What to Do When Your Patient

Has Diabetes
Karen A. McDonough MD
Inpatient Medical Service
UWMC
Stress Hyperglycemia Increases
Morbidity/Mortality in:

• Acute MI
• Acute stroke
• Medical and surgical admits to an
inner city hospital
 Hyperglycemia and Infection
• Abnormal leukocyte function in patients
with diabetes
• Improves with control
• Risk of surgical site infection correlates
with severity of perioperative
hyperglycemia
 Hyperglycemia and Infection
• 1548 patients admitted to a surgical
intensive care unit, almost all post-op
• 13% diabetic
• Randomized to intensive insulin therapy to
maintain blood glucose 80-110 mg/dL
versus usual care
• Mean blood glucose in experimental group
103 mg/dL versus 153 mg/dLfor control
group

Van den Berghe NEJM 2001; 345: 1359

 Intensive
11% insulin
Control
8% 8%
7%
5% 4%

In hospital death Death in ICU ICU sepsis

Other benefits of glucose control
• Less critical illness polyneuropathy
• Less renal failure requiring dialysis
• Less antibiotic use
Van den Berghe NEJM 2001; 345: 1359
• Less osmotic diuresis/electrolyte
abnormalities
• Less gastric dysmotility/vomiting
Goal for inpatient
therapy
ICU: 80-120
Floor: CBG 100-180
Normal Physiologic Insulin
Release

Prandial

Basal

B L D
 Insulin Action - Hours

Onset Peak Duration

NPH 1-2 4-8 12-20
Glargine 2-3 None ~24
Regular ½-1 2-4 6-10
Lispro, ¼ 1 4-6
aspart
 Case # 1
A 58 year old woman with well controlled
type 2 diabetes is admitted with community
acquired pneumonia. Although she has felt
ill for 2 days, she has been able to eat and
has continued her usual insulin - glargine
15U at hs and lispro 5 U before each meal.
Her admission blood glucose is 280.
.
 Sliding Scale??

<90 1 amp of D50

90-200 nothing
201-250 2 U regular subQ
251-300 4 U regular subQ
301-400 6 U regular subQ
401+ 8 U and call H.O.
 “Roller-coaster” glucose control
10U
350 6U

250

150

50
1 amp D50
 Insulin order
• Basal insulin

• Prandial insulin

• OPTION AT UW AND HMC

Supplemental insulin (for pre-meal
hyperglycemia)
150-200 1 U lispro
201-250 2 U lispro
251-300 3 U lispro ...
 Supplemental Insulin
Additional prandial insulin for premeal
hyperglycemia
Lispro and aspart are ideal
rapid onset of action controls hyperglycemia
rapid offset makes later hypoglycemia less likely
NO doses less than 4 hours apart to avoid
“STACKING” and hypoglycemia
GREAT CAUTION with regular insulin
 But how is this different from a
sliding scale?
• Patients get basal insulin, just like at home
• Patients get prandial insulin even if CBG is
normal
• Supplemental insulin is given IN
ADDITION to usual diabetes regimen (not
instead of it) to correct premeal
hyperglycemia
 What if my patient is not eating
as much as usual?

• Reduce prandial insulin

• May need to reduce basal insulin by about a
third
• If stressed by illness, may not need to
reduce usual basal doses
 What if my patient is not eating
at all?
• Stop prandial insulin
• For Type 1 patients on glargine - continue
at usual dose
• For all others - decrease other basal insulin
by 1/3
 Case #2
A 41 year old man with type 1 diabetes
presents with a 12 hour history of nausea and
LLQ discomfort. He is diagnosed with
diverticulitis and admitted. Although he has
been unable to eat, his blood glucose is 234.
His outpatient insulin regimen consists of
NPH and regular insulin before breakfast and
dinner. How should he be managed?
 NPO Type 1 Patient
• MUST have insulin to prevent DKA, death
• OPTIONS:
– Insulin drip
• Preferred treatment at UWMC
• Available on any floor
• More restrictions at HMC
• Only in ICU at VA (but VERY few Type 1 patients)
– Long acting subQ insulin with close monitoring
and supplemental insulin prn (but no more
frequently than lispro/aspart q 4 hours)
 Insulin Drips
• Variable rate IV infusion of insulin
• Adjusted per protocol
• Chemsticks q 1 hour until stable
• Daily Chem 7
• Dextrose containing IV fluids - D51/2NS at
100 cc/hour
 Pitfalls with Insulin Drips
• Turning off dextrose while insulin still
running hypoglycemia
• Failing to notice when blood glucose is
falling too fast
• Stopping an insulin drip without having
given subQ insulin – this causes patients to
develop (or RE-develop DKA)
 Transition to SubQ Insulin
• When able to eat
• Best time to stop is when a dose of basal
and prandial insulin would usually be given
• Strategies for glargine
– Continue the drip as “basal” insulin,
giving mealtime prandial insulin subq,
until glargine due that evening
– give 1/2 usual glargine dose as NPH in
the morning before stopping the drip
 What if I can’t use an insulin
drip?
• BASAL insulin
• AT UWMC/HMC -use RAPID acting
insulin to correct hyperglycemia if CBG >
180
• No rapid acting doses < 4 hours apart!!
• Adjust basal insulin dose if extra insulin
required
 Case #3

A 77 year old woman with type 2 diabetes,

treated with rosiglitazone and metformin, is
admitted to the hospital with unstable
angina. Her diabetes is well controlled, and
blood glucose is132 at admit. She will
undergo cardiac cath at 11 am tomorrow.
How should she be managed?
“Drink plenty of fluids and stay out of the sun”
 Contraindications to Metformin
• Renal insufficiency (Cr  1.5 in men, 1.4 in
women)
• Congestive heart failure requiring drug
therapy
• Acute or chronic acidosis
• Iodinated contrast (until Cr documented to
be normal 48 hours after contrast)
• Relative – liver disease, hypoxia
 Other oral agents…
Glitazones – contraindicated in NYHA Class
3 or 4 CHF
Sulfonylureas – cause hypoglycemia,
especially in the elderly and those with
renal failure
 Case #4
A 22 y.o. man presented 36 hours ago with
DKA and was diagnosed with type 1
diabetes. He has been managed with an
insulin drip, at 0.5 units per hour for the
past 10 hours, and is doing well. He has
been able to tolerate clears without nausea,
and this morning is ready to eat breakfast.
What insulin order will you write?
Starting insulin in type 1 patients
• Start with 0.2-0.4 units per kg per day
• Divide into ½ basal and ½ prandial insulin
• Basal options:
– NPH
– Glargine
• Prandial options:
– Regular
– Lispro or aspart
 Insulin Analogues in T1DM
Rapid acting
• Less postprandial hyperglycemia
• Greater flexibility in meal timing/amount
• Require patient commitment
• No clear improvement in HgbA1c
Long acting
• Less hypoglycemia
• Improved HbA1c in some studies
Hirsch I NEJM 2004; 352:174
 Case #5

A 62 year old man with a 12 year history of

type 2 diabetes is admitted for IV
antibiotics
for hand cellulitis. He is on maximal doses
of glyburide and metformin, and recent
HgbA1c was 10.2%.
 Triple Oral Therapy

• Patients with HgbA1c 8.5% despite

sulfonylurea plus metformin randomized to
addition of troglitazone vs placebo
• At 6 months, 43% of troglitazone patients
had HgbA1c 8%, vs 6% with placebo
• 15% had HgbA1c 7%

Annals of Internal Medicine 2001;134:737

 Triple Oral Therapy

• Glipizide $19.99
• Generic metformin $55.99
• Rosiglitazone $77.99

$153.97
 Bedtime Basal Insulin –
NPH or glargine
• Patients with HgbA1c  7.5% on 1 or 2 oral
agents
• NPH or glargine started at 10 U at bedtime,
and titrated according to a weekly titration
schedule based on self monitored FPG
• Oral agents continued
• Goal FPG  100
Diabetes Care 2003;26:3080
 Bedtime Basal Insulin
• Mean HgbA1c at baseline = 8.6%
• Mean Hgb A1c at end = 7%; 60% achieved
HgbA1c  7%
• Mean daily insulin doses 47 U with
glargine, 42 U with NPH
• Less symptomatic hypoglycemia with
glargine than NPH (13.9 vs 17.7 per
patient/year)
Diabetes Care 2003;26:3080
Starting Bedtime Basal Insulin
• 10-20 units, or 0.1-0.2 U/kg (can start
higher if very poorly controlled)
• Measure CBG before breakfast
• Increase by 4 units if CBG is over 140 on 3
consecutive measures
• Increase by 2 units if CBG is 110-140 on 3
consecutive measures
• Don’t increase if hypoglycemia has
occurred in the past week
JAMA 2003;289:2265
 Teaching opportunities
• Diet review
• Medication teaching
• Review of insulin injection technique
• Review of glucometer use
• Initiation of insulin (in consultation with
PMD)
• Review of foot care
 Case #6
A 52 year old man with diabetes will be
having an EGD/colonoscopy tomorrow. His
diabetes is well controlled with NPH insulin
10 units at 7 AM and 8 units at 9 PM, and
insulin lispro before meals. His AM glucoses
run 90-110 mg/dL.
What is the best approach to diabetes
management for this patient?
 Periprocedural Management
of T1DM

• Must have basal insulin to prevent ketosis

even if not eating
• Ideally minor procedures that require NPO
status should be done first in am
Periprocedural Management of
Type 1 Patient
OPTIONS:
– Long acting subQ insulin with close monitoring
and supplemental insulin prn
– Insulin drip
• Preferred therapy for major procedures at
UWMC
• Nursing staff must be trained
 Type 2 – Insulin treated

• First thing in am for minor procedures

• Insulin drip for major procedures
• Begin when CBG > 120 if they’ve
taken insulin night before or am
• Basal insulin plus supplemental lispro or
aspart
 Type 2 – Diet or Oral Agents
• May not require insulin
• For major surgery, start insulin drip when
CBG above goal range
• For minor procedures, correction doses of
rapid acting insulin for hyperglycemia
• Hold metformin for 48 hours post op,
with normal Cr
• Hold other oral agents til PO intake good
 Case #7
A 22 year old man with type 1 diabetes is
admitted with severe odynophagia due to
HSV esophagitis. He uses an insulin pump
with a basal rate of 1 U per hour, and uses
mealtime boluses of 1 U of insulin per 10
grams of carbohydrate. Oral intake is
limited. How will you manage him?
 Insulin Pumps
• Can continue IF patient with it enough to
manage
• Continue basal rate only if NPO
• Patient may need to increase basal rate if
stressed or on steroids
• Patients managed with pumps are usually
pretty sophisticated – listen to them
 Take home points
• Controlling hyperglycemia is important
• Sliding scale insulin is not the way to do it
• Insulin drips for type 1 patients who are not
eating
• Supplemental insulin in addition to usual
insulin regimen to control stress
hyperglycemia
• Help with diabetes management is always
available – Endocrine Consult Service at all
hospitals, nurse specialist at UWMC and
HMC