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NPO DM Steroid Hypergly Rev Apr - 18..

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11 views2 pages

NPO DM Steroid Hypergly Rev Apr - 18..

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Pilgrim's Progress
Copyright
© © All Rights Reserved
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STEPWISE APPROACH TO INITIAL MANAGEMENT OF STEROID-ASSOCIATED

HYPERGLYCEMIA IN NON-CRITICALLY ILL PATIENTS WITH PRE-EXISTING TYPE 2


DIABETES WHO ARE ON NPO

Monitor capillary blood glucose (CBG) every 4 to 6 hours.

Discontinue non-insulin antidiabetic agents

Previously on insulin therapy?

Yes No

Previously on Previously on Previously on Initiate insulin


basal-bolus basal insulin premixed insulin therapy
insulin

Discontinue Consider decreasing Discontinue


basal insulin doses premixed insulin Start basal insulin
bolus insulin

Estimate total daily doses (TDD) of insulin using any


of the following methods: *
Consider giving correctional rapid-acting
insulin analog or regular insulin. + METHOD 1: Weight-based estimation:
LEAN (BMI 18.5-22.9 kg/m2) 0.1 – 0.2 units/kg/day
OVERWEIGHT (BMI 23-24.9 kg/m2) 0.25 – 0.3 units/kg/day
OBESE (BMI > 25 kg/m2) 0.3 – 0.35 units/kg/day
Adjust insulin doses according to glycemic
responses by 10-20% to reach glycemic METHOD 2: Estimate daily dose from recent insulin infusions given
targets. Decrease doses by 20% in the event
of hypoglycemia.
Consider giving correctional rapid-acting
insulin analog or regular insulin. +

Adjust insulin doses according to glycemic responses by


10-20% to reach glycemic targets. Decrease doses by
20% in the event of hypoglycemia.

Once steroids are tapered, decrease insulin doses


by 10-20% for each 15% decrease in steroid dose

If hyperglycemia is persistent and severe, consider


shifting to intravenous continuous insulin infusion.@
1Suggested glycemic goals: 140-180 mg/dL for the majority of non-critically ill hospitalized
patients. For patients with terminal illness or a limited life expectancy or at high risk for
hypoglycemia, consider a goal of < 200 mg/dL.

2Above guidelines may not be applicable to patients receiving parenteral nutrition.

+ Below is a sample of a supplemental or correctional insulin scale. Give every 4 to 6 hours.

CBG (mg/dL) Regular or rapid-acting insulin


(units SQ)
140 – 180 2
181 – 220 4
221 – 260 6
261 – 300 8

*Body mass indices are based on the Asia-Pacific Classification.

* Decrease TDD to 0.2 – 0.3 units/kg/day if with hypoglycemic risk factors such as: poor oral
intake, acute or chronic renal insufficiency, hepatic impairment, sepsis, cognitive impairment
and advanced age.

* Patients on high-dose steroids may require higher daily insulin doses but lower initial insulin
doses are recommended to avoid hypoglycemia.

@ Consider referral to endocrinology service.

References:
1. Umpierrez GE et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: An
Endocrine Society Practice Guideline. J Clin Endocrinol Metab 2012, 97(1):16-38.
2. American Diabetes Association. 15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes –
2020. Diabetes Care 2020 Jan; 43(Supplement 1):S193-S202.
3. Draznin B. Managing Diabetes and Hyperglycemia in the Hospital Setting: A Clinician’s Guide. American
Diabetes Association 2016.
4. Roberts A et al. Joint British Diabetes Societies for inpatient care. Management of Hyperglycemia and
Steroid (Glucocorticoid) Therapy. 2014.
5. Donihl, A et al. Endocr Pract 2006;12:358-262
6. Moghissi EC et al. American Association of Clinical Endocrinologists, American Diabetes Association.
Endocrine Practice. 2009.

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