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Inpatient Diabetes Mellitus (DM)

Will Bassett

Background

  • 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 hypoglycemia in critically ill patients is more important than targeting ideal BG

Management

  • Initial orders

    • HOLD all home oral diabetes medications (except consider continuing empagliflozin in heart failure pts)
    • Typically recommend dose reducing home insulin (usually 50% of home dose for type 2; varies for type 1) for changes in diet. If AKI present, consider reducing by more.
      • Patients with Type 1 DM always need basal insulin, even if NPO or else will lead to DKA
      • If patients with Type 1 DM are eating, they will need prandial insulin as well
    • Order set “SUBCUTANEOUS INSULIN ORDER(S)”
      • Hemoglobin A1c. Can consider if none in last 3 months and concern for poor outpatient control. A1c 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 ½, do not give while NPO
      • Lispro insulin correction scale: Start with Low or Medium sliding scale and ↑ prn
      • Carb-controlled or carb-restricted diet

  • Insulin adjustments

    • If BGs persistently >200
      • Calculate all insulin needs over 24h (basal + mealtime + sliding scale)
        • Give 50% as basal and other 50% as 3 divided mealtime doses
        • E.g. 10 basal + 0 mealtime + 14 sliding scale total = 24 units total daily = 12u basal + 4u TID with meals
        • If new to basal, safe start is 0.2 u/kg daily if normal GFR
    • If BGs < 70
      • If overnight/AM, reduce basal insulin dose
      • If daytime/post-prandial hypoglycemia, reduce mealtime and sliding scale
      • Less is more! Blood glucose in the low 200s is better than the 50s
      • If endocrine consulted for inpatient glucose management, please notify >24h prior to discharge if you want recommended discharge regimen

Steroid-induced Hyperglycemia

  • Steroids increase insulin resistance causing elevated postprandial BG

  • Insulin adjustments

    • Double mealtime + correction dose with leaving the basal the same
    • Modified basal bolus regimen (30% basal, 70% bolus)
    • Add NPH once daily (weight + dose based, per below*) if on daily prednisone
      • Prednisone 10 mg = 0.1 u/kg NPH
      • Prednisone 20 mg = 0.2 u/kg NPH up to 0.4 u/kg daily
      • lower dose if AKI, administer at the same time as prednisone dosing
    • On discharge, if steroids will be longstanding, increase home insulin regimen per inpatient requirements. If steroids will be tapered or discontinued soon after, either continue hospital regimen for remainder of steroid course or return to home regimen (hyperglycemia is better than hypoglycemia)

Additional Information

  • Tube feeds

    • Dose regular insulin q6h (not TID AC as they don’t have distinct “meals”)
    • Consolidate for bolus feedings based on 24-hour insulin needs prior to discharge

  • 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. This requires a Diabetes Consult.
    • Still order POC BG checks AC/HS for nurse to chart and fill out MedEx pump contract
Last update: 2022-06-20 02:15:49