General Diabetes Management

In The Hospital

Order: Consult to DM nurse specialist for DM education (in the DM hospital order set)

What is the goal blood sugar (BS) range for a critically ill patient in the hospital?

140-180

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What is the goal BS range for non-critically ill patients?

140-180 (the same)

More intense/tighter control has not shown to be beneficial.

Terminally ill patients can have higher BS goals.

What can cause BS to increase in the hospital?

1. Illness itself can cause sugar to increase
2. Glucocorticoids

What can cause BS to decrease in the hospital?

1. A controlled, diabetic diet in the hospital (they may require much less insulin than at home where there is less diet control).
2. Poor PO intake 2/2 illness or labile appetite (older, dementia)
3. Steroid reduction/tapering
4. Acute Kidney Injury. Less filtering of insulin, making half life longer.

Should home ORAL DM medications be continued in hospital?

• Home ORAL DM medications can be continued in certain situations such as patients admitted to OBSERVATION unit who are more stable (even Metformin could be continued if no IV contrast studies anticipated).

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• Need to review each medications to see if any contraindications (AKI, contrast etc).

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• Consider reducing home insulin dose since they will be on a controlled, hospital DM diet, especially if sugar in ER is not too bad.

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• Generally, for INPATIENT admissions, it’s reasonable to hold most ORAL DM medications given the uncertainties with hospital disease course.

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What are the harms of uncontrolled blood sugar in the hospitalized patient?

• Increased risk of infections (sepsis, pneumonia, and wound infections).
• Decreased neurologic recovery for Stroke patients
• Higher mortality rates at one year for ACS patients
• Longer length of hospitalization
• Delayed procedures

Should we be using Sliding Scale Insulin Regimens?

NO!!!

How should we be determining the Insulin Regimen for insulin-naive patients?

By calculating the Total Daily Dose (TDD) of insulin and giving half of the TDD as a long acting/basal insulin and the other half divided among the TID meal times.

What rapid acting and basal insulin are typical in hospital?

Rapid-acting/mealtime insulin: Humalog (Lispro), Novolog (Aspart), etc. Onset: 5-15 mins, Duration: 4-5 hours

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Basal/long-acting insulin: Lantus (Glargine), Basaglar (Glargine) Onset: 1-2 hours, Duration: 20-24 hours

Have all Residents practice how to calculate the Total Daily Dose (TDD) of insulin for the patient below and how the TDD will be divided among the long acting and mealtime insulins (what will their insulin regimen be?).

Age 70

BMI = 27

Normal GFR

Weight = 100kg

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Answer is on next slide

Divide half the TDD of insulin to the basal insulin and the other half to the mealtime insulin.

Answer:

0.5 units/kg/day x Patient weight = TDD of insulin

0.5 Units/kg/day x 100 kg patient = 50 Units of insulin for the TDD

Basal/LONG insulin

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25 units Lantus (glargine) Qhs or Qd

RAPID-acting insulin divided to meal times

25 units Humalog

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Breakfast Lunch Dinner

8 Units 8 units 8 units

8 Units Humalog (lispro) TID before meals

HALF

HALF

What do we give if glucose is high even before the meal time insulin is given?

Correctional Insulin (in addition to the mealtime insulin)! Can be low, medium, or high dose correctional scale

How do we adjust insulin the next day if sugars still higher than 140-180 range?

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1. Add up the total amount of insulin given in the past 24 hours (basal+meal time+correctional) to get a new total daily dose.

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• Increase this new total daily dose by 10-20%.

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3) Give half to Basal dose and other half divided among the mealtime rapid dose.

PVHMC Diabetes Order Set. Have seniors show the EMR orderset

Hypoglycemia protocol (within the DM insulin order set)

LOC = Level Of Consciousness

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Recheck blood sugar after

10-15 minutes (max 30 mins).

How do you determine what DM meds to send patient home on?

• Utilize their HA1C on admission! If it was at goal then restart their same home meds (as long as no contraindications, decreased GFR, etc.)
• If A1c uncontrolled, may need to start insulin (especially if A1C >10) or adjust the other DM meds or stress med compliance. Add or adjust Metformin and SGLT2s. Send Continuous Glucose Monitor (CGM) to pharmacy if covered.
• Need DM nurse teaching prior to discharge and if CGM not covered then send Rx for DM supplies (glucometer, strips, lancets).
• If elderly, consider stopping/lowering insulin and sulfonylureas and instead use the meds with less risk for hypoglycemia: metformin, DPP4, GLP1, SGLT2, Acarbose.

How do you adjust ORAL DM meds if patient is to have surgery the next morning/NPO?

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Hold morning meds and resume after the procedure when no longer NPO. And when tolerating diet.

How do you adjust INSULIN if patient is to have surgery the next morning (if sugars controlled)?

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TYPE 1 DM: always require the basal insulin so either do not adjust basal dose or if conservative then reduce by 10-20%. Stop rapid/short insulins that morning.

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TYPE 2 DM: Can reduce basal insulin by 20-50%. Stop rapid/short insulins that morning. If short procedure, just give usual doses after.

References

1. CHARLES KODNER, MD. Glucose Management in Hospitalized Patients. 2017. https://www.aafp.org/pubs/afp/issues/2017/1115/p648.html
2. Silvio E Inzucchi, MD. Management of diabetes mellitus in hospitalized patients. 2024. https://www.uptodate.com/contents/management-of-diabetes-mellitus-in-hospitalized-patients