IN-PATIENT HYPERGLYCEMIA MANAGEMENT IN NON-CRITICALLY ILL PATIENTS Presented By Dr. Reshma Francis Pharm D (PB)Introduction The selection of method for the glycemic control in non- critically ill in-patients was done based on the results from a prospective, multicenter randomized trial It was done by Emory University School of Medicine, Atlanta Georgia and The University Of Miami School of Medicine Miami, Florida Randomized study of Basal —Bolus Insulin Therapy in the Inpatient Management of patients with Type 2 Diabetes (RABBIT 2 Trial) RABBIT 2.pdf 22Edu yeh Randomized Study of Basal Therapy in the Inpatient Management of Patients With (RABBIT 2 Tria e 2 Diabetes (Gustrmec FE Upsemees, wot ‘Axons Pas acs, ep Biren Sores nt Seow enor, tat ‘Aste Zan ho Avie Fone. sa ‘oenro Magia re ‘Stoners cone an poneass wus pet dahetes au iaw ates thas kaw iacued om he sryect RESEARGH DESIGN AND METHODS — We conducted « propeve, multicenter ‘enclomnsed til to compere thes fenry nel nefeny f= banal bolus ine regumem sith thw of SEESGQSS Ppl le CS pacman wath ype 2 dnbewee@ tonal of 150 carahoenaire patente were randomaned ta texte | Tal gh fnndard St prtocol My ooo 308400 erst cn gore fur ten pe day for bled pine > 190 mar RESULTS — ree seen ndeasnion Hoc qlucoue wes 220 = 6 engi and aL ae (iba glucose target af = 1s0 mghll was achisved mn 60m ot paenintn sr glargne and gioinine (Son anc tm SO thaw i She 2k group. Foe meen day bined glucose bere een gems SEs Caan aa cs Sa gill ak om teal Used ghecee dllerence of 27 mg Po OD) rapt tnagensing watuiin dcaray 14 of patents wetted wah 21 teaneined wal Mood ghee SSTe naga These weve no Sferencs i th rae of ypopiyormas ce lengah of spat sony conciusions ‘ody went ‘ow eraically Treatment wach wnuslan glanging andl gliaine result signdicant 7 tena teas invuhin negimnen te prefereed over St we the tanagemarns of | Notysalzed panienas wh type cakes yperglycemis m hoapttalized pa. of poor clinical outcome and momahty fens ts a common, ceric, and (I~5). Extensive evidence trom cbserea costly health care problem with Gonal sade ‘our ov, indi Drotounclmedculeonuequences increas cates that in ospitalised patients wth Rigevsdchce tndicates that the develop- emlucal Ulness, rypergiycermia is asaoc}= mint of hypermiysemia during mccte sted wth an therm tak of compen Riedical of surgical Winess hota plyst- tions and mortality (2-9). Prospective Skgicor benign condition but iowmarler tandoenised tials it crticaly t have shown that mtcnaive ghicore comtrol ‘edhuces the risk of muslutargan bahure, sy=- temic tnectiona, and. ahort- and erm mortality” Efeaive management of hyperglycemia ts also associaced wath 2 etreasect Teng of intensive care unit and hospual stay (4.0.0~10) and de Gieased total hospitaltcation, sort (10). The importance of glyeermie contrat on outcome inet tinited to pallens CHE Eallcare arcs but also applies «2 patients fdmated to general eurpeal and fmedical wards. In such patients, the presence of Ryperglyecria tas been susociated =k prolonged hospital saay. tniection, die. Shily afer hespital Gischarge, and death 2ST)" general surgery panienes. Use felattve nisk for serous postoperative {ne fections (sepsis, pcurnonia, iechon) wetcased 3.7-0ld When any Postoperative day 1 blood klucose was i Dhcumonia repored that Hypermlycerait She anmocuted with increased Fak of tne Hospital comphicanions and mortality C3 Inulin, given either wntravencesly as 4 contimunas infusion or subcutanccsty, fe ite most efecture agen for tmmedate Control ot hyperglycemia in the Beepital in tie cruicafeare sewing. a wannety of con: Gnuows tmulin unfusion protocols. ave been shown ts be elective i ach hosp Gloutesmes (e-10,13). In general medicine and surgery Services, however, Sppengycemia te freqacnily Sveriocked tat adequately addvessed, Several Fe ports from academic institutions Rave ete ee See ee eee eee nae+ Study Type: Prospective, randomized, open- label trial * Study Sites: Grady Memorial Hospital, Atlanta Jackson Memorial Hospital, Miami + Patient Population Total 130 patients with DM. Oral hypoglycemic agents or insulin therapy pr icoiy Insulin Glargine OD + A ene mee) Glulisine 65 patients Sire etna iy 4 times dailyMethodology + Discontinue oral antidiabetic drugs on admission * Starting total daily dose (TDD): — 0.4 U/kg/d x BG between 140-200 mg/dL — 0.5 U/kg/d x BG between 201-400 mg/dL + Half of TDD as insulin glargine and half as rapid-acting insulin (lispro, aspart, glulisine) — Insulin Glargine - once daily, at the same time/day. — Rapid-acting insulin- three equally divided dosesBlood glucose (mg/dL) 240 220 200 180 460 140 120 100 Blood Glucose Levels During Isulin Treatment SSRI Lantus + glulisine amt 4 2 3 4 5 6 F 68 98 10 Days of TherapyConclusion The percentage of patients within the mean glucose target (140 mg/dl) was 66% in patients treated with Glargine and Glulisine versus 38% in those treated with SSI No difference in hypoglycemia (3% of patients in each arm) | bolus regimen is best for the better ycemic control in non-critically ill bias erie Coates)BASAL BOLUS REGIMEN » Basal bolus regimen involves taking a longer acting form of insulin to keep blood glucose levels stable through periods of fasting and separate injections of a shorter acting insulin to prevent rises in blood glucose levels resulting from meals.BASAL INSULIN > Itis also know as background insulin, is to keep blood glucose levels at consistent level during periods of fasting. > It is needed to keep blood glucose level under control and allow the cells to take in glucose for energy. » Body needs a basic amount of insulin all the time - day and night - even between meals. This is called ‘basa?’ insulin. It helps control blood glucose at times when not eating but body still needs energy. > The amount of insulin you require can vary due to changes in the food you eat and activity or exercise you undertake ° 29> It is usually taken once or twice a day depending on the insulin. » Basal insulin - act over a long period of time and therefore it will either long acting or intermediate acting. Types of basal (long acting) insulin > Intermediate acting insulin — e.g. Insulatard or Humulin I > Long acting insulin — e.g. Glargine (Lantus) or Detemir (Levemir)BOLUS INSULIN » A bolus dose is insulin that is specifically taken at meal time to keep blood glucose level under control following a meal. » Bolus insulin acts quickly. Eg ; short acting or rapid acting > Itis often taken before meals. > When you eat a meal your blood glucose level rises as carbohydrate food is turned into glucose. Insulin helps glucose move from the blood stream into the body cells to make energy. You need ‘bolus’ insulin to cope with the rise in glucose level after meals.Types of bolus (short acting) insulin > Short acting insulin such as Actrapid or Humulin S . should be given 20-30 minutes before a main meal. > Rapid acting insulin such as Novorapid, Humalog, and Apidra ° can be given immediately before or immediately after main meals.Rapid acting insulin at meal time & long Short acting & intermediate acting or acting insulin once or twice a day rapid acting and long acting insulin Advantage of basal bolus regimen > It matches how our own body would release insulin > It allows flexibility as to when meals are taken. Disadvantage of basal bolus regimen > More insulin injection per dayCALCULATING TOTAL DAILY INSULIN Calculate starting basal and bolus doses of insulin by working out the patient’s total daily insulin dose (TDD) requirements. Current diabetes treatment Total initial daily insulin dose Diet 0.3 units/kg Oral / injectable agents 0,3 units/kg> Underweight Older age Hemodialysis 0.4 units/kg > Normal body weight 0.5 units/kg > Over weight 0.6 units/kg> Obese Insulin resistantExamples » 80kg patient diet-controlled TDD = 0.3 x 80kgs = 24 units » 90kg patient taking metformin and gliclazide TDD = 0.4 x 90kgs = 36 unitsCALCULATING BASAL-BOLUS SPLIT . Glargine (basal) - Write up 50% of calculated total daily insulin dose as the glargine (basal) dose . . Rapid insulin with meals (bolus) - 50% of the calculated total daily insulin dose divided into 3 equal doses of rapid acting insulin (Humalog or NovoRapid) with meals. . Correctional rapid insulin (bolus) - rapid acting insulin given in addition to meal time bolus.CALCULATING A CORRECTION DOSE > Ifa patient’s blood glucose level rises above a pre-determined value, he or she may need an insulin bolus to bring it down. » Calculating the supplemental dose is a 2-step process. > First, an insulin sensitivity factor (ISF) is calculated; then, the desired blood glucose level is subtracted from the actual blood glucose reading and divided by the ISF. > ISF determines how much the blood sugar will drop in response to I unit of insulin.Step 1 » Divide 1500 by the total daily dose (eg, 30 units) »® 1500/ 30 = 50 (ISF) [regular insulin : factor is 1500 Rapid acting insulin : factor is 1800] Step 2 » Subtract the desired blood glucose level (110 mg/dL) from the actual blood glucose reading (eg, 240 mg/dL) and divide by the ISF ® 240 — 110/50 = 2.6 additional unitsExample of Correction dose of Insulin ACTRAPID 150 scale (FBS; Insulin dose) ACTRAPID 200 scale (FBS; Insulin Dose) <150— NO INSULIN 151-200 ; 2 Units 201-250 ; 3 units 251-300 ; dunits 301-350 ; 6 units 351-400 ; 8 units > 400; 10 units <200- NO INSULIN 201-250 ; 2 units 251-300 ; 3 units 301-350 ; 4 units > 350; 5 unitsADJUSTING INSULIN DOSES; EXAMPLES > General principles Before adjusting doses review any clinical changes to the patient which may influence insulin requirements Eg infection is improving, appetite returning or increasing mobility. > If there is hyperglycaemia - Dose increases are generally between 10-25%, > If there is hypoglycaemia - Reduce the appropriate insulin by 20-25%, » All Blood Glucose Level's (BGL) consistently high - Indicates not enough basal insulin, suggest increasing the glargine dose.ADJUSTING INSULIN DOSES: EXAMPLES > Fasting BGL - the only insulin impacting on this BGL is the Glargine. There will be no impact from the rapid acting insulin administered at tea time the night before, * high fasting BGL - increase evening Glargine dose * low fasting BGL - decrease evening Glargine dose >» Lunchtime BGL - mainly influenced by the breakfast rapid acting insulin dose. high BGL before lunch - increase breakfast rapid acting insulin low BGL before lunch - decrease breakfast rapid acting insulinADJUSTING INSULIN DOSES; EXAMPLES > Teatime BGL - mainly influenced by the lunch time rapid acting insulin dose. high BGL bejore tea - increase lunch rapid acting insulin low BGL before tea - decrease lunch rapid acting insulin > 21: 00 hours BGL - mainly influenced by the teatime rapid acting insulin dose, * high BGL at 21:00 - increase teatime rapid acting insulin low BGL at 21:00 - decrease teatime rapid acting insulin 022Plasma insulin levels Profiles of Human Insulins and Analogues 2 4 6 8 10 12 14 16 18 20 22 24 Hours. BB Aspart, lispra (4 to 6 hours) Regular (8 to 10 hours) NPH (12 to 20 hours) GB Glargine (20 to 26 hours) BB Ultralente (18 to 24 hours) 223Carbohydrate counting It is one of many meal planning options for managing blood glucose levels, most often used by people who take insulin twice or more times a day. It gives you more choices and flexibility when planning meals. It involves counting the number of carbohydrate grams in a meal and matching that to your dose of insulin. A food that contain 15 grams of carbohydrate is called “one carb serving” Eg: one slice of bread, a small slice of fruit have around 15 grams of carbohydrate.Counselling points Insulin Injection SitesImportance of rotation of injection sites * Insulin should not be injected at a site more than one month Repeated injection at the same site in the body Accumulation of extra fat at the site 4 Improper absorption of insulin 4 Improper glycemic control 026LipohypertrophyStorage Storage of insulin is very important + More chances of error in storage of insulin . insulin_stability_chart.pdf For short term travelling you can take the vial from fridge in a polythene cover with ice cubes (max 3 hrs) 028General counseling points + Don’t use insulin if any particles or any turbid appearance. * Don’t use needle more than 3 times. + Don’t keep the finger at the top of the needle or insulin pen during injection. * Don’t immediately remove the needle or insulin pen after injection. + Ifany symptoms of hypoglycemia occurs like palpitation, shaking limbs , excessive sweating, dizziness, you should immediately take some sugar (4 tea spoons). * Keep some chocolate and the glucometer with you while travelling.Fruits in Diabetes + Can take 2 slices of water melon 2 slices of papaya Guava Apple Orange Musambi * Can't take Sapota Banana Dates Mango . 030Reference * Umpierrez G.E, Smiley D, Zisman A, Prieto.L.M, Palacio A, Mceron A, Puig A, et al; Randomized Study of Basal-Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT 2 Trial); Diabetes Care 30:2181-— 2186, 2007Thank Youlll