Inpatient / Endocrinology
Inpatient Diabetes Management
# Type *** Diabetes
Checklist
-- Chart Check: baseline BG, most recent A1c, home med regimen, h/o DKA, previous complications (neuropathy, LE ulcers, nephropathy/CKD, retinopathy/vision changes, gastroparesis)
-- HPI Intake: foot ulcers/wounds, polyuria, abd pain, previous complications (neuropathy, LE ulcers, nephropathy/CKD, retinopathy/vision changes, gastroparesis)
-- Can't Miss: DKA
-- Admission Orders: hold home oral meds, sliding scale, accuchecks, A1c if nothing in chart for last 3-6 months
Plan:
Workup
-- New diagnosis - BMP, A1c, lipids, urine microalbumin
Treatment
-- holding home ***
-- if home insulin regimen - dose reduce 25-50% depending on PO intake and degree of presenting illness
-- if no home insulin regimen - 0.3-0.4 units per kg of body weight initially vs total insulin used via a sliding scale -> divide into 50% basal, 50% bolus
-- Prandial/Bolus: *** units [before meals vs q6 if NPO]
-- Long-Acting: *** units qhs
-- Sliding Scale: *** [low/medium/high]
-- accuchecks ***
-- If insufficient control, basal increase 10-20% every 2-3 days, prandial increase 1-2 units/dose every 1-2 days
-- further adjustments: if AM is high, increase basal; if pre AM meal is high, increase AM bolus; if bedtime is high, increase PM meal bolus; If NPO, 25-50% dose reduction in basal insulin and take off prandial
-- Neuropathy: *** First Line - Pregabalin (Lyrica) 300-600mg divided BID, gabapentin (neurontin) 1200-3600 divided TID, amitriptyline 10-150 qhs, duloxetine (cymbalta) 60-120mg daily or divided BID, Second Line - venlafaxine 150-225mg daily, tramadol 50-100q4-6 (max 400 per day), Additions - lidociane patch, capsaicin cream
-- Consider endocrine consult for assistance with complex pts with labile sugars
If You Remember Nothing Else
We tend to hold oral diabetic medications when patients are admitted to avoid hypoglycemia and other rarer adverse events, though its probably safe to keep medications like metformin on if they are not critically ill and don't have impaired renal function.
Total daily insulin can start at 0.3 units per kilogram split into 50% prandial/bolus and 50% long-acting. Alternatively, you can wait 24 hours to see how much total sliding scale correctional insulin is needed. Always remember to cut the basal insulin dose by 25-50% if the patient is going to be NPO.
Clinical Pearls
- 10.5% of U.S adults have T2DM (34 million, 7.3 million undiagnosed)
- Patients with diabetes have a 3-fold greater chance of hospitalization compared to those without diabetes.
- In 2016 in the U.S., there were over 7.8 million hospital stays for patients with diabetes
- There is a more lenient blood glucose goal of 100-200 for patients while they are admitted, as more aggressive targets can lead to hypoglycemia
- If at diagnosis A1c >10%, or quickly going up can consider going right to insulin (2 orals will likely not be able to get A1c down 3%+ in a timely manner)
- For T2DM, the total daily insulin requirement is often 0.4 units per kg of body weight; If T1DM, elderly, or CKD it is closer to 0.3 units per kg
- Metformin and other oral medicines are generally held, but metformin is probably safe unless HD unstable and renal function is impaired
- Dietary habits are often very different in the hospital, and patients will eat less than usual - a good rule of thumb is to decrease overall home insulin doses
- The general goal is to keep random BG <180 and preprandial <140
- In general, when thinking about the sliding scale, for every 50 above BG of 150, add 1 unit to the prandial as a “correction”
Trials and Literature
- Management of Diabetes and Hyperglycemia in Hospitalized Patients (Endotext, 2020)
- AFP - Treating Painful Diabetic Peripheral Neuropathy (Am Fam Physician, 2016)
- There are many trials investigating the role of intensive glycemic control in ICU populations - and they largely lead to no difference in mortality, length of stay, or end-organ failure
Other Resources
- Curbsiders - #330 and #331 Inpatient Diabetes
