in patient treatment of diabetes mellitus

Question 1

Blood Glucose Classifications

Hospital hyperglycemia:

hypoglycemia:

Severe hypoglycemia

Stress hyperglycemia:

Answer 1

Blood Glucose Classifications

Hospital hyperglycemia: BG>140

hypoglycemia: <70 mg/dL

Severe hypoglycemia <40 mg/dL

Stress hypoglycemia: elevation in BG in a patient with no history of dm (AND AN A1C <5.5%

Question 2

ASSESSMENT on Admission

Answer 2

ASSESSMENT on Admission

1. determine patient history. either type 1 or type 2
2. obtain laboratory blood glucose testing
3. recommend to obtain A1c for all pts with a hx of DM or BG>140
   a. if no A1C from the past 3 mo.
   b. if no hx of DM but BG>140 mg/dL
   c. A1C >/= 6.5% indicates DM
4. If pt. has hx of DM or A1C comes back >/= 6.5%-> regular POC blood glucose monitoring

Question 3

Point of Care Blood Glucose Mintoring

Answer 3

Point of Care Blood Glucose Mintoring

Point of Care (POC) BG monitoring: mentoring glucose at beside. preffered method for testing BG in the hospital setting

if eating: recommend before meals and at betime

if NPO or not reacieving ocntinuous enteral feeds, recommended q4-6hr

Question 4

BG Targets

Non Critical Patients

Pre meal:
Random BG:
when to modify:

Answer 4

BG Targets

Non Critical Patients

Pre meal: BG <140 mg/dL
Random BG: <180 mg/dL
when to modify: <100 mg/dL

Question 5

Overview of pharmacologic therapy

Answer 5

Overview

1. hold all oral antidiabetics (holding metformin is controversial. put in flash cards why)
2. SQ insulin recommended for most patients (Work horse)
3. continous insulin infusion recommended for some patients

Question 6

Insulin regimen: The preffered approach

Answer 6

Insulin: The preffered approach

1. Basal Insulin; manages fasting BG (ex. glargine)
2. nutritional regimen : prevents the rise in glucose after eating meals (short or rapid)
3. correctional: extra insulin beyond the schedules regimensto help correct bG that is still above target

Question 7

Dosing of Insulin

I.Type 1

II.Type 2

Answer 7

Dosing of Insulin

I. Type 1
1. obtain patient weight in kg

2. calculate total daily dose: 0.2-0.4 units/kg/day
3. choose dosing schedule:
   a. 50-60% basal
   b. 40-50% as nutritional insulin
   c. use correctional insulin for BG values above goal

adjust based on BG values, change in clinical status, or made NPO

II.Type 2

1. D/C all oral and non insulin injectable antidiabetics on admission
2. calculate total daily dose:
   insulin naive patient: 0.3-0.5 units/kg/day. use lower doses in elderly and in renal impaired.

if patient has Outpatient use of insulin: reduce outpatient dose by 20-25% due to dietary changes while in patient

3. choose dosing schedule:
   a. 50% basal
   b. 50% as nutritional insulin
   c. use correctional insulin for BG values above goal

Question 8

Drug induced alterations of blood glucose

increase HYPER:

Answer 8

Drug induced alterations of blood glucose

increase HYPER:
corticosteroids
atypical antipsychotics
fluroquinolon ABX 
calcineurin inhibitors
protease inhibitors
thiazide diuretics

Question 9

Drug induced alterations of blood glucose

increase HYPO:

Answer 9

Drug induced alterations of blood glucose

increase HYPO:
beta blockers
fluoroquinolone ABX
alcohol
pentamidine

Question 10

Risk reductio strategies:

Answer 10

Risk reductio strategies:

calla with hospital dietitians to adjust nutrition components for a diabetic patient

coordinate BG testing ih insulin administration and meal delivery

use good communication skills during patient transfer between floor, shifts

double check orders for completion and accuracy before prescribing prescribers and verifying (pharmacy)

performing best practices to avoid medications errors with insulin

stocking ily one concentration of insulin infusion bags

sadradize insulin protocol for various situations

adjust insulin regimen appropriately based on glucose reading.

fasting and primal glucose >140, increase dose of glargine by 20%

For hypoglycemia

protocols to manage hypoglycemia

anticipate scenarios that may require a decrease in insulin dosing (Enteral feeds r TPN D/C, reduction of food intake or change to NPO status, reduction/ D/C of meds that can increase BG (including IV dextrose)