RUSH INPATIENT ADULT DIABETES MANAGEMENT GUIDELINES
July 2008

INITIAL ASSESSMENT OF THE HYPERGLYCEMIC PATIENT

Preexisting Diabetes

• What types of insulin or oral agents?
  
• What are the doses and the dose timing?
  
• What have the blood glucoses been at home?
  
• When was diabetic therapy last taken?
  

New Onset Hyperglycemia

• Is it TYPE 1 or TYPE 2 ?
  
• Younger age and ketones favor TYPE 1
  
• Older age, FH of DM, overweight suggest TYPE 2
  
• Is there a provocation: infection or other stress?
  
• Is there glucocorticoid Rx?
  
• Is there hyper-alimentation or tube feeds?
  

Initial Evaluation

• Nausea and vomiting are important clues for DKA
  
• DKA is increasingly common in type 2 diabetes
  
• 10% of DKA's have blood glucose < 300 mg/dL
  
• Criteria for diagnosis of DKA
  
  • Venous pH<7.3
    
  • Blood ketones (beta-OH-butyrate) > 1.5 mmol
    
  • Serum or urine acetone are less reliable
    
• Treatment: see Rush DKA protocol
  
• What is the IV fluid? Is the patient eating?
  
• How insulin resistant is the patient? i.e. overweight?
  
• Patients with TYPE 2 diabetes tend to be insulin resistant and require more insulin. Patients with TYPE 1 diabetes are usually very insulin sensitive and require much less insulin.
  
• Always get a HBA1C on admission on all patients with diabetes or new onset hyperglycemia in order to plan discharge therapy/doses.
  

INITIAL APPROACH TO INPATIENT HYPERGLYCEMIA

• Check HBA1C and begin QID glucoses by fingerstick.
  
• Patients who were treated with oral anti-diabetic agents prior to admission should be placed on basal insulin if they are NPO (e.g. post-op), or if glucose is > 180 mg/dl. It is best to avoid sulfonylureas in NPO patients, metformin in severely ill patients or patients with serum creatinine >1.5, and glitazones in patients with heart failure. In general, most inpatients with type 2 diabetes should be started on insulin therapy, and have oral agents discontinued while they are hospitalized.
  
• The hypoglycemia protocol must be ordered on all pts.
  
• HBA1C >7% represents suboptimal diabetic control, and diabetic Rx should be improved prior to discharge.
  
• Each oral diabetic agent can only lower HBA1C by 1-2%.
  
• Inpatient blood glucose targets:
  
  • ICU 100-150 mg/dl
    
  • Non-ICU AM (fasting) 100-140 mg/dl
    
  • Non-ICU after meals- 140-180 mg/dl
    
• There are potentially 2 types of SQ insulin that will need to be ordered: basal, and prandial.
  

BASAL INSULIN GUIDELINES

• All patients receiving insulin must first have an order for basal insulin. Basal insulin is required to meet the fasting needs of the patient. Basal insulin represents 100% of the total daily insulin needs in NPO patients, and ~ 50% of the total daily insulin needs in patients who are eating. Patients who are eating will also need prandial insulin to accompany meals. Patients must have basal insulin even if NPO to avoid developing diabetic ketoacidosis and/or severe hyperglycemia.
  
• First, select a basal. The choices are glargine insulin, detemir insulin or NPH insulin.
  
• If a patient is new to insulin and NPO: start with glargine insulin 0.3 units per kg SQ every 24 hours. Glargine is given daily at 8 AM or 6 PM. This is recommended for all post-op patients, except ICU patients who are treated with an IV insulin infusion.
  
• If a patient is new to insulin and eating: start with NPH 0.2 units/kg Q8 AM and 0.1 units/kg Q6 PM, detemir 0.2 units/kg BID, or glargine as above.
  
• If a patient is admitted and already taking glargine or detemir insulin, initially continue the same doses whether NPO or eating.
  
• If a patient is admitted already taking NPH insulin, initially continue the same doses if eating. If NPO reduce the AM dose by 50% and continue the same PM dose.
  
• If a patient is currently treated with 70/30 or 75/25 insulin: continue 70% of these total doses as NPH insulin.
  
• Increase glargine/detemir doses daily by 10% if 6 AM blood glucose is > 140 mg/dl, or by 20% if > 180 mg/dL. Decrease by 20% daily if 6 AM is < 100 mg/dl.
  
• Increase PM NPH dose daily if 6 AM glucose is > 140 mg/dl, or by 20% if > 180 mg/dL. Decrease by 20% daily if 6 AM is < 100 mg/dl.
  
• Increase AM NPH insulin dose daily by 10% if 6 PM glucose > 180 mg/dL, or by 20% if > 240 mg/dL. Decrease by 20% daily if 6 PM is < 100 mg/dl.
  

HYPERALIMENTATION / TUBE FEEDS

• Hyperglycemic patients who are placed on continuous tube feeds should receive glargine once daily or equal doses of NPH or detemir Q 12 hrs. Insulin doses should be revised daily based on QID blood glucose tests.
  
• Remember to begin 10% dextrose (D10W) IV fluid immediately if tube feeds are ever interrupted in patients receiving insulin. Use the same rate as the tube feeds. This is critical to prevent hypoglycemia.
  
• Hyperglycemic patients on TPN should have regular insulin added to the TPN bag each day. They may also receive some SQ insulin until the TPN bag has enough regular insulin.
  

HIGH DOSE GLUCOCORTICOIDS

• Steroid therapy may create new hyperglycemia and will worsen preexisting hyperglycemia.
  
• Oral agents are ineffective and NPH +/- aspart insulin is usually required BID, often at high doses.
  
• Unlike methylprednisolone and dexamethasone, prednisone given QAM only lasts ~20 hours and PM dosing of NPH requires reduction or elimination to avoid AM hypoglycemia. Glargine/detemir are best avoided.
  

PRANDIAL INSULIN GUIDELINES

• Prandial insulin is rapid acting insulin which specifically accompanies meals when patients are eating.
  
• Aspart insulin is always preferred to regular insulin due to aspart's more rapid onset (15 min), peak (60 min) and shorter duration (3 hours).
  
• The 3 rapid acting insulins: aspart, lispro, and glulisine are all equivalent.
  
• If a patient is admitted already taking lispro, glulisine or regular insulin, substitute unit per unit with aspart.
  
• Aspart insulin is given 0-20 min. after each meal at 8 AM and 6 PM to patients on NPH basal insulin
  
• Aspart insulin is given 0-20 min. after each meal at 8 AM, 1 PM and 6 PM to patients on glargine or detemir.
  
• If a patient is admitted already taking prandial insulin and is eating, initially continue the same doses.
  
• If a patient is admitted already taking 70/30 or 75/25 insulin, convert each total dose to 70% NPH and 30% aspart. Give the 30% aspart doses at 8 AM and 6 PM.
  
• If a patient is new to insulin and eating start with: 0.1 unit per kg aspart insulin after meals at 8 AM, 1 PM, and 6 PM if receiving glargine or detemir basal, or at 8 AM and 6 PM if receiving NPH insulin.
  
• Increase prandial insulin doses daily by 10-20% if pre-lunch, pre-dinner or bedtime blood glucose levels are > 160 mg/dl. Decrease by 20% daily if these blood glucose levels are < 100 mg/dL.
  
• If the blood glucose is above 200 mg/dl before breakfast, lunch, or dinner and the patient is eating, may increase the aspart dose by 20-40% as a one-time intervention. If the bedtime glucose level is above 300 mg/dl, may repeat 1/2 of the previous dinner aspart dose times 1.
  

IV INSULIN FOR ICU PATIENTS

• Begin in ICU if blood glucose > 150-200 mg/dl
  
• Target blood glucose 100-150 mg/dL
  
• Follow Rush Continuous IV Insulin Protocol
  

TRANSITION TO SQ INSULIN

• Patients who are NPO or have minimal oral intake should receive insulin glargine dosed @ 20x the last stable IV insulin infusion rate.
  
• If eating, patients may receive NPH @10x and insulin aspart @2x the last stable insulin infusion rate.