Dysglycemia in hospital

Question 1

Define HHS and DKA

Answer 1

HHS
- Sugar in the urine. Pulls fluid out and may result in dehydration

DKA
- associated with the use of fat for energy, leading to ketones in the blood

Question 2

When is A1C screening indicated in hospital (4)

Answer 2

• Patients experiencing new hyperglycemia
• Patients who have not had A1C done in 3 months
• Patients who have risk factors for diabetes
• Patients who have history of diabetes

Question 3

What are the A1C in hospital targets
Outpatient
Inpatient
Frail/Elderly

Answer 3

Outpatient
- 7% or under

Inpatient
- 7% or under

Frail/elderly
- 8.5% or under

Question 4

What are the BG in hospital targets?
For non-critically ill (pre-prandial, random)
Critically ill

Answer 4

More conservative: 5-10 mmol/L

Non-critical
- Pre-prandial: 5-8 mmol/L
- Random Bg <10 mmol/L

Critically ill: 6-10 mmol/L

Question 5

What is the BG monitor frequency for NPO, continuous enteral feeding, TPN alone

Answer 5

q4-6h

Question 6

What is the monitoring for continuous IV insulin

Answer 6

q1-2h

Question 7

What is the first-line treatment in acute hyperglycemia

Answer 7

Insulin

Question 8

Metformin
A1C lowering?
Avoid in eGFR?
Disadvantages (2)

Answer 8

A1C lowering?
- 1.0 mmol/L

Avoid in eGFR?
- <20

Disadvantages (2)
- Hold in N/V
- Hold 48 hrs post radiocontrast dye

Question 9

SGLT2i
A1C lowering?
Avoid in eGFR?
Disadvantages (2)

Answer 9

A1C lowering?
- 0.4-0.7

Avoid in eGFR?
- <20

Disadvantages (2)
- AKI
- Risk of euglycemic DKA (mostly in T1DM)

Question 10

Gliclazide
A1C lowering?
Avoid in eGFR?
Disadvantages (2)

Answer 10

A1C lowering?
- 0.7-1.3

Avoid in eGFR?
- <15 mmol/L

Disadvantages (2)
- increased hypoglycemia risk
- stop insulin if started

Question 11

DPP4i
A1C lowering?
Disadvantages (2)

Answer 11

A1C lowering?
- 0.5-0.7

Disadvantages (2)
- dose adjust in AKI
- switch to LINAGLITPIN in AKI

Question 12

Insulin
A1C lowering?
Avoid in eGFR?
Disadvantages (2)

Answer 12

A1C lowering?
- 0.9-1.2

Avoid in eGFR?
- Safe in AKI

Disadvantages (2)
- hypo risk
- requires diligent BG monitoring

Question 13

Semaglutide
A1C lowering?
Avoid in eGFR?
Disadvantages (2)

Answer 13

A1C lowering?
- 1.0

Avoid in eGFR?
- may exacerbate acute renal failure

Disadvantages (2)
- Hold in N/V, nutrient deficiency

Question 14

When would you switch to insulin in-hospital? (6)

Answer 14

• Renal function can’t support oral agents
• Oral meds held (eg. NPO, N/V, AKI)
• uncontrolled BG
• Corticosteroid-induced hyperglycemia
• Symptomatic hyperglycemia
• HHS, DKA

Question 15

Insulin dose in hospital

Answer 15

Basal + Bolus TDD - 0.4-0.5 u/kg/day
40-50% basal, the rest as bolus

General insulin dose for insulin naive:
- Basal 10units SC daily, titrate by 1 unit per day

Question 16

What are the long-acting insulin given regardless of meals?

Answer 16

Glargine
Detemir
Degludec
NPH

Question 17

Which rapid acting insulin is preferred?

Answer 17

aspart
Lispro

Question 18

Why should we avoid premixed insulins?

Answer 18

• Higher rate of hypo
• Insulin dose is fixed and cannot be adjusted for each meal
• Twice daily dosing
  ** only good for cognitively impaired patients who cannot manage 4x/day insulin

Switch to basal + bolus

Question 19

When is sliding scale useful?

Answer 19

When oral intake is variable
- NPO
- Before and after surgery

Question 20

Rapid insulin (aspart)
Onset
Maximum effect
Duration

Answer 20

Onset
- 10-20 min

Maximum effect
- 1-3 hr

Duration
- 3-5hr

Question 21

Short acting insulin (humulin R)
Onset
Maximum effect
Duration

Answer 21

Onset:
- 30 min

Maximum effect
- 2.5-5 hrs

Duration
- 6-8 hrs

Question 22

What is the objective of insulin sliding scale

Answer 22

Rescue and reduce a high BG that HAS ALREADY OCCURRED

Question 23

When does the sliding scale start for inslin dependant vs insulin naive patient?

Answer 23

insulin dependant
- If BG at 4-5.9 subtract 1 unit from baseline
- Give baseline dose at 6-7.9

insulin naive patient
- Start if BG at 8-9.9

Question 24

How do you calculate the insulin sliding scale for a patient

Answer 24

calculate ISF = 100/TDD

Question 25

What type of insulin is preferred in enteral/parenteral nutrition

Answer 25

Short acting insulin q4-6h - there is no fasting period - MAY add basal Dose insulin before bolus feeds

Question 26

In a case where they have a TPN What is considered fasting level What insulin to use and when?

Answer 26

Fasting level 1hr before TPN starts Give short-acting DURING TPN feed q4-6h Can keep basal dose if they already have

Question 27

Which drugs can cause hyperglycemia? (3)

Answer 27

Fluoroquinolones (cipro, levo, moxi) Corticosteroids IV fluids containing dextrose

Question 28

What is the MOA of glucocorticoid induced hyperglycemia Reversible/irreversible

Answer 28

- Increased insulin resistance - increased gluconeogenesis

Question 29

When do you consider insulin AHA treatment in glucocorticoid induced hyperglycemia for BG level

Answer 29

FBG levels consistently 7.8+ AND PPG levels 11.1+ for over 1 week

Question 30

What is the order of effect on BG from most to least Hydrocortisone Dexamethasone Prednisone/methylprednisone

Answer 30

1. Dexamethasone 2. Prednisone 3. Hydrocortisone

Question 31

Preferred treatment for glucocorticoid induced hyperglycemia

Answer 31

Scheduled insulin

Question 32

AHA agents before surgery Metformin Gliclizide SGLT2i DPP4i GLP1 agonist

Answer 32

Metformin - hold morning of Gliclizide - hold morning of SGLT2i - hold 3 days before DPP4i - Continue GLP1 agonist - hold 1 week before

Question 33

Basal insulin (T1 + T2) Evening before surgery Morning of surgery

Answer 33

Evening before surgery - 80-100% of usual dose T1 - 75% of usual dose T2 Morning of surgery -75-100% of usual dose

Question 34

What are risk factors for hypoglycemia in hospital

Answer 34

- Frail, elderly - Alcohol use - Rapid weight loss - Decreased oral intake - On insulin - NPO - Delerium (unable to report)

Question 35

What is the hypoglycemia protocol

Answer 35

If BG under 4 - 16-20g glucose if BG under 2.8 - chew tab q15 min PRN

Question 36

Hypoglycemia if cannot take oral?

Answer 36

if BG under 4 - Dextrose 50% in 50ml (25 G dextrose) or - glucogon 1mg SC

Question 37

How to convert IV insulin to SC on discharge When do you start it

Answer 37

calculate IV TDD over 24hrs or 6-8 hrs of continuous infusion SC insulin 60-80% once daily Rapid: 20-40% Start: - 2-3 hrs before d/c IV insulin