Therapeutics II - Exam 1 - Inpatient Hyperglycemia

when should you check a patient's A1C in an inpatient setting?

- hyperglycemic (qualified as BG >140 mg/dL inpatient!)

- DM without a recent A1C (within the last 3 months)

_____________ guides drug therapy upon discharge

admission A1C

- especially when A1C >6.5%

what are the 3 levels of hypoglycemia in inpatient settings? provide the ranges/definition for each

- level 1: BG 54-69 mg/dL

- level 2: <54 mg/dL

- level 3: clinical event (change in mental status or physical functioning that requires assistance from another person for recovery)

when should glucose-lowering therapy be initiated in inpatient settings?

when BG is persistently >180 mg/dL (2+ measurements within 24 hours)

what is the BG goal for ICU vs non-ICU patients being treated for hyperglycemia?

ICU: 140-180 mg/dL

non-ICU: 100-180 mg/dL

when should you check a patient's BG in inpatient settings if they are eating (PO diet)? if they are not eating? if they receive an IV insulin drip?

- eating: BEFORE meals

- not eating: every 4-6 hours

- IV insulin drip: hourly (30 min-2 hrs)

- CGM +/- automated insulin delivery (AID) (only if patient can manage this themselves!)

what is the preferred glucose-lowering treatment in critical care settings? describe the administration rate

continuous IV infusion of regular insulin

- infusion rate should be protocolized; rate should be changed depending on the rate of change in BG

what is the recommended treatment regimen for non-critical care patients who are NPO/have poor PO intake? who have adequate nutritional intake? on continuous tube feeds?

- NPO/poor PO: basal insulin +/- correctional dose insulin (CDI) subcut

- PO: basal + prandial + CDI subcut

- continuous tube feeds: basal + q4-6h bolus + CDI subcut

T/F: CDI can be given alone as adequate treatment for hyperglycemia

FALSE

- CDI should NOT be given alone; given in addition to subcut basal or basal + bolus regimen

what is Jefferson's CDI regimen dependent on? (institution-specific)

- PO or NPO

- degree of insulin requirements

what types of insulin can be used as CDI? when in BG measured during each treatment type?

rapid-acting (lispro, aspart, glulisine)

- for PO patients

- measure BG via POC testing before meals, 9 pm, and 2 am

regular insulin

- for NPO or continuous tube feed patients

- measure BG via POC testing q6h

what are the primary indications for SGLT2i in hyperglycemia? how is this adjusted during hospitalization?

DM + HF

- continue or initiate during hospitalization and at D/C

- D/C 3-4 days before scheduled surgeries!

you should AVOID using SGLT2i for hyperglycemia in the case of...?

- severe illness

- ketonuria, ketonemia

- prolonged fasting

- surgery

what are the prime conditions for adding a DPP4i to a patient's glucose-lowering regimen? when should these agents be D/C'd?

safe for patients with mild-moderate hyperglycemia and low risk of hypoglycemia

- +/- basal insulin

- D/C saxagliptin and alogliptin in patients with HF!

how do you transition a patient from IV insulin to basal/bolus regimen?

give subcut basal insulin 2 hours before stopping IV infusion

how do you transition a patient from insulin to a non-insulin therapy?

resume pre-hospital non-insulin therapies 1-2 days before discharge from the hospital

what BG level indicates immediate intervention is needed for inpatient hypoglycemia?

<70 mg/dl

what are some of the common hypoglycemia triggers for inpatients?

- inappropriate insulin dosing/timing/administration

- failure to decrease insulin dose after hypoglycemia

- missed or delayed POC BG testing

- improper use of other glucose-lowering agents

- nutrition-insulin mismatch

- AKI

- reduced dose of steroids or IV dextrose

- inability of patient to report sx of hypoglycemia

what are some of the common hyperglycemia triggers for inpatients?

- d/c of home anti-hyperglycemia meds

-receiving ONLY CDI

- receiving glucocorticoids

- physiologic stress

- tube feeds

describe patient counseling for hyperglycemia in inpatient settings

- asses DM self-management knowledge on admission

- provide counseling throughout hospitalization

- discharge counseling should include med dosing/administration, meal planning, BG monitoring, recognition and management of hypogylcemia