Inpatient Guide For Diabetics
Based on Diabetes Facts and Guidelines 2005 by Yale
General Principles:
1. Type 1 patients require at least some basal insulin at ALL times to prevent ketosis, even when they are NPO
2. Review diabetic meds
3. Order fingersticks QID in all pts with diabetes (QAC and HS if eating; Q6 hr if NPO) for at least first 48 hrs. If pt stable and under good glycemic control and if on oral agent or one insulin injection/day, can decrease to BID.
4. In-hospital glucose target in most pt should be <110 mg/dL pre-meal; <180 mg/dL at all other times. Pregnant women and critically ill pt (in ICU) require tighter control (80-110).
5. Revise insulin regimen continuously (every 1-2 days)
↑ AM intermediate-acting insulin (e.g. NPH) to ↓ pre-supper BG (blood glucose)
↑ PM long/intermediate-acting insulin (eg glargine, NPH) to ↓ fasting BG
↑ AM short/rapid-acting insulin (e.g. regular, lispro) to ↓ pre-lunch BG
↑ PM short/rapid-acting insulin (e.g. regular, lispro) to ↓ bedtime BG
6. Don’t leave pt on RISS (regular insulin sliding scale) as ONLY form of treatment. Adding long acting insulin (e.g. glargine) will stabilize glycemic control.
7. Try to approximate at-home regimen as long as possible BEFORE discharge
8. Call diabetes educator to teach pt about managing diabetes
Oral Agent Patients:
A. The hospitalized pt who is NPO (or in whom oral intake is doubtful)
1. Pt well-controlled on oral hypoglycemic agent (OHA) i.e. sulfonylurea
- D/C OHA and use RISS or lispro SS
- If need SS >24-48 hr, add long acting insulin
2. Pt well controlled on oral agent that does not cause hypoglycemia (e.g. metformin, TZDs)
- D/C metformin (due to contrast studies, dehydration, renal fxn)
- If pills ok, can continue TZD unless have abnl LFTs or new edema
3. Pt poorly controlled on oral agents
- Place pt on insulin; can try SS for 24-48 hr to assess insulin requirements or proceed straight to regimen with long-acting insulin
B. Hospitalized pt who is eating
1. Pt well controlled on OHA
- May continue. Consider dose reduction by 25-50% due to more rigid diet
- D/C metformin if hemodynamic instability, CHF, dehydration, or altered renal or hepatic fxn, or if plan to do contrast studies
- continue TZDs unless abnl LFTs or new edema
2. Pt poorly controlled on oral agents
- Calorie restricted diet
- Then add insulin while adding other orals
Insulin-treated patients:
A. Hospitalized pt who is NPO
Type I DM
- Can use IV insulin drip
- Can give ½-2/3 of long acting insulin + SS
- Unless very hyperglycemic, give D5W or D5 1/2NS@75-125 cc/hr to prevent catabolism
- Check BG Q6 hr
- Consider short acting insulin if need rapid correction of hyperglycemia
Type II DM
- May be able control with diet restriction and SS
- Can give ½ long acting insulin + SS
- If giving insulin, give D5W or D5 1/2NS
- Check BG Q6 hr
B. Hospitalized pt who is eating
-Continue insulin but consider dose reduction by 25% in controlled pt
Bedside glucose monitoring:
- Order QID for insulin pt
- If on oral agents alone or only one insulin injection per day, can decrease sticks to BID (pre-breakfast and pre-supper) if good control
- If NPO, do sticks Q6 hr
Hypoglycemia:
- If pt alert, give 15-30g carbs via:
8 oz juice/soda = 30 g carbs
2 graham cracker squares = 10 g carbs
- 15 g carbs will increase BG by 25-50 mg/dL
- Non-alert pt: give 25 g dextrose IV (1 amp D50) or 1 mg glucagon IM if no IV access and recheck BG after 5-10 min
- If severe or recurrent hypoglycemia, use D5 or D10 drip