diabetes inpatient management

  • Discontinue oral hypoglycemics, especially metformin & sulfonylureas
  • Basal Bolus insulin regimen is the preferred guideline driven inpatient regimen
  • Inpatient BG goal: 140-180 mg/dL pre-prandially, without severe or recurrent hypoglycemia. ebm NICE-SUGAR trial
  • If a patient is having hypoglycemia, they have no BG targets, other than resolving the hypoglycemia.
  • Total daily dose (TDD) = basal + prandial + correction

1. Assess Basal Insulin Dose

  • Goal of basal insulin is to hold BG stable in fasting state
  • Goal is not to correct hyperglycemia or cover food
  • Thus, bedtime BG and AM BG should be the same
  • most people need less bolus and more prandial
  • Total basal dose (TBD) = 0.4 x TDD
  • T1DM: TBD = 0.273 x TDD
  • Calculate change between bedtime BG and fasting AM BG
    • if AM BG has increased by >15-20% compared to bedtime, increase basal insulin dose
    • if AM BG has decreased by >15-20%, decrease basal insulin dose
    • if AM BG is within 15-20% of bedtime BG, basal insulin dose is correct (even if both readings are above goal because that means the dinner dose of lispro is too low)
  • Dose Lantus usually 8PM for easier management in am. Alternatively, dose BID
  • Change Lantus dose based on BG:
    • BG in 100s: change by 10%
    • 200s: 20%
    • 300s: 30%

2. Assess Prandial Insulin Dose

  • Patient is eating => give standing prandial insulin, do not use SSI only
  • work backwards in time to alter pre-prandial BG readings
  • To change bedtime BG, raise or lower pre-dinner prandial lispro dose
  • To change pre-dinner BG, adjust pre-lunch prandial lispro dose
  • To change pre-lunch BG, adjust pre-breakfast prandial lispro dose
  • Change dose 10-20%

3. Assess Corrective Insulin Dose

  • is corrective insulin correcting hyperglycemia? If not, the increase correction scale

The 4 things that go into a patient’s BG at any given time:

  • Medication on board
  • Food ingested (or TF or TPN)
  • Activity (or lack thereof)
  • Stress (physical stress of illness and in some cases, psychological stress)

Important questions to ask the patient &/or nursing when trying to figure out daily BG patterns:

  • Did you eat a bedtime snack or eat overnight?
  • Did you NOT eat bedtime snack or eat overnight?
  • Did you walk 50 laps around the unit yesterday?
  • Was the food gross? Was the food delicious?
  • Was the pt made NPO?
  • Missed insulin doses? Mistimed insulin doses?
  • Mistimed POC BG? Missed POC BG?
  • Bedtime or middle of the night correction insulin given?
  • Tube Feeds turned off or on?

Cases

  • no night time BG available
  • should decrease basal bolus

  • hyperglycemia at lunch time because AM prandial dosing was held
  • nurse did not give AM insulin because BG 88 in the morning
  • decrease basal to bring BG 140-180

  • basal bolus adequate
  • prandial dose need to go up

Resources