Glycemic Management Guideline

Adult Inpatient 2016-2017

This guideline was constructed by the Diabetes, Endocrinology, and Metabolism (DEM) team to promote safe and effective glycemic management. This serves
a general guide and is NOT intended to replace clinical judgement. Doses may be adjusted as a prescriber deems appropriate on an individual patient basis

Inclusion Criteria: Adult inpatients with Type I or Type 2 diabetes or “new” hyperglycemia as defined below

GENERAL PRINCIPLES
 Hyperglycemia in the inpatient setting is associated with poor outcomes. Both hyPERglycemia (blood glucose > 180
mg/dL) and hyPOglycemia (blood glucose < 70 mg/dL) requires identification and appropriate management regardless
of a diagnosis of diabetes.
 Oral hyPOglycemics are generally INAPPROPRIATE in the inpatient setting:
o Only consider use in clinically stable patients eating regular meals and without contraindications.
Optimal glycemic control with oral hyPOglycemics takes days to weeks while hyPOglycemia and
drug side effects can be immediate.
o In addition, many of the patients hospitalized have the following contraindications to oral
hyPOglycemic therapy during hospitilization:
Comorbidities / Procedures / Nutritional states
NMC GLYCEMIC GOALS GUIDELINES:
Blood glucose (BG) goals should be individualized to the patient. Consider less restrictive goals for patients at risk of
hypoglycemia (e.g., elderly / renal or hepatic impairment).
Location BG Goals (mg/dL)
Non-ICU:
 Pre-meal < 140
 Other times < 180
ICU: BG Goals (md/dL)
 Medical / Surgery / Trauma 140 – 180
 Burn 100 – 140
 Cardiac < 180
Peripartum: 80 – 120
Enteral / Parenteral Nutrition 140 – 180
BG MONITORING AND DIAGNOSIS
 Obtain HbA1C for all patients with diabetes and those with new hyperglycemia (BG > 180 mg/dL X 2 in 24-hours) if
none available within previous 90-days:
o HbA1C > 6.5: Considered diagnostic of diabetes
 o HbA1C of 5.7-6.4: Indicative of “Pre-diabetes”
 All patients with diabetes and “new” hyperglycemia (BG > 180 mg/dL X 2 in 24 h) need fingerstick BG monitoring
with meals and bedtime OR every 6-hours if NPO
BG ASSESSMENT AND INSULIN SUBCUTANEOUS DOSE ADJUSTMENTS
 Evaluate blood glucoses daily
 If not at goal, adjust every 24-48 hours
 If > 2 fasting blood glucoses (FBG) not at goal (BG 100 – 140 mg/dL): ADJUST basal dose
 If > 2 pre-lunch, pre-dinner blood glucoses not at goal (BG 100-140 mg/dL): ADJUST insulin lispro dose
 For patients with continuous enteral tube feedings: Adjust both insulin glargine and insulin lispro OR regular by
same percentage
Dose Adjustment Guideline Table
BG (mg/dL) Dose Adjustment
< 50 Decrease by 50%*

50 – 69 Decrease by 20%*

70 – 89 Decrease by 10%*

90 – 140 NO CHANGES

141 – 180 Increase by 10%**

181 – 229 Increase by 20%**

230 – 279 Increase by 30%**

> 280 Increase by 40%**

*
Investigate to determine the cause of hypoglycemia
**Patients with: Renal / Hepatic impairment / Elderly / Type I DM - may require less of a dose increase
INSULIN TITRATION ALOGRITHM
If AM fasting BG is too HIGH or LOW Adjust Glargine

If pre-lunch, pre-dinner or bedtime is too HIGH or LOW Adjust Lispro

Patients with End Stage Renal Disease (ESRD)

 Have SIGNIFICANTLY DECREASED insulin requirements due to prolonged insulin actions
 Are at increased risk for hypoglycemia, particularly in the fasting state
 For insulin naïve patients, initial insulin glargine dose SHOULD NOT exceed 0.1 units/kg
 PATIENTS RECEIVING STEROID
General Principles:
 Patients are highly variable in their response to steroid, although most times insulin dose needs to be increased
 Full dose NPH given at the same time as glucocorticoid administration except:
o Methylprednisolone -or- Hydrocortisone dosed every 4 to 6 hours -or- dexamethasone utilized:
- Give NPH three times per day at 8 am, 4 pm, and 10 pm (the 10 pm dose should be reduced by 25%).
o If the patient is NPO give 50% of NPH dose.

Low Dose Glucocorticoid High Dose Glucocorticoid

Daily dose Daily Dose
Hydrocortisone 10 – 159 mg Hydrocortisone > 160 mg
Prednisone / Prednisolone 10 – 39 mg Prednisone / Prednisolone > 40 mg
Methylprednisolone 8 – 31 mg Methylprednisolone > 32 mg
Dexamethasone 1.5 – 5.9 mg Dexamethasone > 6 mg

NON-Diabetics* Diabetics* NON-Diabetics* Diabetics*

5 units of NPH per 10 units of NPH per 10 units NPH per 20 units NPH per
glucocorticoid dose glucocorticoid dose glucocorticoid dose glucocorticoid dose
* If the patient is NPO give 50% of dose * If the patient is NPO give 50% of dose
ALTERNATIVE STEROID DOSING #1
Intermediate/Base Insulin Dose*
Prednisone Equivalent
(Administer NPH at the SAME TIME as steroid given)
> 40 mg 0.4 units/kg
> 30 mg 0.3 units/kg
> 20 mg 0.2 units/kg
> 10 mg 0.1 units/kg

* Hydrocortisone / Prednisone / Prednisolone: consider administering NPH with steroid dose given
* Methylprednisolone / Betamethasone: consider administering Glargine with steroid dose given

ALTERNATIVE STEROID DOSING #2

NPH Dose
Hydrocortisone Dose (Administer NPH at the SAME TIME as steroid given)
First 20 mg of hydrocortisone 1 unit of NPH per 1 mg of hydrocortisone
Second 20 mg of hydrocortisone 0.5 unit of NPH per 1 mg of hydrocortisone
Each subsequent mg of hydrocortisone > 40 mg 0.25 unit of NPH per 1 mg of hydrocortisone
Example: Patient is administered 40mg per day of Prednisone
 1. Convert Prednisone to Hydrocortisone: 5mg of prednisone = 20 mg of hydrocortisone, therefore 40mg of
prednisone = 160mg of hydrocortisone
2. [20mg of hydrocortisone X 1 = 20 units of NPH] + [20mg of hydrocortisone X 0.5 = 10 units of NPH] + [120mg of
hydrocortisone X 0.25 = 30 units of NPH]
3. 20 + 10 + 30 = 60 units of NPH given at the same time as 40mg of prednisone

ESTIMATING THE APPROPRIATE DOSE OF INSULIN FOR THE PATIENT

If the patient has these features . . . Multiplying Factor

Malnourished, elderly, CKD, Dialysis, SEVERE Liver Disease 0.3 x Pt’s weight (kg)
Normal-weight patients, T1DM Patients 0.4 x Pt’s weight (kg)
Overweight Patients 0.5 x Pt’s weight (kg)
Obese, high dose steroids or other marker of significant
0.6 x Pt’s weight (kg)
insulin resistance
 NON-ICU PATIENT WITH HYPERGLYCEMIA

TYPE 1 DM TYPE 2 DM OR *New* Hyperglycemia

NPO EATING NPO EATING
BASAL MUST take home basal. Insulin naïve and
NO BASAL NO BASAL
INSULIN MUST take home basal. Consider decrease by 20% BG < 180 mg/dL
 Consider decrease by 20%
-or-
-or-

Insulin glargine 0.1 unit/kg

Recent history of
basal
Insulin lispro prandial scale
Insulin lispro NPO -or- Insulin glargine
-Plus- Check insulin glargine box
{Correction scale} Insulin naïve with 0.1 unit/kg
CORRECTION/ Bedtime scale
BG > 180 mg/dL X
PRANDIAL
2 in 24-hours
INSULIN
Insulin lispro prandial scale
Insulin lispro NPO -PLUS-
correction scale Bedtime scale

PATIENTS RECEIVING ENTERAL TUBE FEEDINGS

TYPE 1 DM TYPE 2 DM OR *New* Hyperglycemia
BASAL Continuous Feeds Continuous Feeds
INSULIN Insulin glargine: either home or weight based from Check insulin glargine box from
CORRECTION/ Continuous Feeds: Insulin regular scale EVERY 6 hours, hold if tube feeds HELD or BG < 80 mg/dL
PRANDIAL Overnight Feeds: Not eating: Insulin lispro NPO scale EVERY 6 hours
INSULIN Eating: Insulin lispro prandial scale + bedtime scale

DIABEETES MEDICATION ADJUSTMENT GUIDELINES

PRIOR TO PROCEDURE AND SURGERY

Medications Day BEFORE Procedure / Surgery Day OF Procedure / Surgery

Oral Sulfonylureas
Glyburide (Micronase), glipizide (Glucotrol), Take only morning and/or lunch doses NONE
glimepiride (amaryl)
All other oral agents Take usual dose(s) NONE

Non-insulin injectables Take usual dose(s) NONE

Rapid / Short acting Insulins Morning dose:
Type 1 DM:
Regular (Humulin R, Novolin R), Lispro (Humalog), Take usual dose
Reduce dose by 30%
Aspart (Novolog), Glulisine (Apidra)
Dinner / bedtime dose:
Type 2 DM:
Type I DM: Reduce dose by 20%
Reduce dose by 50%
Type 2 DM: Reduce dose by 30%
Insulin NPH Morning dose: Type 1 DM:
Humulin N, Novolin N Take 100% Reduce dose by 20%

Dinner / bedtime dose: Type 2 DM:

Reduce dose by 20% Reduce dose by 50%
Long-acting insulins Morning dose: Type 1 DM:
Glargine U-100 (Lantus), Detemir (Levemir), Take 100% Reduce dose by 20%
Glargine U-300 (Toujeo),
Dinner/bedtime dose: Type 2 DM:
Reduce dose by 20% Reduce dose by 50%
Pre-Mixed Insulin Ask patient to contact PCP/endocrinologist
Humulin 70/30, Humulin 50/50, Novolin 70/30, -or-
Novolog Mix 70/30, Humalog Mix 75/25, Humalog Type 1 DM:
Mix 50/50 Reduce dose by 20%
Type 2 DM:
Reduce dose by 30%
Insulin Pumps Reduce all basal rates by 20% for outpatients. DEM consult mandatory for all inpatients.

DISCHARGE PLANNING
 If HbA1C on admission is at goal (i.e., <7% for most patients), consider discharging patient on home diabetes regimen; evaluate new medical
conditions and medications that may preclude the use of certain agents or require dose adjustments.
 If HbA1C on admission is above goal, consider maximizing diabetes home regimen and/or adding insulin(s) depending on patient ability to perform
self-care safely.
 Initiate diabetes education by nursing staff and call diabetes educator as needed early in the hospital stay especially if blood glucose monitoring
and/or insulin therapy is a new skill or regimen has been intensified.
 Recommend contacting outpatient provider to communicate diabetes discharge regimen.
 Transition Guide For Patients From Inpatient to Outpatient Regimen
HbA1C < 7% HbA1C 7-9% HbA1C > 9%

Best option: Basal insulin at 75-100% of

current dose & quick acting insulin with
meals at FIXED -or- CALCULATED dose
Return to same home regimen unless Restart home regimen if not contraindicated.
Other options:
contraindicated Keep basal at 50-100% of inpatient dose
 Basal Plus (basal insulin + rapid acting
insulin at largest meal)
 Pre-mixed insulin before breakfast &
dinner

Basal insulin: glargine, detemir, toujeo, treseba Bolus insulins: aspart, lispro, glulisine Pre-mixed insulin: 70/30 & others as listed