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What To Do When Your Patient Has Diabetes: Karen A. Mcdonough MD Inpatient Medical Service Uwmc
What To Do When Your Patient Has Diabetes: Karen A. Mcdonough MD Inpatient Medical Service Uwmc
What To Do When Your Patient Has Diabetes: Karen A. Mcdonough MD Inpatient Medical Service Uwmc
Has Diabetes
Karen A. McDonough MD
Inpatient Medical Service
UWMC
Stress Hyperglycemia Increases
Morbidity/Mortality in:
• Acute MI
• Acute stroke
• Medical and surgical admits to an
inner city hospital
Hyperglycemia and Infection
• Abnormal leukocyte function in patients
with diabetes
• Improves with control
• Risk of surgical site infection correlates
with severity of perioperative
hyperglycemia
Hyperglycemia and Infection
• 1548 patients admitted to a surgical
intensive care unit, almost all post-op
• 13% diabetic
• Randomized to intensive insulin therapy to
maintain blood glucose 80-110 mg/dL
versus usual care
• Mean blood glucose in experimental group
103 mg/dL versus 153 mg/dLfor control
group
Prandial
Basal
B L D
Insulin Action - Hours
250
150
50
1 amp D50
Insulin order
• Basal insulin
• Prandial insulin
• Glipizide $19.99
• Generic metformin $55.99
• Rosiglitazone $77.99
$153.97
Bedtime Basal Insulin –
NPH or glargine
• Patients with HgbA1c ≥ 7.5% on 1 or 2 oral
agents
• NPH or glargine started at 10 U at bedtime,
and titrated according to a weekly titration
schedule based on self monitored FPG
• Oral agents continued
• Goal FPG ≤ 100
Diabetes Care 2003;26:3080
Bedtime Basal Insulin
• Mean HgbA1c at baseline = 8.6%
• Mean Hgb A1c at end = 7%; 60% achieved
HgbA1c ≤ 7%
• Mean daily insulin doses 47 U with
glargine, 42 U with NPH
• Less symptomatic hypoglycemia with
glargine than NPH (13.9 vs 17.7 per
patient/year)
Diabetes Care 2003;26:3080
Starting Bedtime Basal Insulin
• 10-20 units, or 0.1-0.2 U/kg (can start
higher if very poorly controlled)
• Measure CBG before breakfast
• Increase by 4 units if CBG is over 140 on 3
consecutive measures
• Increase by 2 units if CBG is 110-140 on 3
consecutive measures
• Don’t increase if hypoglycemia has
occurred in the past week
JAMA 2003;289:2265
Teaching opportunities
• Diet review
• Medication teaching
• Review of insulin injection technique
• Review of glucometer use
• Initiation of insulin (in consultation with
PMD)
• Review of foot care
Case #6
A 52 year old man with diabetes will be
having an EGD/colonoscopy tomorrow. His
diabetes is well controlled with NPH insulin
10 units at 7 AM and 8 units at 9 PM, and
insulin lispro before meals. His AM glucoses
run 90-110 mg/dL.
What is the best approach to diabetes
management for this patient?
Periprocedural Management
of T1DM