DM Inpat Rx - Inpatient Management of Diabetes Mellitus...

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Inpatient Management of Diabetes Mellitus William Harper, MD, FRCPC Assistant Professor of Medicine, McMaster University
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BS > 11.1 mmol/L Renal threshold for glycosuria (normal GFR) Decreased WBC function Chemotaxsis Phagocytosis Decreased Wound Healing
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Evidence to support Inpatient BS control? DIGAMI 620 patients AMI, prior dx DM or BS > 11 mM IV insulin gtt started @ 5 U/h Titrated to keep BS 7-10.9 mM Insulin IV > 24h MDI > 3 months No in-hospital mortality benefit. Rx Increased hospitalization by 1.8d 0.5% reduction HbA1c @ 3 months @ 1 year % on Insulin: 72% Rx Group 49% Cntrl Group 1 year mort: ARR 7.5% NNT 13 3.4 y mort: ARR 11% NNT 9
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Evidence to support Inpatient BS control? Leuven, Belgium Study 1548 ICU patients (63% CV Sx) If BS > 6.1 mM Start IV insulin @ 2-4 U/h, titrated to BS 4.4-6.1 mM Ave insulin dose: Rx group 3.0 U/h Cntrl group 1.4 U/h Once out of ICU relaxed treatment goal to < 11.1 mM Mortality in ICU: ARR 3.4% NNT 29 Mortality in-hospital: ARR 3.7% NNT 27 Greatest reduction in mortality was sepsis-related . Insulin Rx reduced: bacteremia, ARF needing HD, need for PRBC, critical illness polyneuropathy, duration of ventilation and length of stay in ICU To what extent were benefits nutrition related as opposed to insulin related?
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Goals of Inpatient DM Management “Avoid hypoglycemia and marked hyperglycemia” Target BS: 7.0 - 11.0 mM (5.0 – 10.0 mM) Avoid Hypoglycemia Precipitating arrhythmia or other cardiac events Inducing seizure, focal or cognitive defects periop Avoid Marked Hyperglycemia (BS > 11.1 mM) Treat (and avoid) DKA, HONC
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DM Inpatient Management 1. Eating 2. NPO: temporary (for a test or surgery) 3. NPO: prolonged
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DM Inpatient Management 1. Eating Diet (T2DM) OHA (T2DM) Insulin (T2DM and T1DM) 1. NPO: temporary (for a test or surgery) 2. NPO: prolonged
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Pathophysiology of T2DM Blood glucose diet Hepatic glucose output INSULIN Peripheral Tissue Uptake + _
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GLUCOSE ABSORPTION GLUCOSE PRODUCTION Metformin Thiazolidinediones MUSCLE PERIPHERAL GLUCOSE UPTAKE Thiazolidinediones
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This note was uploaded on 12/21/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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DM Inpat Rx - Inpatient Management of Diabetes Mellitus...

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