MD Conference Express ADA 2012 - (Page 27)
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Table 1. Glycemic Targets in the Noncritical Care Setting.
1. A premeal glucose target of <140 mg/dL (7.8 mmol/L) and a random blood glucose of <180 mg/dL (10.0 mmol/L) for the majority of hospitalized patients with noncritical illness. Modification of glycemic targets according to clinical status. For patients who are able to achieve and maintain glycemic control without hypoglycemia, a lower target range may be reasonable. For patients with terminal illness and/or with limited life expectancy or at high risk for hypoglycemia, a higher target range (BG <11.1 mmol/L or 200 mg/dL) may be reasonable. To avoid hypoglycemia, reassess antidiabetic therapy when BG values fall below 5.6 mmol/L (100 mg/dL). Modification of glucose-lowering treatment is usually necessary when BG values are below 3.9 mmol/L (70 mg/dL).
Supplemental insulin adjustment • If fasting glucose and premeal plasma glucose are persistently above 7.8 mmol/L (140 mg/dL) in the absence of hypoglycemia, increase insulin scale of insulin from the insulin-sensitive to the usual or from the usual to the insulin-resistant column • If a patient develops hypoglycemia [BG <3.8 mmol/L (70 mg/dL)], decrease regular or rapid-acting insulin from the insulinresistant to the usual column or from the usual to the insulinsensitive column C. Supplemental insulin scale BG (mg/dL) >141–180 181–220 221–260 261–300 301–350 351–400 >400 Insulinsensitive 2 4 6 8 10 12 14 Usual 4 6 8 10 12 14 16 Insulinresistant 6 8 10 12 14 16 18
2.
3.
Source: Umpierrez GE et al. J Clin Endocrinol Metab 2012.
Table 2. Example of a Basal Bolus Insulin Regimen for the Management of Noncritically Ill Patients with T2DM.
A. Basal insulin orders • Discontinue oral diabetes drugs and noninsulin injectable diabetes medications upon hospital admission • Starting insulin: calculate the total daily dose as follows: • 0.2 to 0.3 U/kg of body weight in patients aged ≥70 yr and/or glomerular filtration rate less than 60 ml/min • 0.4 U/kg of body weight per day for patients not meeting the criteria above who have BG concentrations of 7.8 to 11.1 mmol/L (140 to 200 mg/dL) • 0.5 U/kg of body weight per day for patients not meeting the criteria above when BG concentration is 11.2 to 22.2 mmol/L (201 to 400 mg/dL) • Total calculated dose as approximately 50% basal insulin and 50% nutritional insulin • Give basal insulin once (glargine/detemir) or twice (detemir/NPH) daily, at the same time each day • Give rapid-acting (prandial) insulin in 3 equally divided doses before each meal; hold prandial insulin if patient is not able to eat • Adjust insulin dose(s) according to the results of bedside BG measurements B. Supplemental (correction) rapid-acting insulin analog or regular insulin Supplemental insulin orders • If a patient is able and expected to eat all or most of his/her meals, give regular or rapid-acting insulin before each meal and at bedtime following the “usual” column (Section C) • If a patient is not able to eat, give regular insulin every 6 h ours (6–12–6–12) or rapid-acting insulin every 4 to 6 hours following the “sensitive” column (Section C)
The numbers in each column of Section C indicate the number of units of regular or rapid-acting insulin analogs per dose. “Supplemental” dose is to be added to the scheduled insulin dose. Give half of supplemental insulin dose at bedtime. If a patient is able and expected to eat all or most of his/ her meals, administer supplemental insulin before each meal following the “usual” column dose. Start at insulin-sensitive column in patients who are not eating, elderly patients, and those with impaired renal function. Start at insulin-resistant column in patients receiving corticosteroids and those treated with more than 80 U/d before admission. To convert mg/dL to mmol/L, divide by 18. Adapted from Clement S et al. Diabetes Care 2004; Umpierrez GE et al. Diabetes Care 2007; Umpierrez GE et al. J Clin Endocrinol Metab 2009.
Other topics included pharmacological treatment of hyperglycemia in the non-intensive care unit setting (eg, avoidance of prolonged use of sliding scale insulin therapy as the sole method for glycemic control in hyperglycemic patients with a history of diabetes during hospitalization) [Umpierrez GE et al. J Clin Endocrinol Metab 2012]; insulin therapy in patients with type 2 diabetes [Umpierrez GE et al. Diabetes Care 2007]; and transition from hospital to home (Figure 2). Figure 2. Discharge Insulin Algorithm.
Discharge Treatment (D/C)
HbA1C <7%
HbA1C 7% to 9%
HbA1C >9%
Re-start outpatient treatment regimen (oral antidiabetic drug and/or insulin)
Restart oral agents and D/C on glargine once daily at 50% to 80% of hospital dose
D/C on basal bolus at same hospital dose Alternative: restart oral agents and D/C on glargine once daily at 50% to 80% of hospital dose
Reproduced with permission from G Umpierrez, MD.
Peer-Reviewed Highlights from the American Diabetes Association 72nd Annual Scientific Sessions
27
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Table of Contents for the Digital Edition of MD Conference Express ADA 2012
MD Conference Express ADA 2012
Contents
ORIGIN Trial Results
New Lessons in Hypertension and Diabetes
Closed-Loop Insulin Therapy in Young Children
The Precocious “AGE’ing” Effect of Type 1 Diabetes in Children
Abatacept in Patients with New-Onset Type 1 Diabetes: One-Year Follow-Up
Explaining the UKPDS Legacy Effect
Insulin and Cancer
Insulin Analogs
Dyslipidemia
Insulin Therapy
Incretin Therapies
Diabetes and Chronic Kidney Disease Guidelines Update
Managing Hyperglycemia in Hospitalized Patients
CVD Prevention and Treatment in Women With Diabetes
China Da Qing Study: Lifestyle Change in Women With IGT Extends Life
Markers of Macrovascular Complications in Pediatric Diabetes
Nonoperative Management of the Infected Diabetic Foot
Diabetic Retinopathy: Changing Prevalence and Severity Require Flexible Interventions
New ADA/EASD Position Statement Endorses a Patient-Centered Approach
MD Conference Express ADA 2012
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