Management of inpatient hyperglycemia

1. Management of InpatientManagement of Inpatient
HyperglycemiaHyperglycemia
By- Dr. Armaan SinghBy- Dr. Armaan Singh

2. Case VignetteCase Vignette
45 year old obese female with DM type II is admitted for acute nausea,
vomiting, and epigastric pain. CT Abdomen with IV contrast
demonstrates acute pancreatitis. Her diabetes is usually controlled on
metformin 1000mg BID and glyburide 10mg BID. Admission BMP shows a
random glucose of 240. How do you manage her hyperglycemia?
A. Continue home regimen
B. Continue home glyburide and discontinue metformin
C. Start sliding scale insulin
D. Start correction insulin

3. Learning ObjectivesLearning Objectives
• Appreciate difference between sliding scale insulin vs correction
insulin
• Understand optimal glycemic control goals in ICU vs non ICU settings
• Review the pharmacokinetics of different insulin preparations
• Learn how to use correction insulin and initiate insulin therapy on UCI
wards

4. The problem with sliding scale insulinThe problem with sliding scale insulin
Time 0700
Break-
fast
0800 1200
Lunch
1300 1700
Dinner
1800 2100
Blood
Glucose
275 350 400 250
Sliding
scale
6
units
10 units 12 units 6
units
•Sliding Scale Insulin
- Treats hyperglycemia with only short/rapid acting insulin without
long-acting basal insulin
- Reactive therapy
-Treats current hyperglycemia, does not prevent future hyperglycemia
- Can cause large swings in glucose levels throughout day
Typical day battling hyperglycemia

5. Correction InsulinCorrection Insulin
• Correctional Insulin
o Results in physiologic subcutaneous insulin administration
o Treats current hyperglycemia with the goal of preventing further
hyperglycemic events during the hospital course
o Includes initiation of three components:
1. basal insulin (long acting)
2. nutritional insulin (rapid acting, pre-meal)
3. correctional insulin (rapid acting, for real time adjustment)
o Administer correction scale insulin BEFORE the meal using a rapid
or short acting insulin

6. A better day when using correction insulinA better day when using correction insulin
Time 700 EAT 0800 1200 EAT 1300 1700 EAT 1800 2100
Blood
Glucose
170 275 210 350 250 400 250
Sliding
Scale
6 10 12 6
Correction
Scale
2
units
4
units
6
units
6
units
Sliding scale: 34 units of rapid/short acting insulin administered
Correction scale: 18 units of rapid/short acting insulin
Remember, it is the concept of correction insulin we want to practice.
If this patient remains hyperglycemic, adjust basal/nutritional insulin therapy

7. AACE/ADA Consensus Statement onAACE/ADA Consensus Statement on
Management of Inpatient HyperglycemiaManagement of Inpatient Hyperglycemia
BG goals Avoid Tips
MICU •140-180 <110 •If >180, initiate IV short acting insulin
General
Wards
•Pre-meal
<140
•Random
<180
<100 •In glucocorticoid therapy, initiate accuchecks
for 48 hours and then initiate insulin therapy
as appropriate
•Avoid routine use of corrective insulin at
bedtime unless continuous nutrition/TPN

8. Rapid (Prandial,
Bolus)
Short (Prandial,
Bolus)
Intermediate
(Basal)
Long
(Basal)

9. Correction Insulin TipsCorrection Insulin Tips
Start with If uncontrolled add
On insulin
at home
(DM I, some
DM II)
NPO *Home basal insulin *Correctional scale insulin
Eating *Home basal insulin (reduce 50%)
*Home prandial insulin (reduce
doses by 25-50%)
*Correctional scale insulin
Not on
insulin
(pre-DM,
DM II)
NPO Stop all oral anti-hyperglycemics.
Start correctional scale
*Basal insulin
Eating Cautiously use oral anti-
hyperglycemics
OR
Start *basal, *prandial, AND
*correctional scale insulin
*Basal insulin
*Prandial insulin
*Correctional scale

10. Current UCI Glycemic Monitoring ProtocolCurrent UCI Glycemic Monitoring Protocol
UCI is aggressively pursuing the concept of correction insulin and
preventing hyperglycemia. Many more patients will be initiated on
insulin therapy
When to pursue insulin therapy
• All DM I
• Most DM II receiving medication treatment
• Uncontrolled hyperglycemia > 180 (2 episodes in 24 hours)
• If unsure, then monitor qAC/qHS glucose monitoring for 24 hours and
then continue if BG > 180

11. How to Initiate Insulin TherapyHow to Initiate Insulin Therapy
(if not already on insulin OR if uncontrolled diabetes)(if not already on insulin OR if uncontrolled diabetes)
Regimen Tracts
Dose Low
(DM I,
Lean DM II)
Standard
(Normal
weight DM)
Moderate
(Overweight
DM)
Aggressive
(Obese DM)
Total Daily
Dose (TDD)
0.3
units/kg/day
0.4 units/kg/d 0.5unit/kg/d 0.6unit/kg/d
Basal ½ TDD
Prandial ½ TDD divided into 3 meals
Correction
Scale
Yup, they will also receive this too
It should be the same rapid/short acting insulin as used
for prandial insulin
See next page

12. Correction Scale with MealsCorrection Scale with Meals
Regimen Tracts
Dose Low
(DM I,
Lean DM II)
Standard
(Normal
weight DM)
Moderate
(Overweight
DM)
Aggressive
(Obese DM)
Total Daily
Dose (TDD)
0.3 units/kg/d 0.4 units/kg/d 0.5unit/kg/d 0.6unit/kg/d
161-200 1 units 2 units 3 units 4 units
201-250 2 units 4 units 5 units 6 units
251-300 3 units 6 units 7 units 8 units

13. Insulin Dose Adjustment for CKDInsulin Dose Adjustment for CKD
• No dose adjustment if GFR >50
• Use 75% of baseline insulin dose if GFR 10-50
• Use 50% of baseline insulin dose if GFR <10
Example: At home takes 40 units of glargine qHS
If GFR 30: give 30 units of glargine qHS
If GFR <10: give 20 units of glargine qHS

14. Long Beach VA Guidelines on Adjustment of InsulinLong Beach VA Guidelines on Adjustment of Insulin
• If glucose above target, increase insulin doses by 10-20% (2-5 units)
every 1-2 days
• Once patient clinically stable on insulin regimen, d/c correctional
insulin and check glucose 2 hours after meals (target BS <150 two
hours after a meal)
How to Adjust:
Patient on NPH/Regular insulin regimen
• If fasting glucoses elevated, increase evening NPH
• If pre-lunch or 2 hr post breakfast elevated, increase AM pre-
breakfast regular
• If pre-dinner or 2 hr post lunch elevated, increase AM NPH
• If bedtime or 2 hr post-dinner elevated, increase pre-dinner regular
• May need bedtime snack once glucoses are well controlled

15. Long Beach VA Guidelines on Adjustment of InsulinLong Beach VA Guidelines on Adjustment of Insulin
Patient on Lantus with Regular/Aspart insulin:
• If fasting elevated, increase Lantus
• If pre-lunch or 2 hr post breakfast elevated, increase pre-breakfast
regular/Aspart
• If pre-dinner or 2 hr post lunch elevated, increase pre-lunch
regular/Aspart
• If bedtime or 2 hr post-dinner elevated, increase pre-dinner
regular/Aspart
• If all glucoses elevated, may need to increase all insulins

16. Case VignetteCase Vignette
45 year old obese female with DM type II is admitted for acute nausea,
vomiting, and epigastric pain. CT Abdomen with IV contrast
demonstrates acute pancreatitis. Her diabetes is usually controlled on
metformin 1000mg BID and glyburide 10mg BID. Admission BMP shows a
random glucose of 240. How do you manage her hyperglycemia?
A. Continue home regimen
B. Continue home glyburide and discontinue metformin
C. Start sliding scale insulin
D. Start correctional insulin

17. Case Vignette Answer: DCase Vignette Answer: D•Answers A and B incorrect because patient likely to be NPO
•Answer C, sliding scale insulin is no longer in favor.
CORRECT ANSWER(S)
Option 1:
Initiate insulin therapy (basal, prandial, corrective scale) on admission
Option 2:
Start q6 accuchecks with correction scale (regular insulin is commonly
used). Correct BS per Aggressive Regimen since is obese DM type II
BS 160-200 – 4 units
BS 201-250 – 6 units, etc.
If BS is still >180 after 1-2 days, then initiate longer insulin therapy (basal,
prandial, corrective scale).
Note Option 2 less preferable because random BS>180 and requires high
doses of PO meds already so odds are she will have uncontrolled
hyperglycemia

18. Last QuestionLast Question
55 year old male with DM I comes from with cough and fevers. Admitted
for treatment of pneumonia. He normally takes 20 units glargine qHS
and 6 units aspart with each meal. How would you manage his blood
sugar?
A. Continue home regimen
B. Give 10 units glargine qHS and 2 units aspart qAC
C. Give home glargine dose only
D. Give home aspart doses only

19. Correct Answer is BCorrect Answer is B
Patient likely can eat, albeit he may eat less in setting of illness and
restrictive hospital diets. He is DM type I so he needs continuous insulin
coverage. The safest option is to decrease his insulin doses by 25-50%
and monitor.
His goal BS is a FBG <140 and random BS <180. If he continues to
experience hyperglycemia, then do the following.
•Basal insulin: uptitrate the glargine or redose based on a TDD of
0.3units/kg/day
•Prandial insulin: uptitrate the aspart or re-dose based on a TDD of 0.3
units/kg/day
•Initiate correction scale: Give additional aspart for BS >160.

20. Take Home PointsTake Home Points
• Correction insulin is a concept to prevent hyperglycemia. It may
include the initiation of insulin therapy (basal insulin, prandial insulin,
AND correction scale)
• Avoid hypoglycemia. A safe inpatient BS goal is no lower than 100
• Avoid severe hyperglycemia. A good target is a random BS <180
• Reassess insulin needs after any change in nutritional status (NPO, PO,
tube feeds)
• Readjust basal and nutritional insulin if still requiring additional
correctional scale insulin or hyperglycemia persists every 1-2 days

21. Easy self-directed learning materialsEasy self-directed learning materials
• American Association of Clinical Endocrinologists and American Diabetes
Association Consensus Statement on Inpatient Glycemic Control. Diabetes
Care June 2009 32(6) 1119
• Intensive insulin therapy in critically ill patients. NEJM 2001; 345(19): 1359
• Management of Hyperglycemia in the Hospital Setting. Inzucci et al. NEJM
2006; 355: 1903-1911
• The Nice-Sugar study investigators: Normoglycemia in Intensive Care
Evaluation Survival Using Glucose Algorithm Regulation Intensive vs
conventional glucose control in critically ill patients. NEJM 2009; 360:1283
• UpToDate “Management of DM in hospitalized patients” and “General
Principals in Insulin Management.” Accessed on June 11, 2012.
• UCI Inpatient Glycemic Monitoring and Treatment Guidelines. 2012