Glycemic management for

sick patient at home

Physiology of insulin secretion
 Physiological Insulin Secretion in
Response to Glucose Levels
Serum Insulin levels
Total insulin secretion*
24 + 6 + 6 + 6 =
42 units/day
Or approx 0.6 units/kg

6 6 6

Basal Secretion (Approx 1 unit/hr = 24 units/day)

BF Lunch Dinner 10pm 4am

* 70kg with minimal insulin resistance

 Anti-diabetic agent classes
Classes
Insulin sensitizers Biguanides
TZDs
Insulin providers Insulin and analogues
Sulphonylureas
Glinides
Insulin enhancers GLP-1 receptor agonist (GRA)
DPP4 inhibitors
Glucose excretor SGLT-2 inhibitors
Glucose restrictor Alpha-glucosidase inhibitors
Member agents
Metformin
Pioglitazone
Soluble, NPH, glargine, detemir, aspart
Gliclazide, Glimepride
Repaglinide
Liraglutide, Semaglutide
Sitagliptin, Linagliptin, Vildagliptin, Tenagliptin
Empagliflozin, Canagliflozin, Dapagliflozin
Acarbose, Voglibose
 Estimated Efficacy of Hypoglycemic
Drugs (Available in US)
Drug A1c% decrease Drug A1c% decrease
Metformin 2000mg 1.01 Dapagliflozin 5mg 0.65
Metformin 2550mg 1.09 Dapagliflozin 10mg 0.73
Gliclazide MR 60mg 0.8 (Polavarapu et al 2020) Empagliflozin 10mg 0.69
Glipizide 5-20mg 0.86 Empaglifozin 25mg 0.77
Glimepride 1-8mg 0.97 Liraglutide 0.6mg 0.88
Pioglitazone 15mg 0.62 Liraglutide 1.2mg 1.13
Pioglitazone 30mg 0.85 Liraglutide 1.8mg 1.25
Pioglitazone 45mg 0.98 Linagliptin 5mg 0.59
Canagliflozin 100mg 0.84 Sitagliptin 100mg 0.72
Canagliflozin 300mg 1.01 Basal insulin 1.5
The decrease in A1c are modeled for drug naïve patients with an A1c of 8% and a weight of 90kg after 26 weeks of treatment.

https://www.ncbi.nlm.nih.gov/books/NBK279141/
Sick Day Rule
Sick days
• It is the times when the patient cannot eat solid food or follow their
regular meal plan because of concurrent illnesses, dental or
outpatient surgery.

• Potential problems during sick days are

• Dehydration
• Ketoacidosis
• Hyperglycemia
• Hypoglycemia
Sick day rules
The following are key messages that should be given to all patients with
diabetes if they become unwell:
• Increase frequency of blood glucose monitoring to four hourly or
more frequently
• Encourage fluid intake aiming for at least 3 litres in 24hrs
• If unable to take struggling to eat may need sugary drinks or milk to
maintain carbohydrate intake
• It is useful to educate patients so that they have a box of 'sick day
supplies' that they can access if they become unwell
• Access to a mobile phone has been shown to reduce progression of
ketosis to diabetic Ketoacidosis
Sick day rules
If a patient is taking oral hypoglycaemic medication,
• they should be advised to continue taking their medication even if they are not
eating much.
• Remember that the stress response to illness increases cortisol levels pushing
blood sugars high even without much oral intake.
• The possible exception is with metformin, which should be stopped if a patient is
becoming dehydrated because of the potential impact upon renal function.

If a patient is on insulin,
• they must not stop it due to the risk of diabetic ketoacidosis.
• They should continue their normal insulin regime but
• ensure that they are checking their blood sugars frequently.
Sick day rules
• Insulin requirement may increase during illness and supplemental insulin (5-
20% increase above the daily required dose based on blood glucose level) may
be required to prevent DKA.
• Patients should be able to check their ketone levels and if these are raised and
blood sugars are also raised they may need to give corrective doses of insulin.
• The corrective dose to be given varies by patient, but a rule of thumb would
be total daily insulin dose divided by 6 (maximum 15 units).
• If glucose > 13 mmol/l, increase insulin by 2 units/d until control is achieved or
use top-up injections of short-acting insulin PRN.
• Conversely, hypoglycemia may also be encountered in case of GI illness and
dose reduction in insulin may be required.
• The patient should continue eating foods and drinking fluid even if there is
vomiting and/or diarrhea.
Sick day rules
Possible indications that a patient might require admission to hospital
would include:
• Suspicion of underlying illness requiring hospital treatment e.g. myocardial
infarction
• Inability to keep fluids down - admit if persisting more than a few hours
• Persistent diarrhea
• Significant ketosis in an insulin dependent diabetic despite additional
insulin
• Blood glucose persistently > 20mmol/l despite additional insulin
• Patient unable to manage adjustments to usual diabetes management
• Lack of support at home e.g. a patient who lives alone and is at risk of
becoming unconscious
Insulin Management For
Acutely Ill Condition
Change in glycemic balance during severe illness
High sugar Low sugar
“Stress hyperglycaemia”  Reduced nutrition intake
 Steroid effect  Meal interruption
 Increased catabolism  Missing oral tablets
 Insulin stacking (using rapid
 IV DW, DS acting insulin multiple times at
 Fear of hypoglycaemia closed intervals)
 Reduced physical activity
Characteristics of patients with insulin deficiency

• Known type 1 DM

• History of pancreatectomy or pancreatic dysfunction

• History of wide fluctuations in blood glucose levels

• History of diabetic ketoacidosis

• History of insulin use for > 5 years and/or diabetes for > 10 years
Challenges in using oral anti-diabetic drugs
during severe illness
• Metformin – risk of acidosis

• Sulphonylurea – pancreatic exhaustion, risk of hypoglycaemia in ESRD

• Pioglitazone – risk of fluid overload

• SGLT- 2 inhibitors – risk of dehydration and ketoacidosis

• Acarbose – based on oral intake

Challenges in starting insulin treatment in
acutely ill patient at home
• Care giver
• Commitment to insulin therapy
• Friendliness to insulin treatment
• Cost
• Feasibility of monitoring
• Emergency plan
• Support service
Methods of insulin use during acute condition
• Sliding scale/Basal bolus or multiple dose insulin

• Continuous IV insulin - Fixed rate insulin infusion (FRII)

• GKI - variable rate insulin infusion (VRII)

 sliding scale vs insulin infusion
Sliding scale Insulin infusion
Less tight control Tight control
Quarterly adjustment per day Rapid adjustment
SC insulin use IV insulin use with syringe
Nursing care needs + Insulin infusion pump needs
See-saw effect Closed monitoring
Nursing care needs +++
Catheter complications
Basal bolus and
sliding scale
Sliding scale insulin
• This regimen is indicated for patients with poor control of RBS who are not so ill
and taking food orally or with nasogastric tube.
• Sliding scale insulin therapy may be still useful in situations with unpredictable
glycemic responses and where more frequent monitoring is not feasible because of
resource limitation.
• Hyperglycaemia and hypoglycaemia commonly occurs when sliding scale insulin
dosing is used without basal insulin therapy or continuation of OHA.
• Initial sliding scale for a few days (1-3 days) should be followed by basal bolus
regimen based on the blood sugar trends.
• It is better to review the trends of blood sugar results twice a day.
• If the patient’s meals are still not regular, and the BS is still > 200mg/dl for 2-3
occasions step up to higher scale.
Basal bolus or multiple dose insulin
• Scheduled subcutaneous insulin with basal, nutritional and correction
components is the preferred method for achieving and maintaining
glucose control in non-critically ill patients
• Starting dose = 0.3 to 0.5 unit x weight in kg
• Bolus dose regular insulin or rapid acting analogue (aspart/lispro) =
20% of starting dose at each meal or according to carbohydrate loads
• Basal dose NPH or long acting analogue (detemir/glargine) = 40% of
starting dose given at bedtime or any time
• Correction bolus = (current BS – 140mg/dl)/CF
Additional correction boluses if BS > 140mg/dl or reduction of dose if BS < 100mg/dl can be
done.

Easy fixed rule for correction:

Insulin sensitive – 1 U – 50mg/dl; insulin intermediate – 1 U – 25mg/dl; insulin resistance – 1 U – 15 mg/dl
Sliding scale to basal bolus
• After 24 to 48 hours, if patients’ condition improve and oral feeding is
more regular, it should be changed to basal bolus type with inclusion
of intermediate or long acting insulin such as isophane (NPH at bed
time or insulin glargine or Levemir).

• The dosages prescribed are depending on the previous day’s RBS

trends and patterns.
Basal bolus to fixed insulin regimen
• When the glucotoxicity is over and food intake is more regular, total
daily dose can be calculated and then pre-mixed and split mixed
regimen can be given if there is long term insulin therapy is indicated.

• In some patients, insulin therapy can be replaced by OAD.

Premixed insulin regimen
Split-mixed insulin regimen
Basal insulin regimen
Case study
55 year old man
• Single, living alone in own house
• House call is invited by a relative (who lives far from his house)
• Complaint:
• Dizziness and fatigue x 1 day
• Request for IV tonic
• Initial impression:
• normal consciousness, exhausted
Further assessment
• Recent history of: Vital signs and examination
• Vomiting x 3 times • T – 96.2 F
• Loose motion x 3-4 times
• Urine output (+), scanty
• BP – 170/110
• Past medical history • PR – 99
• DM and HT • Sp02 – 98%
• Numbness in both legs • RBS – 526 mg%
• Drug history • GC – dehydrated
• Metformin 500mg od cm
• Lungs – crackles in Rt lung base
• Amlodipine 10mg od cm
(self-prescribed and taking • Abdomen – NAD
irregularly) • No oedema
Monitoring chart
Day Temp BP PR Sp02 RBS Urine Glycemic Insulin IV Fluid
output control unit
1 3:00pm 96.2 170/110 99 98 526 Nil Novorapid 10 unit NS2, RL2
5:00pm 154/96 101 508 Novorapid 5 unit
6:00pm 140/88 100 368 + Novorapid 10 unit
11:00pm 164/99 100 370 Novorapid 10 unit
2 6:00 am 162/94 95 280 + OHA NS1, RL1
9:00 am 164/96 96 375 10 unit
12:00 pm 178/98 375 + Novorapid 10 unit
5:30 pm 151/85 95 397 Novorapid 10 unit
8:00 pm 135/85 97 Glargine 10 unit
3 6:00 am 153/89 93 317 +++ Novorapid 10 unit Omit drip
9:00 am 163/96 88 251
12:00 pm 156/91 351 Initiate sliding scale
6:00 pm 160/78 137