Guidelines for inpatient diabetes management.xls

GUIDELINES FOR INPATIENT DIABETES MANAGEMENT
These recommendations do not take into account individual patient situations, and do not substitute for clinical judgment. Changes in diet, activity, medications (i.e.: steroids), and acuity of illness (i.e.: infection, renal insufficiency)
may quickly change treatment requirements
Inpatient Blood Glucose Targets: 80-180mg/dL (In the ICU setting: 80-150 mg/dL)
Initiate Hypoglycemia Treatment Protocol (HTP) for capillary blood glucoses <70mg/dL
Suggested timing of Capillary Blood Glucose (CBG) Monitoring:
QAC & HS (before meals and at bedtime): patients with consistent oral intake at mealtimes
BID (before breakfast and supper): stable patients receiving oral agents or one insulin injection daily
Q 6 hours: patients who are NPO or receiving continuous nutrition over 24 hours
Q 4 hours: patients who are NPO or receiving continuous nutrition with fluctuating blood glucoses requiring close monitoring
Q 3 AM: added to QID or BID regimens for patients at risk for nocturnal hypoglycemia
Initiating Subcutaneous Insulin: Usual starting dose is 0.2-0.4 units/kg/day
• 50%-70% of total daily dose is given as intermediate or long acting insulin • If NPH used as the basal insulin, give 1/2 to 2/3 of total daily dose in AM and 1/3 to 1/2 in PM• If insulin glargine (Lantus®) is used as the basal insulin, start once daily in AM or PM • 30-50% of total daily dose is given as short or rapid acting insulin as Nutritional/Prandial in 2-3 divided doses with meals Managing Subcutaneous Insulin Therapy: General Guidelines for the prescriber (all insulin MUST be ordered in number of units to be given)
Adjusting subcutaneous insulin
• If 2 or more CBG were < 80 mg/dL – use 80% of previous day's total daily dose• If 2 or more CBG were > 180 mg/dL and none were < 80 mg/dL, increase total daily dose by 10% If patient is made NPO
• NPH insulin: Give ½ usual dose plus correction insulin• Insulin glargine (Lantus®): Give 50-80% of usual dose plus correction insulin • Pre-mixed insulin: Give 1/3 of the usual dose as NPH (for example: for 30 units 70/30, give 10 units NPH)—this approximates ½ the usual NPH component of the pre-mixed insulin dose • When full doses of basal insulin are given, and patient is made NPO • For patients previously eating: begin IV of D5 at 75-100 ml/hour (if able to tolerate IV fluids) • For patients previously on enteral feedings: begin D10W at the same rate of enteral feeding, • Continue IV fluid for 12 hours following last NPH dose or 24 hours following last glargine (Lantus ®) dose Subcutaneous Insulin: Scheduled insulin
Correction Insulin
Basal insulin:
Nutritional/Prandial Insulin:
Sliding scale:
Intermediate or long acting insulin required to Short or rapid acting insulin used to prevent a rise Short or rapid acting insulin used to treat Reduce the dose if NPO
Hold if NPO
Do NOT hold if NPO
• Basal insulin is required for all patients with • Regular insulin: onset of action is 30-60 • Supplement to scheduled insulin or oral minutes (best given 30-60 minutes before • Basal insulin should be used for patients • Rapid acting analogues (insulin lispro and • Use without basal insulin is contraindicated aspart): onset of action is 15-30 minutes. In the hospital, it is best to give when meal monotherapy and still have 2 or more blood tray is in front of patient or immediately after eating (if it is unclear whether the patient will eat).
• Usually accounts for about 50-70% of total • Usually accounts for about 30-50% of total • Can be used short term (less than 24-48 daily dose of insulin, divided by 3 meals hours) as monotherapy to help determine b Pre-mixed Insulin: HumuLIN® 70/30; NovoLOG® Mix 70/30; HumaLOG® Mix 75/25; HumuLIN® 50/50
• Pre-mixed combination of intermediate acting and short or rapid acting insulin (basal and nutritional/prandial)• Pre-mixed formulations do not allow for precise dose adjustments Suggested Correction Scale based on clinical presentation
• Very Low Dose Scale: Suggested starting point for thin and elderly and those on nutritional insulin with each meal• Low Dose Scale: Usual suggested starting point for most patients, including those being initiated on TPN• Moderate Dose Scale: Suggested for insulin-resistant patients and those receiving high dose corticosteroids• High Dose Scale: Used rarely except for patients with severe insulin resistance Oral Diabetes Medications:
• May be continued during hospitalization unless contraindicated • To avoid hypoglycemia, hold sulfonylureas and nonsulfonylurea insulin secretagogues (repaglinide [Prandin ®] or nateglinide [Starlix®]) if patient is NPO or has significantly lower nutritional intake or renal function from baseline • Discontinue metformin and thiazolidinediones (pioglitazone [Avandia ®] or rosiglitazone [Actos®]) for acute exacerbations of CHF• Discontinue metformin for renal insufficiency and hold at the time of and for at least 48 hours after iodinated contrast dye; restart when serum creatinine <1.5 in men and <1.4 in women

Source: http://www.diabetesinstitute.pitt.edu/files/DiabetesOrderSet.pdf