Inpatient Management of Diabetes Mellitus

1
Inpatient Management of Diabetes Mellitus

• William Harper, MD, FRCPC
• Endocrinology Metabolism
• Assistant Professor of Medicine, McMaster
  University

2
DKA

• Monitored setting if Hi-risk
• elderly CAD, pH lt 7.0, severe K disturbance,
  decreased LOC
• IV Fluid Resuscitation (6-8L deficit)
• Potassium (no pee no K)
• IV insulin
• Identify Rx underlying cause
• Noncompliance, infection, MI, etc.

3
DKA IV Fluids

• IV NS 1L/h x 2-3h or longer so no more
  tachycardia, hypotension, orthostatic changes,
  low JVP.
• Then change to 1/2 NS
• 500 cc/h x 1-3h
• 250 cc/h x 4-6h
• If hypotension recalcitrant to fluids consider AI
  (Schmidt PGAS II) and send stat cortisol then
  give solucortef 100 mg IV q8h.

4
DKA Mortality

• Adults 2-4
• Hypokalemia
• MI, CVA, etc.
• Kids 0.2-0.4
• Cerebral edema

5
DKA Potassium

• Need K with initial IV fluid insulin Rx unless
• Anuric
• K gt 5.5 mEq/L or hyperkalemic ECG changes

Initial K Replacement
gt 5.5 mEq/L nil (initially)
5.2-5.5 mEq/L 10 mEq/h
4-5.2 mEq/L 20 mEq/h
3-4 mEq/L 30 mEq/h
lt 3 mEq/L 40 mEq/h
gt 20 mEq/h Cardiac monitor gt 60 mEq/L Central
line
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DKA IV Insulin

• Humulin R or Novolin Toronto
• Bolus 0.1-0.2 U/kg IV
• Then IV gtt _at_ 0.1-0.2 U/kg/h
• (50 U of regular insulin in 500cc D5W
  1U/10cc)
• Monitor CBG q1h
• Monitor Venous BS, electrolytes, creatinine q2h
• Aim is to demonstrate correction of Anion Gap
  (AG) and decrease in BS 4.4 mM/L/h
• Monitoring serial serum ketones NOT useful
• ßHß (not detected) DKA Rx Acetoacetate
  (detected)

7
DKA IV Insulin

• Using insulin to treat 2 different and separate
  metabolic disturbances in DKA
• Ketoacidosis
• Hyperglycemia

8
DKA IV Insulin

• If AG not correcting and/or BS not decreasing
  then increase IV gtt rate 1.5-2X
• If BS lt 13 but AG still not corrected do NOT
  decrease insulin IV gtt.
• Instead start IV glucose gtt
• D5W-D10W _at_ 100-200 cc/h
• Once AG corrected than titrate IV insulin to BS
• When BS lt 13 and AG normal reduce IV insulin gtt
  to 1-2 U/h and add IV glucose if not already done.

9
DKA IV Insulin

• Can consider switch to SC insulin when
• AG normalized
• BS lt 15 mM
• Insulin IV gtt requirements lt 2U/h
• Patient able to eat
• Overlap insulin IV gtt with 1st SC insulin by
  3-4h to avoid recurrent ketosis.

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DKA Other Rx

• Bicarbonate
• May exacerbate hypokalemia
• Only give if pH lt 6.9 AND evidence of
  cardiovascualr instability (arrythmia, CHF,
  hypotension)
• 1-2 amps bicarb in 1L D5W IV over 2h until pH gt
  7.1
• Phosphate
• Routine IV not recommended
• Rx symptomatic hypophosphatemia (rhabdo,
  unexplained CHF or respiratory failure, severe
  confusion)
• 10cc K Phos soln (3.0mEq Pi and 4.4 mEq K/cc) in
  1L NS IV over 8-12h

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DKA Other Rx

• Cerebral Edema
• Usually only kids
• Persistent decreased LOC despite standard Rx of
  DKA
• CT scan to confirm diagnosis
• Decadron 10 mg IV
• Mannitol 25 mg IV

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HONC

• BS gt 55
• Serum OSM gt 350
• Coma 25-50
• Mortality rate 25-70

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HONC

• Coma Management
• ABCs, O2, narcan, D50W, thiamine, etc.
• IV Fluid Resusciation (10L free water defecit)
• Insulin
• IV fluids will decrease BS by 4 mM/L/h by itself
• For most patients insulin not absolutely
  neccesary
• Insulin IV bolus 5-10 U, gtt _at_ 1-2 U/h
• Potassium (replace as in DKA)
• Identify Rx underlying precipitant

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BS gt 11.1 mmol/L
Renal threshold for glycosuria (normal GFR)
Decreased WBC function Chemotaxsis Phagocytosis
Decreased Wound Healing
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Goals of Inpatient DM Management

• Avoid hypoglycemia and marked hyperglycemia
• Target BS 7.0 - 11.0 mM
• Avoid Hypoglycemia
• Precipitating arrhythmia or other cardiac events
• Inducing seizure, focal or cognitive defects
  periop
• Avoid Marked Hyperglycemia (BS gt 11.1 mM)
• Treat (and avoid) DKA, HONC

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DM Inpatient Management

1. Eating
2. NPO temporary (for a test)
3. NPO prolonged

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DM Inpatient Management

• Eating
• OHA (T2DM)
• Insulin (T2DM and T1DM)

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OHA
Drug BG HbA1c Side-effects
Sulfonylurea FBG 20 1.5-2.0 Hypoglycemia Weight gain
Biguanide FBG 20 1.5-2.0 Lactic acidosis GI intolerance
TZD FBG 2.2-3.6 mM 1.0-1.6 Edema Weight gain
a-glucosidase Inhibitor FPG 14 PPG 25 0.5 GI intolerance
Meglitinide FPG 4 mM PPG 5.6 mM 1.8 Hypoglycemia
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Insulin
Type Starts Peaks Duration
Humalog NovoRapid 5-10 min 1-2 hrs 3.5 hrs
Regular 30 min 2-4 hrs 6-8 hrs
NPH Lente 1-2 hrs 6-10 hrs 16-24 hrs
Ultralente 4-6 hrs 8-24 hrs 24-36 hrs
Glargine Immediately None Up to 24 hrs
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BIDS Therapy

• T2DM Introduction to insulin
• Keep on OHAs
• Start NPH 0.2 U/kg SC qhs
• Increase by 2-4 U q4d until FBS 4-7
• If dose gt 30-40U or if BS high late in day
  despite OK FBS than split into 2 injections with
  2/3 acB and 1/3 acD

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Starting Insulin Regimen

• TDD 0.5-0.7 U/kg
• 2/3, 1/3 Regimens
• 2/3 of TDD acB, 1/3 acD
• 2/3 of TDD as Long-acting, 1/3 as short acting
• Pre-mix acB 30/70 acD 30/70
• MDI Regimens
• 2/3, 1/3 Regimen move acD long acting to qhs
• i.e. acB N, H acD H qhs N
• ac meals H qhs N (bolus 60, basal 40)
• ac meals H UL q12h (bolus 50, basal 50)

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Insulin Regimens

• acB
  acL acD qhs
• Bedtime NPH (/-bids) N
• NPH bid N N
• 30/70 bid 30/70 30/70
• MDI (3 injections) H N H
  N
• MDI (gt4 injections) H (/-N) H
  H N
• MDI (gt4 injections) H UL H
  H UL
• CSII (Insulin Pump)

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Guideline for Insulin Adjustments

• Adjust the insulin that accounts for the high or
  low reading.
• Always compare an abnormal BS reading with the
  one previous.
• If insulin dose is
• Less than 8U, adjust by 1U
• 8-20U, adjust by 2U
• gt 20 U, adjust by 10 (increase), 20 (decrease)
• Dont forget to compensate for a successful
  adjustment

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acB acL acD qhs Rx
22 (5R) 9 3.1 (O.J.) 15 acB N20 R10 acD R5 qhs N10
20 15 7 8 acB N20 R10 acD R5 qhs N10
22 17 (RN calls) acB N20 R10
Surgeon ? Internal Medicine ? Endocrinologist
?
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acB acL acD qhs Rx
22 (5R) 9 3.1 (O.J.) 15 acB N20 R10 acD R5 qhs N10
20 15 7 8 acB N20 R10 acD R5 qhs N10
22 17 (RN calls) acB N20 R10
Surgeon Give 5 U Regular SC now Internist Incr
ease qhs N to 12 tonight and acB R to 12
tomorrow Endocrine Increase qhs N to 12 start
tonight Decrease acB N15 R7 starting tomorrow
AM Check 3AM BS tonight
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Guideline for Insulin Adjustments

• Adjust the insulin that accounts for the high or
  low reading.
• Always compare an abnormal BS reading with the
  one previous.
• If insulin dose is
• Less than 8U, adjust by 1U
• 8-20U, adjust by 2U
• gt 20 U, adjust by 10 (increase), 20 (decrease)
• Dont forget to compensate for a successful
  adjustment

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SC Insulin Supplemental Scale
CBG Action
lt 4.0 Call MD
4.1-11.0 nil
11.1-15.0 Humalog 7U SC (0.1U/kg)
15.1-19.9 Humalog 10U SC (0.15 U/kg)
gt 20.0 Call MD
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DM Inpatient Management

1. Eating
2. NPO temporary (for a test)
3. NPO prolonged

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NPO for a test T2DM on Diet Rx

• Schedule test for the AM
• Hold OHAs on AM of test
• CBG _at_ 7AM
• lt 3.0 Consider postpone test
• 3.1-4.0 IV D5W gtt _at_ 75-100 cc/h
• 4.1-11.0 Proceed with test, no Rx necessary
• gt 11.1 IV insulin gtt
• IV D5W gtt _at_ 75-100 cc/h
• gt 20.0 Check urine ketones, consider postpone test

31
NPO for a test T1/T2DM on Insulin

• Schedule the test for the AM
• Hold AM Insulin on day of test
• CBG _at_ 7AM
• lt 3.0 Consider postpone test
• 3.1-11.0 Give ½ of total AM insulin dose as NPH
  SC
• IV D5W gtt _at_ 75-100 cc/h
• gt 11.1 IV insulin gtt
• IV D5W gtt _at_ 75-100 cc/h
• gt 20.0 Check urine ketones, consider postpone test

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DM Inpatient Management

• Eating
• NPO temporary (for a test)
• NPO prolonged
• Patient put on D5W if not on feeds or TPN
• IV insulin gtt
• SC NPH or UL q12h (/- supplemental scale)

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Insulin IV gtt

• Add 50 U of Human regular insulin (Humulin R or
  Novolin Toronto) to 500cc D5W (1U/10cc).
• Flush discard first 50cc.
• Infuse insulin solution by IVAC (intravenous
  infusion pump), piggybacked into D5W running at
  100cc/h.
• Start insulin _at_ 0.9 U/h (9cc/h) or start at a
  rate dependent on patients insulin dose
• IV insulin gtt rate ( ½ TDD ) / 24

34
Insulin IV gtt

• CPG q1h x 2, then q2h (if BS stable x 2-3
  readings consider q4h)
• Adjust Insulin IV infusion rate as per scale
  below
• lt4.0 Call MD
• 4.1-5.0 0.7 U/h ( 7cc/h)
• 5.1-6.0 0.9 U/h ( 9cc/h)
• 6.1-7.0 1.2 U/h (12cc/h)
• 7.1-9.0 1.5 U/h (15cc/h)
• 9.1-11.0 2.0 U/h (20cc/h)
• 11.1-13.0 2.5 U/h (25cc/h)
• 13.1-15.0 3.0 U/h (30cc/h)
• 15.1-17.0 3.5 U/h (35cc/h)
• 17.1-20.0 4.0 U/h (40cc/h)
• gt20.1 Call MD

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Evidence to support Inpatient BS control?

• DIGAMI
• AMI, prior dx DM or BS gt 11 mM
• IV insulin gtt started _at_ 5 U/h
• Titrated to keep BS 7-10.9 mM
• Insulin IV gt 24h ? MDI gt 3 months
• No in-hospital mortality benefit.
• Rx Increased hospitalization by 1.8d
• 0.5 reduction HbA1c _at_ 3 months
• _at_ 1 year on Insulin 72 Rx Group 49 Cntrl
  Group
• 1 year mort ARR 7.5 NNT 13
• 3.4 y mort ARR 11 NNT 9

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Evidence to support Inpatient BS control?

• Leuven, Belgium Study
• ICU patients (63 CV Sx)
• If BS gt 6.1 mM Rx with IV insulin gtt TPN /-
  tube feeds
• Start IV insulin _at_ 2-4 U/h, titrated to BS
  4.4-6.1 mM
• Ave insulin dose Rx group 3.0 U/h Cntrl
  group 1.4 U/h
• Once out of ICU relaxed treatment goal to lt 11.1
  mM
• Mortality in ICU ARR 3.4 NNT 29
• Mortality in-hospital ARR 3.7 NNT 27
• Greatest reduction in mortality was
  sepsis-related.
• Insulin Rx reduced bacteremia, ARF needing HD,
  need for PRBC, critical illness polyneuropathy,
  duration of ventilation and length of stay in ICU
• To what extent were benefits nutrition related as
  opposed to insulin related?