DIABETES CARE IN

HOSPITALIZED

Dr. WIDYATI, MClinPharm, Apt

Farmasis Klinik RSAL Dr. Ramelan
Magister Farmasi Klinik Ubaya
 Background Setting

Uncontrolled
DM
Main Diseases

DM in Complications
hospitalized

Underlying Acute diseases

Diseases
Chronic
diseases
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 Uncontrolled DM

Non-adherence
Inadequate OAD Hiperglikemia
Inadequate insulin
Inappropriate OAD
Inappropriate insulin
Insulin resistence Hipoglikemia
Insulin tolerance
Infection
Kegagalan OAD

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 HYPERGLYCEMIA
 Symptoms: 3P, weight loss, lethargy, pruritus vulvae,
skin infection, visual, mual, muntah.
 Pertimbangan Klinik: Non-adherence, insulin
resistance, ketidakcukupan OAD or insulin, pemilihan
OAD yang kurang tepat.
 Patients with hyperglycemia fall into three categories:
 Medical history of diabetes
 Unrecognized diabetes: hyperglycemia occurring during
hospitalization and confirmed as DM
 Hospital-related hyperglycemia: hyperglycemia occurring
during the hospitalization that reverts to normal after hospital
discharge. 4
 HYPOGLYCEMIA
 Definition Blood glucose concentration <60 mg/dL:
Patient may or may not be symptomatic. Blood glucose
<40 mg/dL: Patient is generally symptomatic. Blood
glucose <20 mg/dL can be associated with seizures and
coma.
 Signs and Symptoms Blurred vision, sweaty palms,
generalized sweating, tremulousness, hunger, confusion,
anxiety, circumoral tingling, and numbness. Patients
vary with regard to their symptoms. Behavior can be
confused with inebriation. Patients become combative
and use poor judgment.
Nocturnal hypoglycemia: nightmares, restless sleep, profuse
sweating, morning headache, morning “hangover.” 5
 Hypoglycemia
 Clinical Considerations:
Irregular eating patterns
↑ Physical exercise
Gastroparesis (delayed gastric emptying)
Excessive dose of sulfonylurea
Alcohol ingestion
Drugs Treatment : Ingest 10–20 g rapidly absorbed
carbohydrate. Repeat in 15–20 min if glucose remains
<60 mg/dL or if patient is symptomatic.
If patient is unconscious : Glucagon 1 mg SC, IM, or IV
(response time, 6.5 min);Glucose 20 g IV (dextrose
40%; response time, 4 min) 6
 Non-Adherence
 Patient-Related: needle phobia; fear of initiating insulin;
nonadherence to self-monitoring of blood glucose (SMBG),
diet, exercise, or medications; lack of motivation; depression;
low socioeconomic status; and limited access to specialized
care such as a diabetes or endocrinology clinic.

 Treatment –Related: ineffective diet/nutrition regimens,

complex drug regimens, mode of delivery of insulin therapy,
failure of clinicians in treating aggressively in a treat-to-target
approach, underutilization of insulin therapy, polypharmacy,
and adverse effects such as hypoglycemia, edema, nausea,
bloating, and weight gain.
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Acute Metabolic Chronic
complications Complications

Makrovaskuler:
Hyperosmolar cardiovascular
Hyperglycemia disorders, Peripheral
State (HHS) Vascular Disease

Mikrovaskuler:
Ketoacidosis Retinopati, Nefropati,
Neuropati
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 HYPERGLYCEMIC CRISES

• Criteria: FPG> 600mg/dl, pH

>7,30, HCO3 > 15, ketonuria dan
Hyperosmolar serum minimal, osmolaliltas serum
> 320, stupor/coma
Hyperglycemia:

• Common acute complication of

DM Type1
Diabetic • Criteria: FPG>250 mg/dl, pH < 7
ketoacidosis: (severe)-7,3; Keton (+) dlm
urin/serum, osmolalitas variable;
alert-coma
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 DKA & HHS TREATMENT
 Requires correction of :
 dehydration,
 hyperglycemia,
 electrolyte imbalances;
 identification of comorbid precipitating events
 Insulin Therapy
 Hypokalemia must be excluded
 Bolus of regular insulin at 0.15 units/kg body
weight, followed by a continuous infusion of
regular insulin at a dose of 0.1 unit/kg/jam (5 to 7
units per hour in adults)
 If plasma glucose does not fall by 50 mg/dL from
the initial value in the first hour, check hydration
status; if acceptable, the insulin infusion may be
doubled every hour until a steady glucose decline
between 50 and 75 mg/hour
Chronic Complications
 1. CARDIOVASCULAR DISEASE
 CVD is the major cause of mortality in DM, major
contributor to morbidity of DM
 Type 2 DM is independent risk factor(RF) for CVD
 Emphasis should pleced on reducing RF:
 BLOOD PRESSURE CONTROL
 MANAJEMEN DISLIPIDEMIA
 ANTI-PLATELET
 SMOKING CESSATION
 CHD SCREENING & TREATMENT

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 BLOOD PRESSURE CONTROL
 Target : BP < 130/80 mmHg
 Pt w/ 130-139 / 80-89 mmHg should be given lifestyle and
behavioral therapy for 3 months, if targets are not achieved start
drug therapy.
 Initial drug therapy: ACE, ARB, diuretics, CCB
 Multiple drugs generally is required
 Type 1, HT, albuminuria: ACE delay the progression of
nephropathy
 Type 2, HT, microalbuminuria: ACE and ARB delay the
progression to macroalb
 Type 2, HT, macroalb: ARB delay the progression of
nephropathy

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MANAJEMEN DISLIPIDEMIA
 Type 2, test for lipid disoreders annually
 Reduction of saturated fat and cholesterol
intake, weight loss, phys act↑ shown to improve
lipid profile
 Goal: LDL < 100 mg/dl

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 MANAJEMEN DISLIPIDEMIA
Lipid Profile Monoterapi Terapi
Kombinasi
LDL↑, HDL (N), Resin or Statin Resin+Niacin/St
TG (N) or Niacin atin or Statin +
Niacin
LDL ↑, TG ↑ Statin Statin+Niacin/
Ezetimibe
TG ↑ Niacin Niacin + Fibrate
Fibrate
LDL ↑, HDL↓ Niacin Statin+
Statin Niacin/Ezetimibe
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 Terapi Anti-Platelet
 Use Aspirin (75-162mg/day) as a secondary prevention
in DM w/ MI, CABG, stroke or TIA, PVD,
Claudication , Angina
 Use Aspirin (75-162mg/day) as a primary prevention in
Type 2 w/ over 40 y.o., HT, CVD, dyslipidemia,
smoking, albuminuria
 People who allergy, bleeding tendency, receiving
anticoagulant, recent GI bleeding, clinically active
hepatic disease are not candidates for aspirin and
should have other anti-platelet

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 2. NEPHROPATHY
 Occurs in 20-40% of DM and major cause of
ESRD
 Micro alb (30-299mg/24h) early stage of
nephropathy in type 1 and marker for
nephropathy development in type 2
 Treatment of both micro & macroalb using
ACE or ARB except during pregnancy
 With presence of nephropathy, initiate protein
restriction

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 3. RETINOPATHY
 The prevalence related to to the duration of Diabetes
 Optimal glycemic control can substantially reduce the
risk and progression of Diabetic Nephropathy
 Optimal BP control reduce the risk and progression of
Diabetic retinopathy
 Adults with Type 1 should have eye exam within 5
years, Type 2 shortly after diagnosis of DM
 Laser therapy can ↓ the risk of vision loss

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 4. NEUROPATHY
 Peripheral diabetic neuropathy may result in pain, loss
of sensation, and muscle weakness
 Autonomic involvement can affect gastrointestinal,
cardiovascular, and genitourinary function
 Improvement in neuropathy should be sought by
increased attention to blood glucose control.
 Relief can be provided by various medications,
alterations in medical nutrition therapy, or specialized
procedures.

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 Intercurrent
illness:
Trauma,
surgery

Acute
Diseases +
DM
Acute
events: Comorbid:
dislipidemia,
Stroke, HT
ACS, Sepsis

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 INTERCURRENT ILLNESS
 Intercurrent illness: Trauma, surgery, infections,
acute event, CH, gagal ginjal
 The Stress of illness aggravate glycemic control,
precipitate hyperglycemic crises
 Aggressive management w/ insulin may reduce
morbidity in severe acute illness.

9-8-15 22
 Comorbid Conditions

Atherosclerosis Dyslipidemia Hypertension

• Associated with • Intensive treatment is • UKPDS: Intensive
↑cholesterol (esp. important for control of BP reduces
LDL) protection from • Diabetic complications
by 24%
• Occur primarily in macrovascular
complications • Diabetes related deaths
large & medium by 32%
arteries • Treatment:Statins, • Strokes by 44%
• Aggressive treatment Fibrates, Bile acid
• Heart Failure by 56%
include plaque sequestrant,
• Microvascular
stabilization with Nicotinic Complication by 37%
aspirin or ACE acid,Ezetimib
• Treatment: ACE or β-
blocker

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 DM in Acute Events

Sepsis Stroke ACS

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 DM in Chronic Diseases
 CH, CKD : mungkin sudah tidak perlu
OAD/insulin
 Bila hiperglikemi masih ada, maka pilihan:
insulin, gliquidone
 Cancer exacerbate insulin resistance syndrome

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 BLOOD GLUCOSE TARGET
 Ada hubungan antara hiperglikemi dengan
peningkatan mortalitas.
 Pada pasien penyakit dalam dan bedah kadar gula>
220mg/dl memiliki laju infeksi tinggi
 Ada hubungan antara kadar gula dengan mortalitas
pada AMI
 Pencapaian kadar gula target berkaitan dengan
menurunnya mortalitas dan laju infeksi pada bedah
jantung
 Kadar Gula < 110mg/dl meningkatkan survival rate
pada critically ill.
 TREATMENT OPTIONS
 OAD:
 Sulfonilurea dan meglitinide tidak
direkomendasikan karena risiko hipoglikemia pada
pasien yang tidak mengkonsumsi diet normal,
sulitnya penyesuaian dosis
 Metformin memberikan risiko lactic acidosis
khususnya pada COPD, renal insuff,hipoperfusi,
CHF, manula.
 Thiazolidinedion: delayed onset, me↑volume
intravaskuler
 Insulin
 Insulin Therapy in the Hospital
 Subcutaneous insulin therapy:
 Dapat digunakan untuk hampir semua pasien
hospitalisasi
 Scheduled insulin
 Correction-dose insulin
 Tidak ada studi membandingkan antara reguler dengan
lispro sebagai dosis koreksi
 Dosis Insulin
TDD Estimation Patient Characteristics
0.3 units/kg body weight Underweight
• Older age
• Hemodialysis

0.4 units/kg body weight Normal weight

0.5 units/kg body weight Overweight

≥ 0.6 units/kg body weight Obese

• Insulin resistant
• Glucocorticoids
 Insulin Therapy in the Hospital
 Intravenous insulin infusion:
 Tidak ada keuntungan menggunakan lispro or
aspart dibanding reguler
 Indikasi: DKA, HHS, intraops, critically ill
 Insulin Therapy in the Hospital
 Transisi Dari i.v. ke s.c.
 Tidak ada lit spesifik yang menemukan
bagaimana transisi
 Pasien yg akan beralih ke s.c. perlu disuntikkan
reguler or lispro 1-2 jam s.c. sebelum iv berakhir
 Pasien yg akan beralih ke intermediate or long
acting perlu disuntikkan intermediate or long
acting 2-3 jam sebelum iv berakhir
 Current Recommendation
 Recommendation 1: The American College of
Physicians recommends not using intensive insulin
therapy to strictly control blood glucose in non-surgical
intensive care unit/medical intensive care unit
(SICU/MICU) patients with or without diabetes
mellitus (Grade: strong recommendation,
moderate-quality evidence). (ACP, 2011)
 Why?
 Current evidence does not show any reduction in
mortality with a target blood glucose level of 4.4 to 10.0
mmol/L (80 to 180 mg/dL)
 IIT was associated with an excess risk for hypoglycemia
in almost all trials and no clear differences in mortality
were observed at any target level.
 Evidence from some studies showed an increase in
mortality associated with IIT and hypoglycemia. Data on
the effects of IIT targeted to normoglycemia on
reduction in length of ICU stay are mixed.
Current Recommendation (cont.)
 Recommendation 2: ACP recommends not using
intensive insulin therapy to normalize blood glucose in
SICU/MICU patients with or without diabetes mellitus
(Grade: strong recommendation, high-quality
evidence).
 Recommendation 3: ACP recommends a target blood
glucose level of 7.8 to 11.1 mmol/L (140 to 200 mg/dL) if
insulin therapy is used in SICU/MICU patients (Grade:
weak recommendation, moderate-quality
evidence).(ACP, 2011)
DRUG INDUCED
HYPERGLYCEMIA
 Glucocorticoids
 Mechanism: primarily by inhibiting glucose uptake
into muscle.
 Postprandial glucose levels are generally most
affected
 Patients who are treated with a basal/bolus regimen
will probably require a higher percentage of their
TDD as bolus insulin while on glucocorticoids.
 It is important to reduce insulin doses as
glucocorticoids are tapered to avoid hypoglycemia.
 Drugs that can increase blood
glucose level
 2-Agonists, -Adrenergic blockers
 Corticosteroids
 Diuretics
 Diazoxide
 Pentamidine
 Protease inhibitors
 Cyclosporine

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 Drugs that can decrease blood
glucose level
 2-Agonists, -Adrenergic blockers
 Disopyramide
 Ethanol
 Pentamidine:occurs days to 2 weeks after
initiation of therapy
 SU, Insulin

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 Case 1
 Ny HT, 58 th, 65 kg, TB150 cm
 PC: unconscious, ascites, RBG 75 mg/dl
 RP: DM 15 th
 RO: Metformin 3 x 500 mg, Glibenclamide 1-1-
0
 Dx: Hypoglycemia + CH

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 Case 2

 Tn H, 59 th, 50 kg TB 163 cm
 MRS dengan DM Hiperglikemi, luka di kaki yang kotor. Obat
DM yang terakhir diminum adalah Glucodex 1-1-0,
metformin 3x850mg disertai riwayat hipertensi yang terkontrol
dg Diltiazem 3 x 30 mg; Captoril 3x25mg, Aspirin1x100mg
 BP: 170/110 mmHg, GDA 529 mg/dl
 Apa rencana farmasis?

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 Online Resources
 Texas Diabetes
Council:www.tdctoolkit.org/algorithms-
guidelines/
 ADA
 NDEP
 Summary
 Managing diabetes and hyperglycemia during
hospitalization is vital for optimal clinical
outcomes.
 Insulin is the best treatment for inpatient
management but can be very challenging given
the stress of illness, frequently changing caloric
intake throughout the hospital stay, and
limitations to care provided by hospital
personnel.