Endocrinology Book


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Diabetes Mellitus Control in Hospital

Aka: Diabetes Mellitus Control in Hospital, Inpatient Diabetes Control, Glycemic Control in Hospitalized Patients, Inpatient Glucose Management, Emergency Department Hyperglycemia Management, Glucose Control in the Intensive Care Unit, ICU Glycemic Control
  1. See Also
    1. Insulin Sliding Scale
    2. Hourly Subcutaneous Insulin Lispro
    3. Insulin Infusion
    4. Diabetes Mellitus
    5. Type I Diabetes Mellitus
    6. Type II Diabetes Mellitus
    7. Insulin Resistance Syndrome
    8. Glucose Metabolism
    9. Diabetes Mellitus Education
    10. Diabetes Mellitus Complications
    11. Diabetic Ketoacidosis
    12. Hyperosmolar Hyperglycemic State
    13. Diabetes Mellitus Control in Hospital
    14. Diabetes Mellitus Glucose Management
    15. Hypertension in Diabetes Mellitus
    16. Hyperlipidemia in Diabetes Mellitus
    17. Diabetic Retinopathy
    18. Diabetic Nephropathy
    19. Diabetic Neuropathy
  2. Precautions
    1. Avoid Hypoglycemia first
      1. Hypoglycemia may result in acute catastrophic events (Cardiac Arrest, brain injury)
      2. Avoid tight Glucose control in Critical Illness (esp. intubated and sedated patients)
        1. Critically ill patients may develop Hypoglycemia without overt signs
        2. Monitor Glucose in the Critical Care setting
    2. Significant Hyperglycemia in the hospitalized patient (esp. post-surgical) is associated with worse outcomes
      1. Follow systematic approaches (as below) to keep Glucose within relaxed target ranges
      2. Decreasing the acute risk of Hypoglycemia always supercedes the longerterm risk of Hyperglycemia
  3. Approach: Emergency Department
    1. Exclude Diabetic Ketoacidosis (DKA)
      1. Serum Beta Hydroxybutyrate increased AND
      2. Significant Metabolic Acidosis with Anion Gap
    2. Exclude Hyperosmolar Hyperglycemic State (HHS)
      1. Significant Hyperglycemia (typically >1000 mg/dl) AND
      2. Severely hyperosmolar AND
      3. Neurologic deficit (e.g. Altered Level of Consciousness, focal weakness or sensory deficit, Seizure, coma)
    3. Once DKA and HHS are excluded, most Hyperglycemia (<600 mg/dl) in DM2 does not require emergent lowering
      1. Driver (2016) Ann Emerg Med 86(6): 697-705 +PMID:27353284 [PubMed]
    4. Protocol
      1. Glucose detectable on Glucometer (<500-600 mg/dl)
        1. See Nutrition in Diabetes Mellitus
        2. See Carbohydrate Count
        3. Increase Insulin (e.g. 3 units)
          1. See Insulin Dosing
        4. Discharge home with close follow-up
      2. Glucose undetectable on Glucometer (>600 mg/dl)
        1. Lower Glucose in ED to level that will consistently be readable on Glucometer (<400-500 mg/dl)
        2. Administer 1-2 Liters of Lactated Ringers
        3. Administer IV Insulin (e.g. 10 units)
        4. Monitor Glucose and Potassium
        5. When Glucose detectable, educate, adjust Insulin and discharge home with follow-up (as above)
    5. References
      1. Orman and Willis in Herbert (2017) EM:Rap 17(7):8-9
  4. Approach: Hospital Glucose Control
    1. Evaluate status on hospitalization
      1. Check Fasting Blood Glucose
      2. Hemoglobin A1C on admission
    2. Hospitalized Blood Glucose control in non-ICU patients
      1. Glucose monitoring
        1. Oral medications: once daily Blood Glucose (random Glucose is acceptable)
        2. Insulin: At meals and at bedtime (4 times daily)
      2. Non-ICU Blood Glucose goal: 140-180 mg/dl (<140 mg/dl preprandial)
        1. Modify protocol immediately if Blood Glucose below 70 mg/dl (avoid Hypoglycemia)
      3. Continue home Glucose management protocol if possible
        1. Avoid Thiazolidinediones in cardiovascular disease (especially if part of admission indications)
        2. Avoid Metformin in declining Renal Function, if Intravenous Contrast dye used, or if Lactic Acidosis
    3. Hospitalized Blood Glucose control in ICU
      1. Very tight Glucose control in critically ill patients is associated with worse outcomes
        1. Finfer (2009) N Engl J Med 360(13): 1283-97 [PubMed]
      2. Monitor Blood Glucose every 4 hours depending on status
        1. For patients who are eating meals, following the non-ICU protocol above
      3. ICU goal Blood Glucose: 140-200 mg/dl (up to 220 mg/dl in some guidelines)
        1. Modify protocol immediately if Blood Glucose below 70 mg/dl
        2. Treat Hypoglycemia with D50 IV
        3. Consider higher target range (180-250 mg/dl) in chronically uncontrolled Diabetes Mellitus
          1. Plummer (2016) Crit Care Med 44(9):1695-703 [PubMed]
  5. Protocol: Hospital Oral Hypoglycemic Medication Management
    1. Metformin
      1. Metformin is safe, low risk for Lactic Acidosis, and need not be stopped on hospital admission
      2. Decrease Metformin dose for GFR <45 ml/min, and discontinue if GFR <30 ml/min
      3. Metformin is typically stopped for 48 hours after Contrast Media use (some new guidelines allow continuation)
    2. Sulfonylureas
      1. Sulfonylureas (esp. Glyburide) are high risk for Hypoglycemia (occurring in up to 19% of hospitalized patients)
      2. If continued while hospitalized, hold on days with decreased or unpredictable oral intake
    3. Thiazolidinediones
      1. Risk of exacerbating Fluid Overload or Congestive Heart Failure
      2. Hold for several days in Fluid Overload or Congestive Heart Failure
    4. Incretin Mimetic (GLP-1 Agonist, e.g. Exenatide)
      1. Nausea is a common side effect (avoid in acutely ill patients)
  6. Protocol: Hospital Complete Insulin Orders
    1. See Hypoglycemia Management
    2. Precautions
      1. Glucose control should be with basal and Bolus Insulin, with additional coverage with slide scale
      2. Avoid sliding scale Insulin alone as it associated with worse outcomes
        1. Umpierrez (2011) Diabetes Care 34(2): 256-61 [PubMed]
    3. Total Daily Insulin for Insulin-Naive patients
      1. Stage IV Chronic Kidney Disease, not on Hemodialysis: 0.25 units/kg
      2. Underweight (advanced age, Hemodialysis): 0.3 units/kg
      3. Normal weight: 0.4 units/kg
      4. Overweight: 0.5 units/kg
      5. Obese (or Insulin resistant, on Systemic Corticosteroids): 0.6 units/kg
    4. Components
      1. Basal Insulin: Long acting Insulin (e.g. Lantus, NPH)
        1. Do not adjust Lantus for oral intake
        2. NPH may require adjustment if covering mealtime
      2. Rapid-Acting Bolus Insulin: Lispro, Aspart
        1. Cover meals, snacks with units per carbohydrate
        2. See Insulin Adjustment with Carbohydrate Counting
      3. Hyperglycemia coverage: Sliding scale coverage
        1. Cover as units per Glucose 50 mg/dl over 150 mg/dl
        2. Adjust per condition (low dose scale versus high dose scale)
        3. See Correctional Insulin Dosing (Insulin Sliding Scale)
    5. Nutritional intake
      1. NPO Status
        1. Basal Insulin: 25%
        2. Bolus Insulin: None
        3. Correctional Insulin every 4 hours (every 6 hours if using non-rapid, Regular Insulin)
        4. Oral Agents: Hold
      2. Eating Meals
        1. Basal Insulin: 50%
        2. Bolus Insulin: 50% divided equally before meals (or per carbohydrate dosing)
        3. Correctional Insulin with each meal, and at reduced bedtime dosing
        4. Oral Agents: Continue unless otherwise contraindicated
      3. Tube Feedings - Bolus
        1. Basal Insulin: 40%
        2. Bolus Insulin: 60% divided equally before each bolus
        3. Correctional Insulin with each bolus
        4. Oral Agents: Avoid GLP-1 Agonist; do not crush Metformin
      4. Tube Feedings - Continuous
        1. Basal Insulin: 40%
        2. Bolus Insulin: 60% divided equally every 4 hours (every 6 hours if using non-rapid, Regular Insulin)
        3. Correctional Insulin (adjust total Insulin upwards by 80% of prior days correctional Insulin units)
        4. Oral Agents: Same precautions as with bolus Tube Feedings
  7. Management: Hospital Discharge
    1. Review medications
      1. Review home oral hyperglycemic agents (which to restart, continue or stop)
      2. Review new or changed medications
      3. Ensure patient has prescriptions for new medications
    2. Arrange primary care follow-up
      1. Ensure pending results, medication regimen and documentation is sent to follow-up provider
    3. Arrange Patient Education
      1. Review Glucose monitoring and goals
      2. Review Hypoglycemia Management, nutritional intake, Insulin Dosing
  8. Complications: Uncontrolled Blood Glucose in Hospitalized Patients
    1. Decreased survival
    2. Increased cardiac events
    3. Worse outcomes following cerebovascular accident
    4. Increased mortality following acute Myocardial Infarction
    5. Increased nosocmial and Postoperative Infections
    6. Delayed Wound Healing
    7. Prolonged hospitalization stay
    8. Post-surgical Hyperglycemia correlates to complications
      1. Diabetes Mellitus confers 2 relatve risk complication
      2. Blood Glucose >200 mg/dl confers >3 Relative Risk complication
      3. Blood Glucose >250 mg/dl confers >12 Relative Risk complication
      4. (2002) Amer J Cardiol [PubMed]
  9. References
    1. Kodner (2017) Am Fam Physician 96(10): 648-54 [PubMed]
    2. Moghissi (2009) Diabetes Care 32(6): 1119-31 [PubMed]
    3. Maynard (2009) J Hosp Med 4(1): 3-15 [PubMed]
    4. Sawin (2010) Am Fam Physician 81(9): 1121-4 [PubMed]

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