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Inpatient Diabetes Mellitus (DM)

Will Bassett, Sebastian Hinojosa

Background

  • Blood glucose (BG) goal
    • Wards: <140mg/dL fasting; <180mg/dL random;
    • ICU: 140-180mg/dL (NICE-SUGAR Trial)
    • Avoiding hypoglycemia (≤70mg/dL) is more important than targeting ideal BG
    • For pts with terminal illness, limited life expectancy, or high risk for hypoglycemia (E.g. pts with liver disease, impaired kidney function, elderly, poor caloric intake, low BMI), a less aggressive insulin regimen and higher BG target ranges may be reasonable
    • Qs to ask diabetic pt inpt: Type, age of onset, outpt provider, home regimen, method of checking sugars, last HgbA1c, steroids, complications, hypoglycemia (episodes and awareness)

Management

  • Insulin therapy should be initiated for the treatment of persistent hyperglycemia starting at ≥180 mg/dL (checked on at least two occasions)
  • Basal (long acting), prandial (premeal, short acting), and correction (sliding scale) insulin is the preferred regimen for most pts
  • Initial orders on admission
    • Typically HOLD all home oral diabetes medications
    • Order set “SUBCUTANEOUS INSULIN ORDER(S)”
      • Hemoglobin A1c: Obtain on all pts with diabetes or hyperglycemia (BG >140mg/dL) if not performed in the prior 3 months
      • Fingerstick blood glucose: Typically AC/HS (before meals and nightly)
      • Hypoglycemia management: Select all of these
      • Basal insulin: Select insulin glargine
        • Type 2 DM, consider ↓ home dose (50-60% to home dose) as often inpts have reduced PO intake and ↓ renal function
        • Type 1 DM, DO NOT hold basal insulin, and avoid ↓ < 80% of home dose
      • Insulin lispro meal: ↓ home dose by 50%, do not give while NPO
      • Insulin lispro correction: Start with low or medium sliding scale and ↑ prn
    • Carb-controlled or carb-restricted diet (‘no concentrated sweets’ at VA)
  • Insulin adjustments
    • If BGs persistently ≥180
      • Calculate all insulin needs over 24h (basal + mealtime + sliding scale)
        • Give 50% as basal and other 50% as 3 divided mealtime doses
        • E.g. 10 basal + 0 mealtime + 14 sliding scale total = 24 units total daily = 12u basal + 4u TID with meals
        • In insulin naïve pts, consider weight-based dosing as outlined under additional information
        • In insulin naïve pts at high risk for hypoglycemia, may be reasonable to start with basal plus correctional insulin alone and readjust after 24-48 hours
    • If BGs < 70
      • If overnight/AM, reduce basal insulin dose
      • If daytime/post-prandial hypoglycemia, reduce mealtime and sliding scale
      • If endocrine consulted for inpt glucose management, notify >24h prior to discharge for recommended discharge regimen

Steroid-induced hyperglycemia

  • Steroids increase insulin resistance causing elevated postprandial BG
  • Insulin adjustments
    • Double mealtime + correction dose while leaving basal dose the same
    • Modified basal-bolus regimen (30% basal, 70% bolus
    • Add NPH once daily (weight + dose based, per below*) if on daily prednisone
      • Prednisone 10 mg = 0.1 u/kg NPH
      • Prednisone 20 mg = 0.2 u/kg NPH up to 0.4 u/kg daily
      • *lower dose if AKI, administer at the same time as prednisone dosing
  • On discharge, if steroids will be longstanding, increase home insulin regimen per inpt requirements. If steroids will be tapered or discontinued soon after, either continue hospital regimen for remainder of steroid course or return to home regimen (hyper >hypoglycemia).

Additional Information

  • Weight-based insulin dosing
  • Used when starting insulin on pts with type 2 DM who are insulin naïve and hyperglycemic in the hospital
  • Calculate total daily dosing (TDD) between 0.3 to 0.5 units/kg/day. Then split into 50% bolus and 50% as 3 divided prandial doses
  • E.g. 80kg pt using low start of 0.3 u/kg/day would have TDD of 24 units. This equals 12u basal and 4u prandial insulin
  • Consider lower starting insulin TDD of 0.2 units/kg in pts at high risk for hypoglycemia
  • Tube feeds
    • For continuous tube feeds, dose regular insulin q6h (not TID AC as they don’t have distinct “meals”)
    • Consolidate for bolus feedings based on 24-hour insulin needs prior to discharge
  • Insulin pumps
    • Individuals who are comfortable using their diabetes devices, such as insulin pumps and CGM, should be allowed to use them in an inpt setting if they are well enough to care of the devices and have brought the necessary supplies. This requires a Diabetes Consult.
    • Order POC BG checks AC/HS for nurse to chart and fill out MedEx pump contract