diabetes inpatient management

• related: Endocrine
• tag: #note

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• Discontinue oral hypoglycemics, especially metformin & sulfonylureas
• Basal Bolus insulin regimen is the preferred guideline driven inpatient regimen
• Inpatient BG goal: 140-180 mg/dL pre-prandially, without severe or recurrent hypoglycemia. ebm NICE-SUGAR trial
• If a patient is having hypoglycemia, they have no BG targets, other than resolving the hypoglycemia.
• Total daily dose (TDD) = basal + prandial + correction

1. Assess Basal Insulin Dose

• Goal of basal insulin is to hold BG stable in fasting state
• Goal is not to correct hyperglycemia or cover food
• Thus, bedtime BG and AM BG should be the same
• most people need less bolus and more prandial
• Total basal dose (TBD) = 0.4 x TDD
• T1DM: TBD = 0.273 x TDD
• Calculate change between bedtime BG and fasting AM BG
  • if AM BG has increased by >15-20% compared to bedtime, increase basal insulin dose
  • if AM BG has decreased by >15-20%, decrease basal insulin dose
  • if AM BG is within 15-20% of bedtime BG, basal insulin dose is correct (even if both readings are above goal because that means the dinner dose of lispro is too low)
• Dose Lantus usually 8PM for easier management in am. Alternatively, dose BID
• Change Lantus dose based on BG:
  • BG in 100s: change by 10%
  • 200s: 20%
  • 300s: 30%

2. Assess Prandial Insulin Dose

• Patient is eating => give standing prandial insulin, do not use SSI only
• work backwards in time to alter pre-prandial BG readings
• To change bedtime BG, raise or lower pre-dinner prandial lispro dose
• To change pre-dinner BG, adjust pre-lunch prandial lispro dose
• To change pre-lunch BG, adjust pre-breakfast prandial lispro dose
• Change dose 10-20%

3. Assess Corrective Insulin Dose

• is corrective insulin correcting hyperglycemia? If not, the increase correction scale

The 4 things that go into a patient’s BG at any given time:

• Medication on board
• Food ingested (or TF or TPN)
• Activity (or lack thereof)
• Stress (physical stress of illness and in some cases, psychological stress)

Important questions to ask the patient &/or nursing when trying to figure out daily BG patterns:

• Did you eat a bedtime snack or eat overnight?
• Did you NOT eat bedtime snack or eat overnight?
• Did you walk 50 laps around the unit yesterday?
• Was the food gross? Was the food delicious?
• Was the pt made NPO?
• Missed insulin doses? Mistimed insulin doses?
• Mistimed POC BG? Missed POC BG?
• Bedtime or middle of the night correction insulin given?
• Tube Feeds turned off or on?

Cases

• no night time BG available
• should decrease basal bolus

• hyperglycemia at lunch time because AM prandial dosing was held
• nurse did not give AM insulin because BG 88 in the morning
• decrease basal to bring BG 140-180

• basal bolus adequate
• prandial dose need to go up

Resources

• The 2021 ADA Standards of Care section on Inpatient Glycemic Mgmt: https://care.diabetesjournals.org/content/44/Supplement_1/S211

• The Endocrine Society guidelines for inpatient glycemic mgmt. (Umpierrez is the guru of inpatient glycemic mgmt.): https://academic.oup.com/jcem/article/97/1/16/2833111