Transcript Document

Manejo del Paciente Diabetico
en la Unidad de Cuidados
Intensivos y Sala General
Guillermo E. Umpierrez, MD, FACP, FACE
Professor of Medicine
Director, Grady Hospital Clinical Research Unit
Emory University School of Medicine
Director, Diabetes & Endocrinology Section
Grady Hospital CIN (Research Unit)
Grady Health System
Hiperglucemia en el Hospital: Agenda
1. Magnitud del Problema:
 Cual es la frecuencia e impacto de hiperglucemia y
diabetes en el hospital?
 Cuales criterios diagnosticos debemos de utilizar?
 Que niveles de glucosa son recomendables?
2. Como debemos de manejar la hiperglucemia en
UCI y en en sala generales?
 Insulina – Que tipo, regimen, y como comenzar?
 Incretinas – debemos de utilizarlas en el hospital?
 Alta hospitalaria– Cual es el papel de la HBA1c, que
regimen utilizar? HbA1c?
Umpierrez et al. J Clin Endocrinol Metabol. 97(1):16-38, 2012
Distribution of patient-day-weighted mean
POC-BG values for ICU
Data from ~12 million BG readings from 653,359 ICU patients - mean POC-BG: 167 mg/dL
Swanson et al. Endocrine Practice, October 2011
Hyperglycemia: Scope of the Problem
50
Patients, %
40
Diabetes
No Diabetes
50
26%
40
78%
30
30
20
20
10
10
0
0
<110 110-140140-170170-200 >200
<110 110-140140-170170-200 >200
Mean BG, mg/dL
Kosiborod M, et al. J Am Coll Cardiol. 2007;49(9):1018-183:283A-284A.
Perioperative Hyperglycemia in Patients With and
Without Diabetes Undergoing CABG Surgery
No-DM
DM
P-value
150
152
--
29±6
33±8
p<0.001
Admission BG
111±28
171±72
p<0.001
HbA1c
6.1±0.2
8.0±2
p<0.001
Pre-op BG
108±23
155±51
p<0.001
Intra-op BG
138±20
157±31
p<0.001
ICU BG
135±16
149±18
p<0.001
Periop BG >140
83%
98%
P=0.48
Started CII
88%
94%
P=0.06
Insulin dose, Units
61±84
161±229
Transition to basal
insulin after CII
48%
98%
# of pts
BMI
Pasquel et al, Endocrine Society 2014, submitted. Unpublished
P<0.001
Hyperglycemia*: A Common Comorbidity
in Medical-Surgical Patients in a
Community Hospital
12%
26%
62%
Normoglycemia
Known Diabetes
New Hyperglycemia
n = 2,020
* Hyperglycemia: Fasting BG  126 mg/dl
or Random BG  200 mg/dl X 2
Umpierrez G et al, J Clin Endocrinol Metabol 87:978, 2002
Diagnosis & recognition of hyperglycemia
and diabetes in the hospital setting
Admission
Assess all patients for a history of diabetes
Obtain laboratory BG testing on admission
No history of diabetes
BG<140 mg/dl
(7.8 mmol/L)
Initiate POC BG
monitoring according
to clinical status
No history of diabetes
BG >140 mg/dl
Start POC
BG monitoring x 24-48h
Check A1C
A1C ≥ 6.5%
Umpierrez et al. J Clin Endocrinol Metabol. 97(1):16-38, 2012
History of diabetes
BG monitoring
A1C for Diagnosis of Diabetes in the
Hospital
 HbA1c should be measured in non-diabetic subjects
with hyperglycemia (BG>140 mg/dl or 7.8 mmol/L)
and in subjects with diabetes if not done within 2-3
months prior to admission.
 In the presence of hyperglycemia, a patient with
HbA1c > 6.5% can be identified as having diabetes.
 Implementation of A1C testing can be useful:
 assess glycemic control prior to admission
 assist with differentiation of newly diagnosed diabetes
from stress hyperglycemia
 designing an optimal regimen at the time of discharge
Umpierrez et al, J Clin Endocrinol Metabol, 2012
Hyperglycemia in the ICU:
Lecture Agenda
1. Scope of the Problem:
 What is the frequency of hyperglycemia and diabetes?
 Why should we care about hyperglycemia in the ICU?
 Mechanisms for hyperglycemia in acute critical illness
and ICU
2. How should we manage hyperglycemia in the ICU
and non-ICU settings?
 Insulin regimens
 Incretin-base regiments
 Other agents?
Hyperglycemia and Hospital Complications:
What glucose level predicts complications?
N= 55,530 patients records in ICU and non-ICU, Emory University Hospital.
Composite of complications: pneumonia, acute renal or respiratory failure, acute MI,
bacteremia, and death.
Patients with admission BG >400 mg/dL, DKA, and GFR <15 were excluded.
Thirty Day Mortality and Hospital Complications in
Diabetic and Non-diabetic subjects Undergoing
General Non-Cardiac Surgery
*
*
%
†
†p = 0.1
* p= 0.001
#p=0.017
A Frisch et al. Diabetes Care, May 2010
*
*
*
#
Adverse Events Stratified by Perioperative
Hyperglycemia
Diabetes
No Diabetes
§
*
*
BG > 180 mg/dl
*
*
BG < 180 mg/dl
*
P <0.01
§ p <0.05
Known et al. Ann Surg 2013
Proportion of Patients (%)
BG at any point on the day of surgery, post-op day 1 and 2
N= 11,633, colorectal and bariatric surgery;
29.1% with hyperglycemia
Hyperglycemia: An Independent Marker of
In-Hospital Mortality in Patients with
Undiagnosed Diabetes
Mortality (%)
Total In-patient Mortality
16.0% *
1.7%
Normoglycemia
3.0%
Known
Diabetes
* P < 0.01
Umpierrez GE et al, J Clin Endocrinol Metabol 87:978, 2002
New
Hyperglycemia
Inpatient Hyperglycemia: ICU and non-ICU
Lecture Outline
1. What is the frequency of hyperglycemia and
diabetes?
2. What is the association between hyperglycemia
and outcomes?
3. Does treatment of hyperglycemia in ICU
and non-ICU matters?
 What is the evidence for intensive glycemic control?
4. How should we manage hyperglycemia in nonICU setting
Portland Diabetes Project:
Insulin Infusion Reduces DSWI
4.0
DSWI
(%)
SCI
CII
3.0
SCI Group:
Day of surgery: 241 mg/dL
POD #1: 206 mg/dL
2.0
CII Group:
Day of surgery: 199 mg/dL
POD #1: 176 mg/dL
1.0
0.0
87
88
89
90
91
92
93
94
95
96
97
Year
Prospective study of 2,467 consecutive diabetics who underwent open heart surgery.
DSWI, deep sternal wound infection; SCI, subcutaneous insulin; CII, continuous insulin infusion.
Furnary AP, et al. Ann Thorac Surg. 1999;67:352–362.
Hyperglycemia and surgical ICU
morbidity and mortality
Intensive Glucose Management in RCT
Trial
N
Setting
Van den Berghe
2006
1200
MICU
Glucontrol
2007
1101
Ghandi
2007
Primary
Outcome
Odds Ratio
(95% CI)
P-value
ARR
RRR
Hospital
mortality
2.7%
7.0%
0.94*
(0.84-1.06)
N.S.
ICU
ICU
mortality
-1.5%
-10%
1.10*
(0.84-1.44)
N.S.
399
OR
Composite
2%
4.3%
1.0*
(0.8-1.2)
N.S.
VISEP
2008
537
ICU
28-d
mortality
1.3%
5.0%
N.S.
De La Rosa
2008
504
SICU
MICU
28-d
mortality
-4.2%
0.89*
(0.58-1.38)
NR
NICE-SUGAR
2009
6104
ICU
3-mo
mortality
1.14
(1.02-1.28)
< 0.05
*not significant
Griesdale DE, et al. CMAJ. 2009;180(8):821-827.
*
-13%*
-2.6%
-10.6
N.S.
Intensive Insulin Therapy and Hypoglycemic
Events in Critically Ill Patients
Hypoglycemic Events
No. Events/Total No. Patients
Study
IIT
Control
Risk ratio (95% CI)
Van den Berghe et al
Henderson et al
Bland et al
Van den Berghe et al
Mitchell et al
Azevedo et al
De La Rosa et al
Devos et al
Oksanen et al
Brunkhorst et al
Iapichino et al
Arabi et al
Mackenzie et al
NICE-SUGAR
39/765
7/32
1/5
111/595
5/35
27/168
21/254
54/550
7/39
42/247
8/45
76/266
50/121
206/3016
654/6138
6/783
1/35
1/5
19/605
0/35
6/169
2/250
15/551
1/51
12/290
3/45
8/257
9/119
15/3014
98/6209
6.65 (2.83-15.62)
7.66 (1.00-58.86)
1.00 (0.08-11.93)
5.94 (3.70-9.54)
11.00 (0.63-191.69)
4.53 (1.92-10.68)
10.33 (2.45-43.61)
3.61(2.06-6.31)
9.15 (1.17-71.35)
4.11(2.2-7.63)
2.67 (0.76-9.41)
9.18 (4.52-18.63)
5.46 (2.82-10.60)
13.72 (8.15-23.12)
Overall
Favors IIT
Favors Control
5.99 (4.47-8.03)
Griesdale DE, et al. CMAJ. 2009;180(8):821-827.
0.1
1
10
Risk Ratio (95% CI)
NICE-SUGAR Trial: Hypoglycemia and Mortality
The NICE-SUGAR Study Investigators. N Engl J Med 2012;367:1108-1118
2009 AACE/ADA Recommended Target
Glucose Levels in ICU Patients
 Starting threshold of no higher than 180 mg/dL
Not recommended
<110
Acceptable
110-140
Recommended
140-180
Not recommended
>180
Moghissi ES, et al; AACE/ADA Inpatient Glycemic Control Consensus Panel. Endocr Pract. 2009;15(4).
2012 Critical Society Guidelines
ICU Target Glucose Goal < 150 mg/dl
Start Insulin Therapy when BG ≥ 150 mg/dL
Maintain BG values <180 mg/dL
Jacobi, et al. Crit Care Med 2012;40:3251–3276
2012 American College of Physicians (ACP)
 ICU Target Glucose Goal < 200 mg/dl
Annals Intern Med 2012
Glycemic Targets in NON-ICU Setting
1. Premeal BG target of <140 mg/dl (7.8 mmol/L) and
random BG <180 mg/dl (10 mmol/L) for the majority of
patients.
2. Glycemic targets be modified according to clinical status.
3. For avoidance of hypoglycemia, diabetic therapy be
reassessed when BG<100 mg/dl (5.5 mmol/L).
American College of Physicians recommended a target
BG <200 mg/dl (11.1 mmol/L), Ann Intern Med 2012
Umpierrez et al. J Clin Endocrinol Metabol. 97(1):16-38, 2012
Hyperglycemia in the ICU:
Lecture Agenda
1. Scope of the Problem:
 What is the frequency of hyperglycemia and diabetes?
 Why should we care about hyperglycemia in the ICU?
2. How should we manage hyperglycemia in
the ICU and non-ICU settings?
Strategies for Achieving Glycemic Targets in the ICU
Yale Insulin Infusion Protocol2
Leuven SICU Study1
Intensive - Mean BG 103 mg/dL
12
Conventional - Mean BG 153 mg/dL
10
8
6
4
2
0
Admission
Day 1
Day 5
Day 15
MICU Insulin Infusion Protocol (N=69)
450
Blood Glucose (mg/dL)
Blood Glucose (mmol/L)
14
400
350
300
250
200
150
100
50
0
Last day
0
12
24
36
48
60
72
Hours
450
400
160
350
300
250
200
150
100
50
0
NICE-SUGAR4
180
BG, mg/dL
Glucose (mg/dL)
Glucommander3
CIT
140
IIT
120
108
100
0
2
4
6
8
10
12
Hours
14
16
18
20
22
24
80
0
Baseline 1
2 3 4 5 6 7 8 9 10 11 12 13 14
Days After Randomization
1. Van den Berghe et al. N Engl J Med. 2001;345:1359-1367. 2. Goldberg PA et al. Diabetes Care. 2004;27:461-467.
3. Davidson et al. Diabetes Care. 2005;28:2418-2423. 4. Finfer S, et al. N Engl J Med. 2009;360(13):1283-1297.
Hypoglycemia Rates in
Intensive IV Insulin Protocols
Protocol
Hypo definition
% patients
RR
Leuven SICU1
<40 mg/dL
5.1%
7
Leuven MICU2
<40 mg/dL
19%
6
Glucontrol3
<40 mg/dL
8.6%
--
VISEP4
<40 mg/dL
17.4%
4.11
NICE SUGAR5
<40 mg/dL
6.5%
13.7
GLUCO-CABG6
<40 mg/dl
0%
--
Van Den Berghe G, et al. N Engl J Med. 2001:345:1359; Van Den Berghe G, et al. N Engl J Med.
2006;354:449-461; Brunkhorst FM et al. N Engl J Med. 2008; 358:125-139; Preiser JC, SCCM, 2007; Finfer
S, et al. N Engl J Med. 2009;360(13):1283-1297; Umpierrez , ADA 2014
Glycemic Values Achieved with
IV Insulin Protocols
Protocol
IIT
CIT
Leuven SICU
103
153
Leuven MICU
111
153
De la Rosa
120
149
Glucontrol
118
143
VISEP
112
151
NICE SUGAR
118
145
GLUCO-CABG
132
154
IIT: Intensive insulin therapy; CIT: Control, conventional/Conservative insulin therapy
Results are expressed as mean BG during hospital stay, mg/dL
Van Den Berghe G, et al. N Engl J Med. 2001; Van Den Berghe G, et al. N Engl J Med. 2006;De la Rosa,et al, Crit Care 2008;
Brunkhorst et al. N Engl J Med. 2008; Preiser JC, SCCM, 2007; Nice Sugar, NEJM 2009; Umpierrez 2014 (ADA, unpublished)
Recommendations for Managing Patients
With Diabetes in the Hospital Setting
Antihyperglycemic Therapy
Insulin
Recommended
OADs
Not Generally
Recommended
1.ACE/ADA Task Force on Inpatient Diabetes. Diabetes Care. 2006 & 2009
2.Diabetes Care. 2009;31(suppl 1):S1-S110..
Insulin Therapy in patients with T2D
 D/C oral antidiabetic drugs on admission
 Insulin naïve: starting total daily dose (TDD):
 0.3 U/kg to 0.5 U/kg
 Lower doses in the elderly and renal insufficiency
 Previous insulin therapy: reduce outpatient
insulin dose by 20-25%
 Basal bolus regimen: Half of TDD as basal
and half as rapid-acting insulin before meals
Umpierrez et al, Diabetes Care 30:2181–2186, 2007; Baldwin et al, Diabetes Care 10:1970-4, 2011;
Rubin et al, Diabetes Care 34:1723-8, 2011
Inpatient Management in
non-ICU Setting
Sliding Scale
Regular Insulin
Basal Bolus
Insulin Regimen
RABBIT-2D TRIAL:
- Research Question:
In insulin naïve patients with T2DM, does treatment with
basal bolus regimen with glargine once daily and
glulisine before meals is superior to sliding scale regular
insulin?
Umpierrez et al, Diabetes Care 30:2181–2186, 2007
Randomized Basal Bolus versus Sliding Scale Regular
Insulin in patients with type 2 Diabetes Mellitus
(RABBIT-2 Trial)
 D/C 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 rapidacting insulin (glulisine)
 Insulin glargine - once daily, at the same time/day.
 Glulisine- three equally divided doses (AC)
Umpierrez et al, Diabetes Care 30:2181–2186, 2007
Rabbit 2 Trial: Changes in Glucose Levels With
Basal-Bolus vs. Sliding Scale Insulin
240
BG, mg/dL
220
a
200
b
bP<.05.
b
b Group:
 Basal Bolus
b
Sliding-scale
 BG < 60 mg/dL: 3%
Basal-bolus
 BG < 40 mg/dL:
none
160
140
100
Hypoglycemia rate:
a
180
120
aP<.05.
a
Admit 1
2
 SSRI:
3
4
5
6
7
10
8 BG9 < 60
mg/dL: 3%
Days of Therapy
 BG < 40 mg/dL: none
• Sliding scale regular insulin (SSRI) was given 4 times daily
• Basal-bolus regimen: glargine was given once daily; glulisine was given before meals.
0.4 U/kg/d x BG between 140-200 mg/dL
0.5 U/kg/d x BG between 201-400 mg/dL
Umpierrez GE, et al. Diabetes Care. 2007;30(9):2181-2186.
Inpatient Management in
non-ICU Setting
Basal Bolus
Insulin Regimen
NPH and Regular
Insulin-SpiltMixed Regimen
DEAN TRIAL:
- Research Question:
In patients with T2DM on diet, oral agents or insulin
treatment, does treatment with basal bolus regimen with
detemir once daily and aspart before meals is superior to
NPH and Regular split-mixed insulin regimen?
Umpierrez et al, J Clin Endocrinol Metab 94: 564–569, 2009
DEAN Trial: Changes in Mean Daily
Blood Glucose Concentration
240
Detemir + aspart
NPH + regular
BG, mg/dL
220
200
DEAN Trial:
Hypoglycemia
P=NS
 NPH/Regular
180
160
 BG < 40 mg/dl: 1.6%
 BG < 60 mg/dl: 25.4%
140
120
100
Pre-Rx
BG
Data are means SEM.
0
1
3
4
5
6-10
 Detemir/Aspart
2
Duration of Therapy, d
 BG < 40 mg/dl: 4.5%
 BG < 40 mg/dl: 32.8%
Basal-bolus regimen: detemir was given once daily; aspart was given before meals.
NPH/regular regimen: NPH and regular insulin were given twice daily, two thirds in AM, one third in PM.
Umpierrez GE, et al. J Clin Endocrinol Metab. 2009;94(2):564-569.
Randomized Controlled Study
Comparing Basal Bolus with Insulin
Analogs vs Human Insulins in General
Medicine Patients
Basal bolus with glargine QD + glulisine AC versus
NPH b.i.d. & regular AC.
- 0.4 U/kg/d x BG: 140-200 mg/dL
- 0.5 U/kg/d x BG: 201-400 mg/dL
Bueno, Benitez eta al. 2012 ADA Scientific Meeting, New Orleans
Basal Bolus Regimen
Analogs vs. Human Insulins
280
260
240
220
200
180
160
140
TODOS
120
ANALOGOS
100
HUMANAS
80
60
40
20
0
1
2
3
4
5
6
7
8
9
10
11
TODOS
259
188
163
163
159
148
151
143
138
141
135
ANALOGOS
263
194
162
162
156
142
147
145
125
135
133
HUMANAS
255
182
163
164
143
137
142
142
129
146
158
Bueno, Benitez eta al. 2012 ADA Scientific Meeting, New Orleans
Hypoglucemias por brazo de
intervención
ALL
N= 134
Analogs
N=66
Human
N=68
p-value
Patients with
Hypoglycemia, n (%)
49 (37)
23 (35)
26 (38)
OR:1.16
p: 0.68
Severe Hypoglucemia,
n (%)
22 (16)
5
17
Mild Hypoglucemia, n
(%)
95
44
51
26 (19)
10
16
Patients withn ≥2
episodes, n (%)
OR:2.93
P:0.04
Bueno, Benitez eta al. 2012 ADA Scientific Meeting, New Orleans
OR:2.08
P:0.2
Randomized study of basal bolus insulin
therapy in the management of general
surgery patients with T2DM (Rabbit Surgery)
Research Question:
In patients with T2DM on diet, oral agents or insulin
treatment, does treatment with basal bolus regimen with
glargine and glulisine is superior to SSRI?
Primary Outcomes:
•Differences between groups in mean daily BG
•Composite of hospital complications: wound infection, pneumonia,
respiratory failure, acute renal failure, and bacteremia
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
Mean BG before meals and at bedtime
during basal bolus and SSI therapy
Glargine+Glulisine
*
Sliding Scale Insulin
*
*
*
Breakfast
Lunch
*p<0.001
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
Dinner
Bedtime
Postoperative Complications
P=0.003
Glargine+Glulisine
Sliding Scale Insulin
P=0.05
P=NS
P=0.10
P=0.24
* Composite of hospital complications: wound infection, pneumonia, respiratory
failure, acute renal failure, and bacteremia.
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
Percent of patients with hypoglycemia
during basal bolus and SSI therapy
BG <70 mg/dL
P <0.001
25
20
23
BG <60 mg/dL
25
25
20
20
15
15
10
10
5
5
0
5
Insulin Glargine SSI
+ Insulin
Glulisine
BG <40 mg/dL
P <0.001
15
10
12
2
0
Insulin Glargine
+ Insulin
Glulisine
SSI
5
0
P =0.057
4
Insulin Glargine SSI
+ Insulin
Glulisine
There were no differences in hypoglycemia between patients treated with insulin prior to
admission compared to insulin-naïve patients.
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011
0
Insulin Treatment in in Non-ICU Setting
T2DM with BG > 140 mg/dl (7.7 mmol/l)
NPO
Uncertain oral intake
Basal insulin
- Start at 0.2-0.25 U/Kg/day*
- Correction doses with rapid
acting insulin AC
- Adjust basal as needed
Adequate
Oral intake
Basal Bolus
TDD: 0.4-0.5 U/Kg/day
-½ basal, ½ bolus
-- adjust as needed
Do you need basal bolus in ALL patients?
Basal Plus Correction vs. Basal Bolus
Basal plus supplements
 Starting glargine*: 0.25
units/kg
 Correction with glulisine
for BG >140 mg/dl per
sliding scale
* Reduce TDD to 0.15 U/kg in
patients ≥70 yrs and/or serum
creatinine ≥ 2.0 mg/dL
Basal Bolus Regimen
 Starting TDD*: 0.5 U/kg
 Glargine: 0.25 U/kg
 Glulisine: 0.25 U/kg in
three equally divided
doses (AC)
 Correction with glulisine
for BG >140 mg/dl per
sliding scale
* Reduce TDD to 0.3 U/kg in
Umpierrez et al, Diabetes Care 2013
patients ≥70 yrs and/or serum
creatinine ≥ 2.0 mg/dL
Basal-PLUS vs Basal Bolus:
300 medical & surgical non-ICU patients
Blood Glucose (mg/dL)
240
Basal Plus:
glargine once daily
0.25 U/kg plus
glulisine supplements
Basal Plus
Basal Bolus
220
200
Basal Bolus:
TDD: 0.5 U/kg/d
Glargine 50%
glulisine 50%
180
160
140
120
0
1
2
3
4
5
6
7
8
9
10
Duration of Treatment (days)
Preliminary results: Basal bolus 51 patients, basal-plus: 49 patients
Umpierrez et al, Diabetes Care 2013
Differences in glycemic control and frequency of treatment
failures in patients treated with basal bolus, basal plus
and sliding scale regular insulin
Umpierrez et al, Diabetes Care, 2013
Basal-PLUS vs Basal Bolus: Medicine and
Surgery Patients
Medicine
Surgery
Daily BG
Daily BG
BG AC & HS
Smiley et al, Diabetes Care 2013
BG AC & HS
Management of Patients With Diabetes in
Non-ICU Settings
Inpatient
Management in
non-ICU
Basal Bolus
or
Basal Plus
Regimens
What about
Incretin-Based
Therapy?
DPP-4 Therapy in Hospitalized
Patients
 Study Type: Multicenter, prospective, open-label
randomized clinical trial
 Patient Population: Patients with T2D admitted to general
medicine and surgery services at 3 hospitals: Emory
University, Grady, and University of Michigan
 Treatment Groups*
 Group 1. Sitagliptin once daily (n=30)
 Group 2. Sitagliptin plus glargine insulin once daily (n=30)
 Group 3. Basal bolus regimen with glargine once daily
and lispro before meals (n=30)
* All groups received supplemental doses of lispro for BG > 140 mg/dl before meals
Umpierrez et al. Care. 36(11):3430-5, 2013
Mean Daily BG During Treatment
Randomization
Umpierrez et al. Care. 36(11):3430-5, 2013
Mean BG before meals and at bedtime
during Treatment
P=0.22
Data is mean ± SE
Umpierrez et al. Care. 36(11):3430-5, 2013
P=0.15
P=0.52
P=0.57
Randomization Blood Glucose (<180 mg/dl and
>180 mg/dl) and Mean Daily Glucose concentration
Mean Daily Blood Glucose (mg/dL)
p= 0.08
p= 0.91
Umpierrez et al. Care. 36(11):3430-5, 2013
Recommendations for Managing Patients
With Diabetes After Hospital Discharge
Use admission A1C to adjust therapy at discharge
10%
ADD basal or REPLACE with basal/bolus
9%
ADD basal insulin therapy
8%
Adjust original therapy, ADD another agent or basal insulin
7%
Return to original therapy
Umpierrez G et al, J Clin Endocrinol Metabol, 2012
Discharge Insulin Algorithm
Discharge Treatment
A1C < 7%
A1C 7%-9%
Re-start
outpatient
treatment
regimen
(OAD and/or
insulin)
Re-start
outpatient oral
agents and D/C
on glargine once
daily at 50-80%
of hospital dose
Umpierrez et al, ADA Scientific Sessions, 2012
A1C >9%
D/C on basal bolus at
same hospital dose.
Alternative: re-start
oral agents and D/C
on glargine once
daily at 80% of
hospital dose
Hospital Discharge Algorithm Based on Admission
HbA1C for the Management of Patients with T2DM
8.75%
7.9%
%
Umpierrez et al, ADA Scientific Sessions, 2012
7.35%
Hospital Discharge Algorithm Based on Admission
HbA1C for the Management of Patients with T2DM
Primary outcome:
- change in A1C at 4 wks and 12 wks after discharge
All
Patients
OAD
OAD +
Glargine
Glargine+
Glulisine
Glargine
# patients, n (%)
224
81 (36)
61 (27)
54 (24)
20 (9)
A1C Admission, %
8.7±2.5
6.9±1.5
9.2±1.9
11.1±2.3
8.2±2.2
A1C 4 Wks F/U, %
7.9±1.7*
7.0±1.4
8.0±1.4ψ
8.8±1.8ψ
7.7±1.7
A1C 12 Wks F/U, %
7.3±1.5*
6.6±1.1
7.5±1.6*
8.0±1.6*
6.7±0.8*
BG<70 mg/dl, n (%)
62 (29)
17 (22)
17 (30)
23 (44)
5 (25)
BG<40 mg/dl, n (%)
7 (3)
3 (4)
0 (0)
3 (6)
0 (0)
* p< 0.001 vs. Admission A1C; ψp=0.08
Umpierrez et al, ADA Scientific Sessions, 2012
Management of diabetes in
non-critical care setting
So… What really have we
learned?
Thank you!
Guillermo E. Umpierrez, MD
[email protected]
Inpatient Management of Medical
and Surgical Patients with Type 2
diabetes- ICU and non-ICU
Guillermo E. Umpierrez, MD, FACP, FACE
Professor of Medicine
Director, Grady Hospital Clinical Research Unit
Emory University School of Medicine
Director, Diabetes & Endocrinology Section
Grady Hospital CIN (Research Unit)
Grady Health System
Dr. Guillermo Umpierrez,
Personal/Professional Financial Relationships with Industry
External Industry Company Name(s)
Relationships *
Equity, stock, or
None
options in biomedical
industry companies
or publishers
Board of Directors or
None
officer
Royalties from from
None
external entity
Industry funds to
Sanofi-Aventis
Emory for my
Merck
research
Novo Nordisk
Boehringer Ingelhein
Role
Investigator-Initiated
Research Projects
Hyperglycemia in non-critical care setting:
Lecture Agenda
1. Scope of the Problem:
 What is the frequency and impact of hyperglycemia
and diabetes?
 What diagnosis criteria should we use?
 What target glucose should we aim?
2. How should we manage hyperglycemia in ICU
and non-ICU setting?
 Insulin regimens – Which and how to start?
 Incretin-base regimens – are they safe & effective?
 Discharge algorithm – What is the role of the
admission HbA1c?
Umpierrez et al. J Clin Endocrinol Metabol. 97(1):16-38, 2012
Hyperglycemia: A Predictor of Mortality
Following CABG in Diabetics
10
Postop
Mortality
1.8%
P<0.0001
BG >200
n=662
5.0% *
*P<0.001
Adjusted for 19 clinical and operation variables
First Postop Glucose >200
• 2x LOS
• 3x Vent duration
• 7x mortality !!!
CABG, coronary artery bypass graft.
Furnary AP et al. Circulation. 1999:100 (Suppl I): I-591.
8.6
8
Postop Mortality (%)
BG <200
n=1369
5.8
6
3.8
4
2
1.4
1.7
2.1
0
<150
175200225150200
225
250
175
Blood Glucose (mg/dL)
>250
Hyperglycemia and Pneumonia Outcomes
Admission glucose (mg/dl)
*
*
%
BG (mg/dl)
*
*
< 110 110 - <198 198 - <250 ≥250
* p: < 0.05 vs BG < 198 mg/dl (11 mmol/L)
N= 2,471 patients with CAP
McAllister et al, Diabetes Crae 28:810-815, 2005
Pharmacologic Therapy in Non-ICU Setting
 Patients treated with insulin at home require scheduled
SQ insulin therapy in the hospital (1)
 Avoid prolonged use of sliding scale insulin as sole
method for glycemic management (2)
 Scheduled SQ insulin consists of basal or intermediate
acting insulin in combination with RAI or Regular insulin
administered before meals in patients who are eating(1)
 Include correction insulin as a component of scheduled
SQ insulin for treatment of BG above desired range (2)
GE Umpierrez, R Hellman, MT Korytkowski, M Kosiborod, GA Maynard, VM Montori, JJ Seley, GV den Berghe.
J Clin Endocrinol Metabol. 97(1):16-38, 2012
Basal Bolus Insulin Regimen
 D/C oral antidiabetic drugs on admission
 Starting total daily dose (TDD): 0.5 U/kg/day
 TDD reduced to 0.3 U/kg/day in patients ≥ 70 years of
age or with a serum creatinine ≥ 2.0 mg/dL
 Half of TDD as insulin glargine and half as insulin
glulisine*
– Glargine - once daily, at the same time of the day
– Glulisine- three equally divided doses (AC)
*If a patient was not able to eat, insulin glargine was given but, insulin glulisine was held until
meals were resumed.
Umpierrez et al, Diabetes Care 34 (2):1–6, 2011