Inpatient hyperglycemia

32-38%; 33%; 80%

Hyperglycemia occurs in ____ of general hospitalized patients, and ____ have diabetes diagnosis, and up to ____ of ICU patients have diabetes

1. Admitted patients with dx of DM

2. Admitted patients with HYPERglycemia

3. Admitted patients with HYPOglycemia

Three types of patients that are pertinent to inpatient glucose issues

Before meals and likely at bedtime

Patients with diabetes or inpatient HYPERglycemia receiving INSULIN who ARE EATING should have their glucose monitored

every 4-6 hours

Patients with diabetes or inpatient hyperglycemia RECEIVING insulin who are NOT Eating should have their Bg checked 

every 30 minutes to 2 hours

Patients with an insulin infusion/pump should have their BG checked

variably, but typically before meals and bedtime

Patients with DM or inpatient hyperglycemia WITHOUT insulin who ARE EATING should have their BG checked

variably, but usually every 4-6 hours

Patients with DM or inpatient hyperglycemia WITHOUT insulin, who are NOT eating should have their BG checked 

140-180 mg/dL

most common BG range/goal for inpatient population should be ____!!!!!*** (NICE TRIAL)

110-140 mg/dL

Select patient populations including cardiac surgery patients must have their BG range between

all patients with DM or with a BG of >140 mg/dL

A1C should be obtained on ________ upon admission to hospital (unless A1C performed in last 3 months)

6.5%

A1C > _____ indicates that a patient likely had diabetes/hyperglycemia prior to hospitalization

• insulin administration and dosing errors

• nutrition changes

• Emesis

• inappropriate Rx of non-insulin therapies for DM

• Mismanagement if initial hypoglycemia episode

• Renal function decrease

• Reduction in corticosteroid use

Causes of inpatient HYPOglycemia

Repeat BG; If repeat BG <70 mg/dL, treat per appropriate route

If patients Bg is <70 mg/dL, and they have no symptoms, the appropriate action would be to_____

Administer 15g of rapid carbohydrates (rule of 15)

If patients Bg is <70 mg/dL, and they have sx but can take PO meds, the appropriate action would be to_____

Administer glucagon IM 1mg

If patients Bg is <70 mg/dL, and they are symptomatic with no PO OR IV access, the appropriate action would be to_____

Administer 25g dextrose (D50% 50 mL or D10% 250 mL) IV

If patients Bg is <70 mg/dL, and they are symptomatic with no PO but do have IV access, the appropriate action would be to_____

Insulin; HIGH-RISK

____ is typically the preferred agent for inpatient hyperglycemia management in hospital, but is also considered a _______ medication

renally

Insulin must be monitored _____ inpatient-wise because it is eliminated this route

Consistent IV insulin regimen, clinically stable, and if SQ insulin is controlling BG

SQ insulin for inpatient is indicated for

Hyperglycemic emergencies, changing clinical status, hyperglycemia that is refractory to SQ insulin, cardiogenic shock, post-cardiac surgery or dose-finding strategy

IV insulin for inpatient is indicated for

• When insulin is given to basal and/or prandial doses to “correct” an elevated BG

• Can be used short-term for basal dose finding

• rapid (aspart, lispro, glulisine) or short acting (human regular) insulin preferred

What is correction insulin ?

Continue home insulin regimen or slight decrease in insulin; Consider adding correction insulin

For patients with DM/hyper WITH a diet - if they get insulin at home and their BG controlled -

• Increase basal insulin (10-20%) PLUS

• Add/restart prandial insulin PLUS

• Add correction insulin

For patients with DM/hyper WITH a diet - if they get insulin at home and their BG is NOT controlled -

Consider adding correction insulin

For patients with DM/hyper WITH a diet - if they DO NOT get insulin at home and their BG is controlled -

• Start basal insulin at 0.1-0.3 units/kg/day PLUS

• Add prandial insulin PLUS

• Add correction insulin

For patients with DM/hyper WITH a diet - if they DO NOT get insulin at home and their BG is NOT controlled -

• continue home basal insulin regimen (or decrease) PLUS

• Discontinue prandial insulin PLUS

• Consider correction insulin

For patients with DM/hyper WITHOUT a diet - if they get insulin at home and their BG is controlled -

• Continue home basal insulin PLUS

• Discontinue prandial insulin PLUS

• Add correction insulin

For patients with DM/hyper WITHOUT a diet - if they get insulin at home and their BG is NOT controlled -

D/C oral diabetic agents PLUS consider correction insulin

For patients with DM/hyper WITHOUT a diet - if they DO NOT get insulin at home and their BG is controlled - 

Start basal insulin 0.1-0.2 units/kg/day PLUS add correction insulin

For patients with DM/hyper WITHOUT a diet - if they DO NOT get insulin at home and their BG is NOT controlled -

Without a diet ordered (common sense)

Prandial insulin should be D/C’s in all patients _____

AFTER meals

Consider administering prandial insulin _____ for inpatients who do not have a consistent calorie intake to allow for appropriate dose adjustments

Insulin regular (short acting) at 1 unit/mL; 30 minutes to 2 hours

When giving insulin IV, give ______ and monitor every _____

1. When insulin infusion rate is stable > 4 hours

2. When patients clinical status is STABLE

3. When there is a plan in place for patient to continue or to begin nutrition support

When should an inpatient transition from IV to SQ insulin

1. Calculate the 24 hr insulin requirements (eval insulin the patient has received in last 6 hours and multiply by 4 - how much they are getting in 24 hours)

2. Calculate 50-75% of 24 hour insulin requirement - which will be the new total daily dose and assign SQ

3. Administer first dose of SQ basal insulin 2 hours prior to stopping insulin INFUSION

4. Add correction insulin regimen

Steps to transition from IV to SQ insulin

Avoided

Mixed insulins (70/30 + 50/50, etc..) are generally _______ in hospital patients

held

Most non-insulin therapies are _____ at hospital admission, and hospitals need a plan to ensure these therapies are resumed when appropriate

Sulfonylureas; Meglitinides

_____ and ______ are non-sinulin classes that MUST be held upon admission to hospital due to hypoglycemia and renal issues

Metformin; DPP-IV; GLP-1 RA’s

______, ____ and _____ are classes of non-insulins the caution use with in the hospital

SGLT2i’s

Diabetic ketoacidosis is most at risk for patients taking 

TZD’s; Alpha-glucosidase (Acarbose and miglitol), and SGLT2i’s

______, ____ and _____ are OTHER classes of non-insulins to caution use with in the hospital

hold; oral

It is good practice to ______ all _______ medications for diabetes upon admission to the hospital