Inpatient Management of Hyperglycemia

Hyperglycemia is defined as a glucose value >140 mg/dL or 7.8 mmol

-you do not need a diagnosis of DM for this to occur.
DM is usually a secondary diagnosis.
Inpatient hyperglycemia is assctd with
Acute illness/stress
Surgery
Nutritional or clinical instability
Impaired glycemic control from meds
Poor home management of DM
Inpatient hyperglycemia can lead to an increased risk of complications and mortality,
prolonged stay, increased incidence of infection, increased disability after discharge.
Goals

of care
Assess outpatient control
Provide glycemic control while avoiding BG swings
Get BG levels via labs
Obtain HbA1c if uncontrolled or no level within 2 to 3 months

Target glucose levels

Critically ill: 140 to 180 (110 to 140 in some pts if it can be done w/o risk of
hypoglycemia)
Non-critically ill: pre-prandial <140, random readings <180 (if they can be
safely achieved. The more severe the condition the less stringent the control
Note: tight glycemic control was shown to lead to more hypoglycemia.. NOT RECD
Management of hyperglycemia
Can use oral agents like metformin, sulfonyl ureas, alpha glucosidase
inhibitors (acarbose); incretin mimetics like GLP1 analogs (exanatide
liraglutide); DDP 4 inhibs (gliptins); amylin analogs (pramlintide); or insulin.
When in the hospital:
o Asses preadmission DM management
o D/C oral meds
o Insulin therapy is preferred
o Adjust insulin according to clinical status.
Upon admission D/C oral meds because they slow acting, hard to titrate, food status
changes, we see changes in clinical status (ex. ARF), there is a need for diagnostic
testing, may not currently be on formulary.
Insulin is preferred because it is reliable, can rapidly adjust doses, depending on BG,
basal insulin can prevent gluconeogenesis and ketogenesis.
Anticipatory physiologic insulin dosing should be prescribed as a basal/bolus regimen
(right type, right dose, right time all to meet the needs of the patient)
Who gets physiologic insulin?
At the time of admission
o All pts with DM type 1

Pts with DM type 2 that are either insulin dependent at home, poorly
controlled despite high dose PO meds, or req high dose PO meds prior
to admission.
Inpatient admission (if persisntantly hyperglycemic)
Continuous Insulin Infusion.
This is the best way to achive glycemic control
Indicated in
o Hyperglycemic emergency
o Critical care illness
o After cardiac surgery
o MI or cardiogenic shock
o DM type 1 and NPO
o During labor or delivery
o Post organ transplant
o Perioperative period (pre, during, and post surgery)
Utilizes regular insulin
o Either 0.5 unit/mil OR 1.0 units/mil
Requires bedside glucose monitoring Q1 hr (Q2 if they are stable)
Monitor K and replete as necessary.
o

Transitioning from IV to sub-q insulin.

If stress hyperglycemia
o Continue to decrease dose, once condition is stable d/c
Can transition if patients are eating reliably
Calculate the conversion from iv to subq
Overlap the IV and subq to cover gaps
o Glargine: 4 hrs
o NPH: 2-3 hrs
o Rapid acting: 1 hr
Calculate TDD
Reduce basal dose 20 to 33% (accounting for decreasing reqs)
Give subq intermediate or long acting insulin
Mealtime bolus will depend on caloric intake
o Start at 10% of basal dose given at each meal.
Basal Insulin
Provides 24 hour peakless insulin (takes care of background insulin needs)
Suppresses the livers release of glucose during fasting and between meals
Nutritional insulin
Prevents the predicted post meal spike
Covers carbs that are on the plate
Given prior to meal when glucose is still in normal ranges
Correctional Insulin (aka sliding scale)
Corrects hyperglycemia after it occurs
Brings down glucose before meal if it is too high
Given in addition to nutritional insulin
Insulin dosing
Avoid sliding scale as sole method
o It doesnt prevent hyperglycemia!
Initiate basal and meal time insulin in pts that are eating


Insulin

Monitor BG and adjust insulin based on that

types
Humulin mixs (N/R) N=intermediate, R=regular
Novolin mix (N/R)
Humalog mix (lispro protamine/lispro)
Novolog Mix (aspart protamine/aspart)
Long acting
o Glargine (QD) or detemir (QD or BID)
Intermediate
o NPH (peak in 6 hours)
Rapid acting
o Lispro, aspart, glargine
o Meal time insulin
Regular insulin
o Good for tube feeds. It lasts longer and peaks later than the analogs

Insulin Dosing
Step 1: Estimate TDD
Convert from IV dosing.
Wt based
o .2 to .3 mg/kg
if > 70 yo OR GFR < 60
o .4 mg/kg
if BG is 140 to 200 (7.8 to 11.1 mmol)
o .5 mg/kg
if BG 201 400 (11.2 22.2 mmol)
o >.6 mg/kg
obese
insulin resistant
on glucocorticoids
Step 2: Assess nutritional status
regular PO intake vs unpredictable PO intake
bolus tube feeding/continuous tube feeding
TPN
NPO
Step 3a: 50/50 rule
50% as a basal insulin
o to be administered at the same time everyday!
Glargine/Detemir: QHS
NPH: BID (QAM and at dinner time)
50% as a meal time insulin.
o Divided into 3 doses to be given at meal time
o HOLD if pt is not eating!
Step 3b: Correction insulin dose
Divide 1800/TDD
o This is the BG drop seen with 1 unit of insulin
Calculate correction dose based on amount you need to drop BG
o Ex. Need to drop it for 36 points, pt takes 50 U/day
1800/50U = 36 BG points per 1 unit.
Give 1 unit

Step 4 : Assess and adjust

Check BG AT LEAST daily
Adjust based on BG requirements and changes in pts clinical status
NPO patients
Maintain glargine dose (basal insulin for baseline metabolic needs)
NPH dose needs to be reduced 20 to 50% due to is 6 to 8 hour peak
NO nutritional insulin/mealtime insulin
SSI only for corrections
Continuous EN
Basal insulin
o Basal insulin (glargine or detemir)
o NPH given BID
Short/rapid acting
o Rapid = Q4 h
o Short = Q6 hrs
Cycled feeding
Administer basal insulin
Administer short or rapid acting insulin Q 4-6 hrs for the duration of EN
Give last dose 4 to 6 hours priod to d/c of EN
Bolus feeding
Give basal
Give short or rapid acting before each bolus of EN
TPN

Mild hyperglycemia
o Add .1 units of regular insulin per gram of carb
Persistent hyperglycemia
o Add 80% of the previous days correctional insulin
Pre-existing Diabetes
o Basal insulin: 40% of TDD
o Regular insulin: 60% OF TDD into TPN

Glucocorticoids
Cause a decrease in glucose uptake leading to and increase in post prandial
hyperglycemia
All pts on GCs need to have bedside BG testing
Initiate insulin in pts with persistent hyperglycemia
**** initiate CII in pts that have severe and persistent hyperglycemia despite
subq insulin
Perioperative Management
If type 1 DM
o CII OR- basal insulin with bolus as needed
D/C oral hypoglycemic and noninsulin injections
Frequent monitoring
Advise against SSI in post op time period
Insulin pumps

Pt needs to have mental and physical status to operate due to self

administration
Need personnel to be familiar and clear policies in place
BG monitoring
Bedside monitoring is used to guide therapy
If eating you need to match carb intake
If NPO monitor q 4 to 6 hours
CII monitor Q 30 min to 2 hours.
Hypoglycemia
<70 (<3.9)
o Severe hypo <40 (2.8 mmol)
Predictors
o Older adults
o Greater illness severity
o DM
o Use of oral hyoglycemics
Preventing hypoglycemia
o Provide directions for insulin adjustments as well as administration of
dextrose cont IV fluids for planned or sudden changes in nutritional
status
Treating hypoglycemia
o BG < 70, pt is alert and able to eat foods
25 ml d50w (1/2 amp)
start d5W IV at 100 ml/hr
o BG <70 and pt is alert, no IV access
Glucagon 1 mg IM max 2 times
o Recheck BG and repeat tx q15 mins until BG > 80
When pts are discharged they may not need insulin, could restart home meds
If a new dx of DM use guidelines to start meds
If HBA1c was in check, use prehospital regimen
If HbA1c is not in check/ suboptimal condition, consider basal insulin.