Diabetes: Inpatient Management

Inpatient Diabetes Mellitus (DM) – Will Bassett

Blood glucose (BG) goal:

  • Wards: <140 mg/dL fasting; <180 mg/dL random; increase for elderly, “sicker” patients
  • ICU: 140-180 mg/dL (NICE-SUGAR Trial)
  • Avoiding moderate-severe hypoglycemia in ill patients is more important than ideal BG

History: Year of dx, prior DM meds, current meds, last A1c (date and value), home BG readings, history of hypoglycemia, # of hospitalizations for diabetes, history of DKA, history of nephropathy, neuropathy, retinopathy or foot disease.

 

Initial orders:

  • HOLD all home oral diabetes meds
  • Dose reduce home insulin (typically to 50-60% of home dose) for changes in diet and renal function. For AKI consider reducing by more
    • Do NOT hold basal for T1DM- would not reduce <80% of home dose in most cases
  • Sliding Scale Insulin (Order set “SUBCUTANEOUS INSULIN ORDER(S)”)
    • Hemoglobin A1c: can consider if none in last 3 months and concern for poor outpatient control. Does not routinely affect inpatient management
    • Fingerstick blood glucose: Typically AC/HS (before meals and nightly)
    • Hypoglycemia management: Select all of these
    • Basal insulin:
      • Type 2 DM, consider ↓ home dose (50-60% to home dose) as often inpatients have reduced PO intake and ↓ renal function
      • Type 1 DM, DO NOT hold basal insulin, and avoid ↓ < 80% of home dose
      • Unnecessary if no home basal insulin
    • Insulin lispro meal: ↓ home dose by 1/2, can also d/c, do not give while NPO
    • Lispro insulin correction scale: Start with Low or Medium sliding scale and ↑ prn
  • Carb-controlled or carb-restricted diet

 

Adjustments:

  • In EPIC, go to Summary tab and search “glucose” for BG trends and insulin dosing (Easiest to follow this tab if you ask for All results and expand the view fully on the right)
  • If BGs persistently >200
    • Calculate all insulin needs over 24h (basal + mealtime + sliding scale)
      • Give 50% as basal Lantus and other 50% as mealtime doses
      • Ex: 10 basal + 0 mealtime + 14 sliding scale total = 12 Lantus + 4 w/ each meal
      • If new to basal, safe start is Lantus 0.2 un/kg daily if normal GFR (lowest dose 10 un for T2DM, only brittle T1DM may need lower)
    • Can also address mealtime and nightly glucose separately
      • If AM glucoses are high, but prandials well controlled, consider increasing basal
      • If controlled in AM but elevated with meals, consider increasing mealtime
  • If BGs < 70
    • If overnight/AM, reduce basal
    • If daytime, reduce mealtime and sliding scale
    • Less is more! Blood glucose in the 200s is better than the 50s
    • If endocrine consulted (“Glucose management services) for inpt glucose mgmt, please notify >24h prior to d/c if you want recommended d/c regimen!
       

Steroid-induced Hyperglycemia:

        • Steroids increase insulin resistance → elevated postprandial BG most notable
        • 2-3 fold ↑ in TDD insulin usually required w/ high dose (prednisone > 20 mg)
        • Common approaches:
    • Double prandial + correction dose (basal the same)
    • Modified basal bolus regimen (30% basal, 70% bolus)
    • Add NPH (weight + dose based, per below*)— If on prednisone once daily (and not already on MDI), can add NPH once daily (give at same time as prednisone d/t similar pharmacologic profile if terms of peak effect and duration)
      • prednisone 10 mg = 0.1 u/kg NPH
      • prednisone 20 mg = 0.2 u/kg NPH up to max dose NPH 0.4 un/kg daily (w/ prednisone)
      • *lower dose if AKI

 

Additional Information

  • VA tips:  At the VA, NPH is formulary rather than Lantus. If a pt takes Lantus at home, this can be continued, but otherwise you will need to place a PADR consult. NPH’s duration of action is shorter than Lantus (12-18 hrs if normal GFR) and in most cases should be dosed Q12h. The conversion is done by taking total Lantus dose and dividing it two doses.
  • Ex: home Lantus 20 units qhs → NPH 10 units BID
  • Patients getting tube feeds:
    • Best with continuous tube feeds to give regular insulin q6h (not TIDAC since they don’t have  distinct “meals”); you can titrate rapidly, turn off safely (e.g procedures)
    • Then consolidate for bolus feedings based on 24-hour insulin needs prior to d/c
  • Patients with insulin pumps:
    • If a patient has a pump and supplies, reasonably controlled BG, is willing and able to manage pump then s/he can keep the pump on
    • Still order POC BG checks ACHS for nurse to chart and fill out MedEx pump contract
    • Consult Endocrine routinely