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Chemist's and Therapeutics | May 01 2013
Insulin Use in Hospitalized Patients With Diabetes: Navigate With Care
Diabetes Spectr 2013;26(2):124–130
"A human being walks into a bar …" These classic words introduce countless humorous situations.
"A human being enters a hospital …" Unfortunately, these words introduce distinctly serious situations that occur at the rate of > 35 million per year beyond the United states of america.1 These words introduce a story in people's lives that all too often includes mistakes, misadventures, and even preventable deaths.
The infirmary is a dangerous identify. Approximately one-third of all deaths in this country occur in hospitals.2,3 On any given day, up to 30% of all hospitalized patients have diabetes, placing well-nigh 1-third of inpatients at greater take chances for complications that may adversely affect their hospital stay. The majority of these hospitalized patients with diabetes are treated with insulin, a medication that occupies a prominent place on the list of loftier-alarm medications of the Plant for Safe Medication Practices.four It is the leading medication implicated in adverse events requiring handling in a hospital emergency department.five Moreover, insulin is responsible for more drug errors during acute hospital intendance than other commonly used hospital medications.6
What is the best approach to using insulin in the hospital setting? What skills and knowledge must providers have to brand the virtually constructive use of insulin and nevertheless minimize the danger of hypoglycemia? In that location are no unproblematic answers for these questions.
As depicted in Effigy 1, a single hospitalization often involves multiple transitions, each requiring a careful approach to insulin therapy. The transitions begin when patients enter the hospital. Patients may be admitted to a ward or to the intensive care unit (ICU), keep directly to the operating room, or undergo various invasive procedures. Patients then move inside the hospital amidst different levels of intendance with overlapping or sequential interventions such as nothing-by-oral fissure (nil per os [NPO]) status, enteral or parenteral feeding, medications that may worsen glycemic command, and hemodialysis. The clinical course may be influenced by existing or newly developing clinical conditions such equally renal or hepatic failure that change the metabolism of insulin. Finally, patients transition back to an outpatient setting, either directly to their domicile or to an intermediate setting such as a rehabilitation or skilled-nursing facility.
Thus, distinct features of every hospitalization include 1) the fluidity of the clinical situation, with changes in clinical condition and need for interventions; 2) difficulty predicting or planning for when an issue will occur (eastward.g., imaging, surgery, cancellations, NPO condition, or timing of meals); and iii) numerous opportunities for breakdowns in communication among teams and diverse care providers at all levels.
Nosotros suggest a framework in which to consider insulin therapy in the hospital setting, a basic paradigm for starting and managing insulin therapy, with special considerations for specific situations (Table 1). This brief review volition focus on practical aspects of glycemic management of patients with diabetes outside of the ICU setting. It will not include inpatient management of hyperglycemia in patients without diabetes or other important aspects of optimal diabetes intendance in the hospital such equally patient and staff education or dietary considerations.seven
Figure ane.
For patients with diabetes, a single hospitalization may involve multiple transitions. Each transition requires a careful approach to insulin therapy. Patients may be admitted to a ward or to the ICU or proceed directly to surgery. They may so receive different levels of care with overlapping or sequential interventions such as NPO status, enteral nutrition past tube feeding, or total parenteral nutrition (TPN); medications such as steroids that may worsen glycemic control; and dialysis. Patients transition back to an outpatient setting, either direct to their habitation or to an intermediate setting such as a rehabilitation or skilled-nursing facility. The clinical state of affairs may shift often, with numerous opportunities for breakdowns in communication amid teams and various care providers at all levels.
Figure one.
For patients with diabetes, a single hospitalization may involve multiple transitions. Each transition requires a conscientious approach to insulin therapy. Patients may be admitted to a ward or to the ICU or continue directly to surgery. They may so receive different levels of care with overlapping or sequential interventions such as NPO status, enteral nutrition by tube feeding, or full parenteral nutrition (TPN); medications such equally steroids that may worsen glycemic command; and dialysis. Patients transition back to an outpatient setting, either directly to their home or to an intermediate setting such as a rehabilitation or skilled-nursing facility. The clinical situation may shift oft, with numerous opportunities for breakdowns in communication amongst teams and diverse care providers at all levels.
Transitioning from Domicile to Hospital
A cardinal aspect of the bones paradigm of insulin use in the infirmary is an evaluation of patients' glycemic regimen with a current or recent A1C and review of hypo- and hyperglycemia earlier hospitalization. Higher A1C levels are associated with a greater adventure for hospitalization.eight Thus, patients with diabetes who are admitted to the hospital are likely to take poorer glycemic command.
In a majority of patients, the kickoff steps in planning for diabetes intendance in the hospital are the discontinuation of oral glucose-lowering agents and initiation of insulin therapy.nine Patients may exist unable to take oral medications, or they may have contraindications to the employ of non-insulin glucose-lowering agents while hospitalized. The utilize of glucagon-like peptide-1 (GLP-1) agonists or dipeptidyl peptidase-iv (DPP-4) inhibitors may bear witness to be beneficial in select inpatient populations, but at that place are insufficient information at this time to support standing these medications in the hospital setting.
In addition, all patients with diabetes admitted to the infirmary should have 1) blood glucose monitoring at to the lowest degree before meals and at bedtime, 2) articulate parameters and instructions for establishment of a hypoglycemia protocol, and 3) the diagnosis of diabetes clearly indicated in hospital documentation. Clinicians should also have patients' inpatient glycemic goals in mind. For patients admitted to a full general medical ward, the glycemic goal range may exist 110–140 mg/dl preprandially and 140–180 mg/dl postprandially.9
Selecting initial insulin doses in the infirmary. Overall, nosotros highly recommend the use of scheduled doses of insulin rather than "sliding-calibration" insulin. The scheduled-dose insulin regimen is divided into three components: basal, nutritional, and correctional (supplemental) doses.
Selecting an initial basal insulin dose
For patients treated with insulin before hospitalization, the daily insulin dose adjusted for the level of pre-hospitalization glycemic command would be a reasonable starting dose. If patients who are treated with a basal-bolus regimen have nutrition withheld on admission to the hospital (NPO status), only the basal component should be used. Importantly, patients with blazon ane diabetes must never be left without basal insulin.
For patients whose diabetes is managed by nutrition and lifestyle just or who are on noninsulin glucose-lowering agents and have relatively well-controlled diabetes (arbitrarily defined equally an A1C < 8%), a proficient starting indicate would be to constitute a daily basal dose of subcutaneous insulin at 0.2 units/kg body weight/solar day, along with rapid-acting insulin at a set dose before meals (see beneath). For overweight or obese patients who are likely to be more insulin resistant and for those with less well-controlled glycemia as an outpatient (an A1C of 8–9%), the starting dose of basal insulin could exist higher, ranging from 0.3 to 0.5 units/kg torso weight/day. For patients with very poorly controlled diabetes every bit an outpatient (an A1C > 9%), an even college basal dose of insulin may be instituted, ranging from 0.five to 0.8 units/kg body weight/day. Conversely, for patients with an A1C ≤ 7.5% or frequent hypoglycemia, the initial starting basal dose of insulin in the hospital should exist reduced accordingly.
Tabular array ane.
Bones Prototype for Insulin Therapy in Hospitalized Patients With Diabetes
Tabular array 2.
Suggested Initial Insulin Doses in Hospitalized Patients With Diabetes
If the abode dose of basal insulin is to be used, some precautions must be taken into consideration. For patients with an A1C < 7.v–eight%, a dose lower than the outpatient basal insulin dose should be considered. In addition, considering some patients' outpatient basal insulin covers nutritional needs in addition to basal needs, the basal insulin dose ordered for hospitalization should be lower than the outpatient basal insulin dose. Clues that this may be the case include i) a basal insulin dose much > fifty% of the full daily insulin dose for patients on a basal-bolus insulin regimen or two) a full basal insulin dose > 1 unit/kg body weight/twenty-four hours. These recommendations are summarized in Table two.
Selecting initial nutritional and correctional insulin doses
Having selected a basal dose of insulin, attention should be shifted to nutritional-correctional doses of rapid-acting insulin, also known as "mealtime insulin." The rapid-acting insulin protocol should include a safety measure such as a "no carbohydrates" scale with correction dose insulin simply for patients who are NPO or eat < 25% of the calories on their meal tray (Table 2). The rapid-acting insulin modification scale used at our institution also includes a separate correction gene for bedtime that is more bourgeois than the "no carbohydrates" scale to minimize the risk of nocturnal hypoglycemia.
For patients on a sophisticated intensive insulin regimen at dwelling house, at that place is the option of ordering a customized rapid-interim insulin modification scale that includes an insulin-to-saccharide ratio and a correction/sensitivity factor adamant past the provider.
However, for near patients consuming meals in the infirmary, the total daily dose of rapid-acting insulin should be roughly equal to the total basal insulin dose and divided among iii meals. A reasonable correction/sensitivity cistron could be either 1 unit of measurement for every 25 mg/dl that blood glucose is elevated in a higher place goal or i unit of measurement for every l mg/dl that blood glucose is elevated to a higher place goal, with a preprandial claret glucose goal of 110–140 mg/dl (Table 2).
A crucial component of successful insulin therapy in the hospital is synchrony between meals and insulin administration. In many hospitals, repast-time insulin is administered immediately after meals to minimize the risk of hypoglycemia. This is done to avoid situations in which patients do non eat after receiving insulin. If the policy of administering insulin after meals is instituted, a slap-up deal of endeavor should be directed at providing insulin equally soon later meal consumption as possible.
The daily evaluation of blood glucose monitoring records is also of paramount importance. Clinicians must review signal-of-care glucose records and plasma glucose on chemical science panels for episodes of hyper- and hypoglycemia and make adjustments daily as needed. If correction doses of rapid-acting insulin were used, these must be incorporated into the full daily insulin dose, equally additional basal insulin and/or nutritional insulin.
If there has been an episode of hypoglycemia (glucose < 70–80 mg/dl), the precipitating cause should be determined. Was it because of mistimed insulin administration and a delayed repast? Was insulin given in the setting of a missed meal? Did the patient eat less of a repast than expected? Was there overestimation of the sugar content of the meal? Was there stacking of correction dose insulin, with corrections given too frequently?
If any of these factors contributed to the hypoglycemia, a problem-solving approach should be used. If not, then the full daily dose of insulin should be reduced, possibly by 10–20% or more, depending on the specific glucose levels observed. Which dose(south) of insulin should be reduced would depend on what fourth dimension of day the hypoglycemia occurred.
Transitions Within the Hospital
There is oft defoliation nearly the optimal way to dose insulin when patients with diabetes are NPO for a radiological process, a surgery, or because the clinical condition necessitates it. Often, basal insulin may exist continued and the "no calories" rapid-interim insulin modification scale used. Continuing basal insulin and signal-of-intendance glucose monitoring is particularly important for patients with blazon ane diabetes or severe long-standing type two diabetes because a lack of insulin therapy may lead to very severe hyperglycemia and even to diabetic ketoacidosis (DKA).
The transition from an intravenous insulin infusion to a subcutaneous regimen while patients are in the ICU or when transitioning from the ICU to a ward may also cause bug. This is addressed in the adjacent department.
Special Considerations
Transitioning from intravenous insulin infusion
There are various ways to transition patients with diabetes who are on an intravenous insulin infusion to subcutaneous insulin.ten–14 Most patients on an insulin infusion are non eating because of the severity of their critical illness or other factors. In patients who are on a continuous insulin infusion for DKA, assuming that they take not nevertheless started eating while on the insulin infusion, the total daily basal insulin requirement may be estimated past extrapolating from infused insulin received at a stable rate for at least 6–8 hours. The insulin infusion is discontinued 1–2 hours afterward the first dose of basal insulin is administered. If the next day's scheduled basal dose of insulin is < 18 hours from the time of discontinuing the insulin infusion, we adjust the initial dose of basal insulin accordingly.
Equally above, scheduled doses of nutritional rapid-acting insulin are calculated by dividing the total daily basal dose by iii and distributing the insulin beyond three meals.
Insulin and glucocorticoids
Administration of glucocorticoids worsens glycemic control in diabetes,15–17 presenting a significant challenge for inpatient management. The doses and frequency of glucocorticoid administration vary widely, and steroids may be tapered or stopped abruptly. Acute or curt-term administration of methylprednisolone causes predominantly postprandial hyperglycemia that lasts 6–12 hours. Prednisone is similar to methylprednisolone, with hyperglycemic effects occurring half dozen–12 hours after administration, but dexamethasone has an even longer duration of action. In our experience, the result of dexamethasone to increase insulin resistance and thus increase insulin requirements may last every bit long as 48–52 hours.
Considering NPH insulin usually has an onset of action at 2–four hours, a peak of activeness occurring at 6–8 hours, and a duration of action of 10–14 hours, it may be used at the time of methylprednisolone or prednisone administration to annul the hyperglycemic effect of these forms of glucocorticoid.18,19 NPH insulin can then be discontinued every bit shortly as the glucocorticoid is discontinued, providing a safer option than having residuum insulin activeness from loftier doses of long-acting insulin lasting for hours later discontinuation of steroids. The NPH insulin may be added to patients' existing insulin regimen and administered only as long as the patient is on glucocorticoids. Our rule of thumb is to utilize 0.five units of NPH insulin/mg of prednisone or methylprednisolone, ranging between 0.25 and 1 unit of insulin/mg of glucocorticoid (Table iii).
Unfortunately, no systematic inquiry has been published in patients receiving either multiple daily doses of glucocorticoids or in those receiving dexamethasone. We utilize at least twice-daily dosing of NPH or daily long-acting basal insulin in these patients.
An culling to adding NPH insulin to patients' regimen is to increment the basal and bolus insulin doses by 30–50% across the board (Table iii). Anecdotal bear witness suggests that GLP-1 agonists or DPP-4 inhibitors may be useful in treating steroid-induced hyperglycemia. This is an important area for future inquiry.
Insulin and dialysis
Glycemic management in patients on hemodialysis may be fraught with difficulties in the inpatient setting. Patients with renal failure are at higher risk of hyperglycemia because of uremia-induced insulin resistance. The risk for hypoglycemia is also quite high because of decreased insulin clearance, decreased renal contribution to gluconeogenesis, and decreased oral nutrient intake. Yet, skilful glycemic control is specially important in patients with end-stage renal affliction (ESRD) because of this population's increased run a risk for sepsis.
The information for optimal outpatient regimens for ESRD patients on dialysis are thin; there are even fewer data for inpatient regimens. Hemodialysis clears uremia and improves insulin resistance, so individuals with diabetes ofttimes have significantly lower blood glucose levels in the time period post-obit dialysis.xx,21 Therefore, patients may require different insulin regimens before and subsequently hemodialysis. At that place is some evidence to back up reduction of the basal insulin dose by ~ 25% the twenty-four hour period after a hemodialysis session.22 Close monitoring of blood glucose levels is imperative.
Patients with diabetes who are on peritoneal dialysis go hyperglycemic in the post-dialysis period considering of high concentrations of glucose in the dialysate, which is absorbed from the peritoneal crenel.23,24 One might consider using actress NPH insulin at the beginning of peritoneal dialysis in these situations.
Insulin and parenteral and enteral diet
Enteral and parenteral nutrition pose major challenges for glucose management in the hospital. These nutritional approaches oftentimes effect in hyperglycemia, even in patients without a history of diabetes, and have been associated with poor outcomes in the setting of resultant hyperglycemia.25–27 Scheduled subcutaneous insulin may exist difficult to implement safely because of both planned and unplanned interruptions, every bit well as titration of the nutritional source.
Tabular array iii.
Special Considerations for Insulin Therapy in Hospitalized Patients With Diabetes
In the case of enteral nutrition, a small, randomized clinical written report demonstrated that subcutaneous basal insulin is more than effective than correction dosing alone.28 Some other report suggested that using pre-mixed seventy/thirty insulin twice or three times daily (Table 3) may be safer than using long-acting insulin in patients on continuous tube feeding.29 Other approaches such as scheduled brusk-interim insulin may be equally safe and efficacious, but studies are non available.
In the case of TPN, no randomized controlled trials comparing various approaches to insulin therapy are available, although retrospective data suggest that the add-on of insulin in the TPN purse provides adept control with less hypoglycemia than the employ of intravenous or subcutaneous insulin alone.30 This study suggested that an initial insulin-to-dextrose ratio of 1 unit for every 12–15 thou of carbohydrate in the TPN bag is both safe and efficacious (Table 3). This ratio is then adapted daily to achieve a glycemic target of 140–180 mg/dl.
Because patients on TPN and continuous enteral nutrition remain in a postprandial state, more than aggressive glucose lowering is not recommended and could lead to severe hypoglycemia. Nosotros include orders for initiation of a ten% dextrose infusion if tube feeding is interrupted or discontinued abruptly. For both enteral and parenteral nutritional approaches, a computerized intravenous insulin algorithm may provide safer or more effective alternatives, but very few data are available.
Transitioning From Infirmary to Outpatient Settings
Transitioning from hospital to home
For patients with diabetes who are being discharged from the infirmary to home, an immediate effect is timely outpatient follow-up. Another concern is how and when changes to pre-admission medication regimens should exist implemented. Conditions in the infirmary may cause dramatic differences in glucose handling that may non render to baseline just before and later discharge. Doses of insulin recommended at discharge may exist significantly higher or lower than those actually needed at habitation.
Hospitalizations, planning for discharge, and designing a diabetes medication regimen for hospital belch may represent opportunities to change previous outpatient diabetes intendance.31 Unfortunately, this may be a missed opportunity.32
We have into account both patient factors and external factors when recommending a glucose-lowering regimen for discharge. Patient factors include patients' ability and motivation to handle dissimilar levels of complication in a glucose-lowering regimen and are affected by physical limitations, comorbid weather condition, and agreement of diabetes self-care. External factors include patients' support system, resource, and financial considerations. We try to make up one's mind these factors early on in the hospitalization so that the inpatient regimen can exist designed to mimic the proposed outpatient regimen as much as possible.
Transitioning to a rehabilitation or skilled nursing facility
The diabetes regimen recommended for discharge to a rehabilitation or skilled nursing facility might differ from one recommended for employ afterwards discharge to dwelling if there is concern nearly patients' ability or preferred level of involvement in self-intendance in instituting a complex glucose-lowering regimen. These factors, also as the level of nursing care available at the discharge facility, should exist taken into consideration when planning a diabetes regimen for discharge to an intermediate level of care.
Conclusion
The basic prototype for constructive management of glucose levels in the hospital setting takes into consideration the many factors that may come into play. The use of scheduled insulin regimens, close glucose monitoring, daily adjustments, and sensation of the obstacles for glycemic control permit for amend and safer command of glucose levels in hospitalized patients with diabetes.
Acknowledgments
The authors admit the University of Colorado School of Medicine/Anschutz Medical Campus for providing financial support for their piece of work.
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Source: https://diabetesjournals.org/spectrum/article/26/2/124/31910/Insulin-Use-in-Hospitalized-Patients-With-Diabetes
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