weight in kilograms
• Bolus dose (lispro/aspart) 20 of starting dose
  at each meal
• Basal dose (glargine) 40 of starting dose
  given at bedtime or anytime
• Correction bolus (BG - 100)/ Sensitivity
  Factor, where SF 1500/total daily dose

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How to Initiate MDI

• starting dose 0.2 x wgt. in lbs.
• Wgt. 180 lbs which 36 units
• Bolus dose (lispro/aspart) 20 of starting dose
  at each meal, which 7 to 8 units ac (tid)
• Basal dose (glargine) 40 of starting dose at
  HS, which 14 units at HS
• Correction bolus (BG - 100)/ SF, where
  SF 1500/total daily dose SF 40

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Correction Bolus Formula
Current BG - Ideal BG Glucose Correction factor

• Example
• Current BG 220 mg/dl
• Ideal BG 100 mg/dl
• Glucose Correction Factor 40 mg/dl

220 - 100 40
3.0u