IN PATIENT MANAGEMENT

OF DIABETES
RSSDI – GUIDELINES
Not all patients are the same…..
◦ `
Drugs
Different eating
Different activity (steroids, TPN,
pattern
DW fluids

Patient factors
Illness related Diabetes
renal function,
Insulin resistance Phenotype
Liver function
Management of Patients With Diabetes in Non
ICU- Setting

diabetes drugs

Insulin OHDS
Recommended the best (easy if Not generally recommended
you know it ) (recent data with sita)

Iv insulin
Sc insulin
Critically ill and
The usual care
certain situation
Insulin and its Classification
DIAGNOSIS AND CLASSIFICATION
Diabetes can be diagnosed with any of the following criteria:

● FPG ≥126 mg/dL

● FPG ≥126 mg/dL and/or 2-h PG ≥200

mg/dL using 75-g OGTT

● HbA1c≥6.5%

Asymptomatic individuals with a single abnormal test should have

the test repeated to confirm the diagnosis unless the result is
unequivocally abnormal.
DIAGNOSIS AND CLASSIFICATION
 The decision to set diagnostic threshold values was based on the
cost-effective strategies for diagnosing diabetes that was reviewed
in the Indian context.
Criteria for diagnosis of Prediabetes/ intermediate
hyperglycemia:

●Impaired fasting glucose (IFG): FPG 110 mg/dL to 125 mg/dL

● Impaired glucose tolerance (IGT): 2-h plasma glucose (2-h PG)

during 75-g OGTT 140 mg/dL to 199 mg/dL

● HbA1c ≥5.7%-6.4%
Insulin therapy in hospitalized
patients
 Guidelines from the ADA 2019 and RSSDI 2016 recommend basal insulin or a
basal plus bolus correction insulin regimen for noncritically ill hospitalized
patients with poor oral intake and an insulin regimen with basal, prandial,
and correction components for noncritically ill hospitalized patients with
good nutritional intake.

 ADA guidelines also suggest avoiding sliding scale insulin in the inpatient
hospital setting.

 Initial and maintenance insulin dosing protocol for hospitalized patients with
diabetes should be adjusted based on RSSDI clinical practice
recommendations for management of in-hospital hyperglycemia—2016 as
shown in Table9.
Initial and maintenance insulin
dosing protocol
Recommendations from RSSDI for insulin
therapy in hospitalized patient
 • For majority of critically ill patients in ICU, insulin infusion should
be used to control hyperglycemia.

 • BG > 180 mg/dL should trigger insulin initiation.

 Once IV insulin started, glucose level should be maintained between

140 and 180 mg/dL.

 • The exact protocol is probably less important; what is important is

its presence in an institution and adaptation to the individual
hospital needs.
Recommendations from RSSDI for insulin
therapy in hospitalized patient
 The protocol in Table 7 above may be adapted as recommended by
RSSDI inpatient hyperglycemia guidelines 2016.

 • Discontinuation of IV insulin often leads to rebound

hyperglycemia. Hence, intravenous to subcutaneous insulin
transition should be made carefully and only after it is evident that
the patient exhibits stable glycemic control.

 • Transition is more likely to be successful if blood sugar levels are

between 140 and 180 mg/dL with constant insulin drip rate.

 • It should be ensured that there is continuity between IV insulin

infusion and the first dose of SC insulin.
Recommendations from RSSDI for insulin
therapy in hospitalized patient
 • It should be ensured that there is continuity between IV insulin
infusion and the first dose of SC insulin.

 • The total daily insulin requirement calculation can be best

ascertained during a time interval of 4–6 h during which the blood
glucose values are at goal and IV insulin rates are not particularly
elevated or variable.

 • Regular insulin or rapid-acting analogs should be used for the

bolus/prandial insulin and the supplemental insulin. The basal
insulin requirement should be met using NPH or insulin detemir,
glargine, or degludec
MEDICAL NUTRITION THERAPY (MNT) AND
LIFESTYLE MODIFICATION

MNT

 ● The nutrition chart and support should be made by a trained

nutritionist and a physician/diabetologist.

 ● It should be based on TAF- Type, Amount, and Frequency

MEDICAL NUTRITION THERAPY (MNT) AND
LIFESTYLE MODIFICATION
Carbohydrates
 ● Carbohydrate content should be limited to 50%-60% of total
calorie intake.

 ● Complex carbohydrates should be preferred over refined products.

 ● The low glycaemic index (GI) and low glycaemic load (GL) foods
should be chosen.

 ● The quantity of rice (GI: 73) should be limited as it has high GI;
Brown rice (GI: 68) should be preferred over white rice. (Millets are
another alternative)

 ● Fiber intake: 25-40 gm per day.