Academic Day Seminar – Jan 27

✔ Diabetes

Andrea and Rinche did a great job covering diabetes! Despite seeing a lot of insulin sliding scale orders, I have yet to see a BNC insulin regimen and am glad that the session covered this in depth! 🙂

Some ways I will apply this session:

  • Explain “diabetes” in patient-friendly terms
    • T1DM: cannot make insulin
    • T2DM: unable to respond to insulin (insulin resistance) or unable to make enough insulin in response to high blood sugars (abnormalities in insulin action)
  • Clinical Pearls with Insulin:
    • If glargine or detemir is used, the dose adjustment should be based on the morning fasting blood glucose level
    • If NPH is used, the dose adjustment should be based on the morning fasting blood glucose level or the blood glucose level measured before the evening meal
    • If bolus insulin is used, dose adjustment should be based on the next reading
      → Morning insulin – pre-lunch BG
      → Lunch insulin – pre-dinner BG
      → Dinner insulin – HS BG
    • If previously insulin naive, patients who require >10 units/day of insulin in hospital will likely require insulin after discharge
      • Consider NPH 10 units QHS and GP f/u and consult diabetes specialists (RN education/clinic/endocrinologist)
    • Contraindicated/not recommended combinations:
      • Insulin + Linagliptin → possible increase in CV risk
        (not a class effect for DPP-4 inhibitors; relatively low risk of hypoglycemia with DPP-4 inhibitors on its own)
      • Insulin + Pioglitazone → increase risk of fluid retention
      • Insulin + SU → increase risk of hypoglycemia
      • Dapagliflozin + Pioglitazone → individual use in bladder cancer active or hx is contraindicated – therefore, combo in general is not recommended
      • Pioglitazone + MTF + SU → increase risk of fluid retention
  • In-hospital management of non-ICU patients:
    scheduled Basal, Nutritional, Correctional SC insulin → prevents reactively responding to high BS

    • GoTs: use as little correctional insulin as possible + provide most of insulin as regularly scheduled basal and nutrition insulin
    • *Remember to consider patient’s PO intake…any outside food?
    • CDA targets: Non-ICU Pre-prandial: 5-8, Random < 10 mmol/L
    • Evidence:
      1. RABBIT-2 ISS vs. BNC in medical pts
      → BNC resulted in significant improvement in glycemic control but no difference in hypoglycemia or length of hospital stay
      (no clinical efficacy outcomes)
      2. RABBIT-2 Surgery ISS vs. BNC in surgery pts
      → less post-op complications (e.g. wound infection, pneumonia, renal failure, bacteremia, respiratory failure – ?which was driving this), no difference in severe hypoglycemia (<2.2) or length of hospital stay…BUT more hypoglycemia in BNC arm
      3. VGH Post-BNC PPO vs. Pre-BNC PPO
      → BNC PPO resulted in lower BG and less severe hyperglycemia (>12), no difference in hypoglycemia (<4)
  • Clinical Pearls for Special populations:
    • Heart Failure
      • Pioglitazone + Rosglitazone are contraindicated for HF in Canada
        → cause fluid retention
      • Linagliptin, sitagliptin use not recommended; saxagliptin (1 HF hospitalization for every 143 patients over 2 yrs) caution warranted; alogliptin caution in NYHA III and IV
        → mechanism unknown
      • Empagliflozin may be of benefit to reduce HF-related hospitalizations (EMPA-REG)
    • Renal impairment
      • Linagliptin does not have to be renally adjusted until eGFR <15
        • When eGFR < 15, caution and/or reduce dose
        • + it is formulary in hospital
      • Metformin is contraindicated if eGFR < 30mL/min; when eGFR 30-45, do not initiate and reduce dose by 50% according to Lexicomp
        • CDA guidelines more conservative and states caution and/or reduce dose when eGFR 30-60
        • intravascular iodinated contrast agents possibly increase risk of lactic acidosis
      • Out of the SUs, safest for renal impairment is gliclazide which is contraindicated when eGFR <15, with caution and/or reduce dose when eGFR 15-30 AND has a lower risk of hypoglycemia than glyburide
        • However…gliclazide = limited coverage vs. glyburide = regular benefit 😦
      • Acarbose – not recommended when eGFR < 25 mL/min
      • Dulaglutide: once weekly and no renal or hepatic impairment adjustment
        • New GLP-1 agonist
  • Sick Day Meds List: SADDMANS
    Sulfonylurea, ACEIs, Diuretics, Direct renin inhibitors, Metformin, ARB, NSAIDs, SGLT-2 inhibitors

    • If hypoglycemic (BG < 4 mmol/L), give 15-20g of carbohydrates (e.g. 4-5 dextrose tablets/2 containers of apple juice/2-3 packages of honey)
      → Rpt BG in 15 mins, if <4 mmol/L, give another 15-20g of carbohydrates and Rpt BG in 15 mins, if persistently <4 mmol/L contact MD
    • After initial glucose treatment, another carbohydrate containing snack should be taken within 1 hour. If meal more than 1 hour away, a snack with 15g carbohydrate & protein source is also recommended
      • sucrose will not be absorbed with acarbose (give dextrose or honey)
  • CV trials for new diabetic medications:
    • In order for approval by Health Canada – it needs to demonstrate CV safety (i.e. no increased CV risk vs placebo as part of standard care) by non-inferiority