Glycaemic care inpatient (For non critically ill)

Source: Practical Guide To Inpatient Glycemic Care 2020, MEMS MOH

Introduction

Insulin is the preferred choice for pharmacological therapy for hospitalised patients

In hospitalised patients,

• Hyperglycaemia is defined as BG > 7.8mmol/L
• Hypoglycaemia is defined as BG < 4.0mmol/L
• HbA1c ≥ 6.3% suggests pre-existing diabetes

Recommendations

• Inpatient glycaemic target, ICU and non-ICU is 7.8 - 10mmol/L
• Insulin should be initiated once BG persistently ≥ 10mmol/L
• In selected patients, stricter target of 6.1 - 7.8mmol/L can be considered while avoiding hypoglycaemia

Ways of lowering BG

1. Variable rate intravenous insulin infusion (VRIII) - NBM (may cause iatrogenic hypokalaemia)
2. Scheduled subcutaneous insulin – basal bolus/prandial regimen - Tolerating oraly (efective and no danger iatrogenic hypokalaemia)
3. Scheduled subcutaneous insulin – basal plus regimen - NBM (no danger iatrogenic hypokalaemia)

Algorithm insulin

Variable rate intravenous insulin infusion (VRIII)

• for NBM patient
• dose as per VRIII Dosing Protocol (Sliding scale table)
• initially use the standard rate of the scale

Adjustment of scale when

• BG persistently >10mmol/L (on 2 readings) (switch to higher scale)
• The initial BG is >20mmol/L and not falling by 3-5 mmol/L/hour (switch to higher scale)
• BG control is too tight (4-6 mmol/L) or episode of hypoglycaemia, (either switch to a lower scale or increase dextrose in drip).

How to endorse (Example)

50 units of human rapid acting insulin is drawn up an added to 49.5 ml of sodium chloride in a 50 ml syringe and mixed thoroughly (1 unit insulin = 1 ml)

• IVI Actrapid 50 units in 50 mL NS, 2 mL/hr
• IVI Actrapid 50 units in 50 mL NS per sliding scale

Sliding scale

Scheduled subcutaneous insulin - basal bolus/prandial regimen

• once tolerating orally
• dose as per body weight (Total daily dose table)
• correction doses (Top up scale table) can be given (only for fast acting insulin) if pre-meal or in between meal BG is elevated/not at target
• 1 basal, 1-3 bolus (for meal) and correction dose
• Total daily dose (TDD) is divided into 50% basal and 50% prandial insulin.

How to endorse (Example)

Elderly, 60 kg TDD = 0.3 U/kg/day × 60 kg = 18 units/day Basal (50%) = 9 units Prandial (50%) = 9 units → 3 units per meal

• S/C Insulatard 9 units ON
• S/C Actrapid 3 units TDS, top up scale B

Total daily dose

Top up scale

Scheduled subcutaneous insulin – basal plus regimen

• for NBM patient or poor oral intake
• Calculate TDD as in Total Daily Dose
• Administer basal insulin as above
• Give correction dose of short acting insulin 6 hourly using Scale A in Top up scale
• 1 basal and correction dose

How to endorse (Example)

Elderly, 60 kg TDD = 0.3 U/kg/day × 60 kg = 18 units/day Basal (50%) = 9 units Correction (50%) = 9 units → 2 units per shot

• S/C Insulatard 9 units ON
• S/C Actrapid 3 units QID, top up scale A

Oral anti-diabetic (OAD) medications

If patient are

• Clinically stable
• Good glycaemic control prior to admission
• Allowed and taking orally well
• No contraindications for use of OAD medications

How to endorse (example)

• T. Metformin 500mg BD
• T. Gliclazide 80mg OD
• T. Vildagliptin 50mg BD with T. Metformin 500mg BD
• T. Vildagliptin 50mg OD with T. Gliclazide 80mg OD

OAD Meds