Increasing data show a strong association between hyperglycemia and adverse inpatient outcomes. The American Diabetes Association and the American College of Clinical Endocrinology recommend all glucose levels be below 180-200 mg/dL in non-critically ill patients. Since hospitalizationsareunstablesituations, even patients who are well controlled on non-insulin agents as outpatients are usually best managed with insulin while they are inpatients.
Insulin may be safely administered even to patients without previously diagnosed diabetes. As long as the prescribed doses are below what is normally produced by the pancreas, the patient will not become hypoglycemic. If the glucose level drops, endogenous insulin secretion will reduce to compensate. The total daily insulin requirement in insulin-sensitive patients (e.g., type 1 diabetes mellitus [T1DM]) is approximately 0.5-0.7/units/kg/day. Insulin requirements in patients with insulin-resistant type 2 diabetes may vary greatly and can exceed 1-2 units/kg/day. A conservative estimate for initial insulin therapy in any inpatient with hyperglycemia is to start with the T1DM dose (i.e., approximately 0.5-0.7 units/kg/day).
Effective inpatient insulin regimens typically include 3 components
Basal insulin (e.g., scheduled NPH, insulin glargine [Lantus], or insulin detemir [Levemir]), which is used to manage fasting and pre-meal hyperglycemia. Generally half of the total daily insulin dose.
Nutritional or prandial insulin (e.g., scheduledregular insulin, insulin lispro [Humalog], insulin aspart [Novolog], or insulin glulisine [Apidra]), which controls hyperglycemia from nutritional sources (e.g., discrete meals, tube feedings, total parenteral nutrition [TPN], IV dextrose). Generally half of the total daily insulin dose.
Supplemental or correctional insulin (e.g., regular insulin, insulin lispro, insulin aspart, or insulin glulisine), which is used inadditiontoscheduledinsulinto meet unexpected hyperglycemia that is not covered by scheduled insulins.
SampleOrdersfor patient eating discrete meals (not for patients with uncontrolled type 1 diabetes, diabetic ketoacidosis, hyperglycemic hyperosmolar state, or other absolute need for IV insulin):
Also see comment on CPOE subcutaneous insulin order sets at the end of this document
Onadailybasis,adjustscheduledinsulin based on previous days’ blood sugars:
Hypoglycemia: Any blood sugar < 70 mg/dL
Identify possible precipitants: poor or unpredictable PO intake, ill-timed insulin administration, worsening renal function, decreasing steroids, improving medical condition (i.e., less stress)
If no transient or reversible cause, decrease insulin orders by 20-100%, depending on the degree of hypoglycemia
When adjusting basal vs. nutritional insulin, keep in mind that the fasting AM glucose reflects the action of basal insulin (e.g., qd glargine and qhs NPH), while glucose later in the day may reflect the action of both basal (e.g., qd glargine and qam NPH) and nutritional (e.g., qac aspart) insulin
If PO intake is unpredictable, consider ordering insulin aspart to be given immediatelyafter each meal, adjusting the dose for amount of PO intake (e.g., hold insulin if didn’t eat, give half if ate half the food tray, give full amount if ate entire food tray)
Hyperglycemia: Any blood sugars > 180 mg/dL and no hypoglycemia
Add up total insulin (scheduled + sliding scale) given the previous day to determine the new total daily dose (TDD)
Increase the TDD:
If glucoses generally 140-180 mg/dL, increase by 10%
If glucoses generally 180-250, increase by 20%
If glucoses consistently > 250 mg/dL, increase by 30%
Adjust the TDD further (up or down 10-20%) based on clinical considerations (e.g., give more if eating more, improving renal function, increasing steroids; give less if eating less, worsening renal function, tapering steroids, recovering from severe illness)
Maintain a ratio of ~50% basal insulin and ~50% nutritional insulin, keeping the following in mind:
Hold nutritional insulin if patient is NPO
Patients may require proportionately less nutritional insulin if appetite is poor or unknown
Patients may require proportionally more nutritional insulin when treated with steroids
The fasting AM glucose reflects the action of basal insulin (e.g., qd lantus and qhs NPH), while glucoses later in the day reflect the action of both basal (e.g., qd lantus and qam NPH) and nutritional (e.g., qac aspart) insulin
Adjust sliding scale if needed based on the new total scheduled insulin dose:
< 40 units/day scheduled insulin: low scale
40-80 units/day scheduled insulin: medium scale
> 80 units/day scheduled insulin: high scale
Patient should be discharged home on a medication regimen that was similar to the admission regimen (i.e.,theregimenprescribedbythe patient’s primary care physician’s PCP]). Exceptions:
The patient has a contraindication to an admission medication
There is evidence of poor outpatient control (e.g., very high A1C) or hypoglycemia on admission regimen
If a patient is ADMITTED WITH NO INSULIN, and REQUIRES INSULIN TO BE CONTINUED AS AN OUTPATIENT (e.g., newly-diagnosed T1DM, A1C is very high and contraindication to or on maximum oral regimen), limit discharge insulin regimen to as few injections per day as possible (e.g., in T2DM, qhs insulin glargine only, or glargine qhs plus one injection of insulin aspart with the biggest meal). An exception to this is for patients with T1DM who are optimally treated with 3-4 injections/day. Make sure the patient has prompt follow-up with his or her PCP and/or endocrinologist.
Avoid discharging home on “sliding scale” insulin
If a patient is going to require insulin injections and self-monitoring blood glucose as an outpatient, make sure the patient is instructed about how to do perform these; these patients may also require VNA assistance
Letnursingstaffknowearlyinadmission if patient will require insulin administration and/or glucose monitoring instruction before discharge so that they can plan patient education
Indications for calling an Endocrine (Medicine or OB-GYN service) consult
Prolonged periods of NPO (e.g., for procedures) especially in patients with T1DM
Marked hyperglycemia despite following this guideline
Question of type 1 vs. type 2 vs. other type of diabetes
Subcutaneous insulin Order Sets
Order sets are available in the CPOE system to assist with inpatient diabetes management. They can be found under [insert link or specify location].
There are 3 templates, depending on the PO status of the patient: one for discrete meals, one for continuous tube feedingss, and one for NPO. There is also a template for pregnant patients eating discrete meals.
The templates make it easy to order basal, nutritional, and supplemental insulin (including 3 strengths of sliding scales), diet orders, blood glucose monitoring, A1C testing, endocrine consultation, and hypoglycemia orders consistent with the above guidelines.
Shared by ASHP Advantage May-11
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