Diabetes Mellitus Control in Hospital

See Also

Precautions

See Insulin Pump
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
  3. Intense Glucose control (81 to 108 mg/dl) is associated with worse outcomes
  4. Finfer (2009) N Engl J Med 360(13): 1283-97 [PubMed]
Significant Hyperglycemia in the hospitalized patient (esp. post-surgical) is associated with worse outcomes
1. Associated with increased risk of infection, lengths of stay, morbidity, mortality
2. Follow systematic approaches (as below) to keep Glucose within relaxed target ranges
3. Decreasing the acute risk of Hypoglycemia always supercedes the longerterm risk of Hyperglycemia

Approach
Emergency Department

Exclude Diabetic Ketoacidosis (DKA)
1. Serum Beta Hydroxybutyrate increased AND
2. Significant Metabolic Acidosis with Anion Gap
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)
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]
Protocol
1. In IDDM, continue Basal insulin (unless persistent Hypoglycemia) regardless of oral intake or Critical Illness
  1. Continue Basal insulin via Insulin Pump if pump is functional
  2. Initiate Basal insulin in Insulin Pump malfunction
    1. Estimate based on pump Basal insulin dose (or start 1 U/h in adults) OR
    2. Long acting Basal insulin (e.g. Lantus) if not critically ill
  3. Weingart and Swaminathan in Herbert (2022) EM:Rap 22(2): 2-4
2. 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
3. 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)
References
1. Orman and Willis in Herbert (2017) EM:Rap 17(7):8-9

Approach
Hospital Glucose Control

Evaluate status on hospitalization
1. Check Fasting Blood Glucose
2. Hemoglobin A1C on admission (if not performed in last 3 months)
Hospitalized Blood Glucose control in non-ICU patients
1. Glucose monitoring
  1. Oral medications
    1. Once daily Blood Glucose (random Glucose is acceptable)
  2. Insulin
    1. Continuous Glucose Monitor (CGM) is preferred when available
    2. If CGM not available, obtain 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 (see non-Insulin medication guidelines below)
  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
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]

Protocol
Hospital Non-Insulin Hypoglycemic Medications

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)
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
Meglitinides
1. Increased cardiovascular event risk
Thiazolidinediones
1. Risk of exacerbating Fluid Overload or Congestive Heart Failure
2. Hold for several days in Fluid Overload or Congestive Heart Failure
Incretin Mimetic (GLP-1 Agonist, e.g. Exenatide)
1. Nausea and Vomiting is a common side effect (avoid in acutely ill patients)
Dipeptidyl Peptidase-4 Inhibitor (Gliptins)
1. May offer similar Glucose control to Insulin, with less risk of Hypoglycemia
SGLT2 Inhibitor
1. Consider for glycemic control in patients with Heart Failure

Protocol
Hospital Complete Insulin Orders

See Hypoglycemia Management
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. Carbohydrate Counting makes little difference in glycemic control during hospitalization
  1. Fixed Mealtime Insulin doses offer similar efficacy
  2. Consider Carbohydrate Counting if teaching outpatient meal management
Insulin Pump
1. See Insulin Pump regarding when an Insulin Pump should be disconnected
2. Continuing Insulin Pumps during hospitalization reduces hyperglycemic and hypoglycemic events
  1. Consider 20% reduction in Basal insulin rate when patient is NPO
3. However, Insulin Pumps require patient with intact mentation to continue pump management
4. Remove the pump and titrate Insulin for Diabetic Ketoacidosis and hyperosmolar Hyperglycemia
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
Consider preset Insulin protocol for I
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. See Correctional Insulin Dosing (Insulin Sliding Scale)
  2. Cover as units per Glucose 50 mg/dl over 150 mg/dl (or per scale below)
  3. Adjust per Insulin sensitivity (low dose scale versus high dose scale)
    1. Low Dose (<40 Insulin units/day): 1 unit per 50 mg/dl over 150 mg/dl
    2. Moderate Dose (40 to 100 Insulin units/day): 1 unit per 25 mg/dl over 150 mg/dl
    3. High Dose (>100 Insulin units/day): 1 unit per 15 mg/dl over 150 mg/dl
Nutritional intake
1. NPO Status
  1. Basal insulin: Consider 25-50% reduction in basal dose
  2. Bolus Insulin: None
  3. Correctional Insulin every 4 hours (every 6 hours if using non-rapid, Regular Insulin)
  4. Oral Agents (and non-Insulin injectables): 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
5. Total Parenteral Nutrition (TPN)
  1. May incorporate 90% of daily Insulin requirements into TPN
  2. Add Regular Insulin to TPN: 1 unit per 10 g dextrose
Other Factors
1. Steroid induced Hyperglycemia
  1. If on Insulin, may require 20 to 40% increase of total daily Insulin
  2. Not already on Insulin
    1. Give NPH 0.1 units/kg/day per 10 mg Prednisone at time of steroid dose

Management
Hospital Discharge

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
Arrange primary care follow-up
1. Ensure pending results, medication regimen and documentation is sent to follow-up provider
Arrange Patient Education
1. Providing diabetes education during hospitalization decreases Hemoglobin A1C 0.8% at 6 months
2. Review Glucose monitoring and goals
3. Review Hypoglycemia Management, nutritional intake, Insulin Dosing

Complications
Uncontrolled Blood Glucose in Hospitalized Patients

Decreased survival
Increased cardiac events
Worse outcomes following cerebovascular accident
Increased mortality following acute Myocardial Infarction
Increased nosocmial and Postoperative Infections
Delayed Wound Healing
Prolonged hospitalization stay
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]

References