CME/CNE/CPE

Optimizing Diabetes Management in Long-Term Care: A Roundtable Discussion

Derek LeRoith, MD, PhD

Mt. Sinai School of Medicine
New York, New York

The questions below were submitted by your peers based on a recent CME/CNE/CPE activity.
The Course Director, Dr. Derek LeRoith, provides his answers below.

Question 1: In the long-term care setting, how often should we be checking blood sugar (finger testing)? Before and after every meal?

Question 2: What's the best way to manage excessive postprandial glucose excursions in patients who are not taking insulin? The patient is otherwise well-controlled in terms of glucose.

Question 3: We have a patient on an insulin pump who is admitted to the floor for another medical condition; he is running out of insulin. How do you convert him from insulin pump to subcutaneous? How do you start a patient on insulin? At what doses and type of insulin?

In the long-term care setting, how often should we be checking blood sugar (finger testing)? Before and after every meal?

The frequency of blood glucose checks depends on a number of factors:
1. Blood glucose target for the individual patient: The clinical team and the family may decide on more lenient goals for some patients, depending on prognosis and patient preferences. In that case, the frequency of blood glucose checks may be decreased, or they may even be completely eliminated.
2. Patients with well-controlled diabetes may require once-daily testing, if the patient is taking agents that have potential for hypoglycemia. Blood glucose testing may be dropped entirely, provided patients have a quarterly HbA1c and are taking agents that have low risk for hypoglycemia [Farmer A et al. Br Med J. 2007;335:132]. If a once-daily strategy is chosen, the most information can be gleaned from alternating fasting and postprandial blood glucose levels.
3. Patients with brittle diabetes and those receiving more than one insulin injection per day require multiple blood glucose measurements daily. Our standard has been before meals and at bedtime.

What's the best way to manage excessive postprandial glucose excursions in patients who are not taking insulin? The patient is otherwise well-controlled in terms of glucose.

The answer depends on the individual patient and the desired side effect/benefit profile. While metformin should be the mainstay of therapy unless contraindicated, the following agents specifically address postprandial hyperglycemia:

GLP-1 agonists may facilitate weight loss
Acarbose is inexpensive, does not cause weight gain, and does not rely on beta cell function. There is some data supporting its cardiovascular benefit [Hanefeld M, Schaper F. Expert Rev Cardiovasc Ther. 2008;6:153-163].
Meglitinides are short-acting hypoglycemic agents taken right before a meal. They are expensive, and the cardiovascular benefit is dubious [Nathan D. N Engl J Med. 2010;362:1533].
Rapid-acting insulin analogues are the most certain way of preventing postprandial glucose excursions

We have a patient on an insulin pump who is admitted to the floor for another medical condition; he is running out of insulin. How do you convert him from insulin pump to subcutaneous? How do you start a patient on insulin? At what doses and type of insulin?

These are several questions requiring several answers.

If the patient is alert and demonstrates proficiency with the insulin pump, he may be allowed to stay on the pump [Leonhardi B et al. J Diabetes Sci Technol. 2008;2:948]. Under no circumstances should the patient be managed simultaneously with the pump and injections. Conversion should take place based on pump review data from the last few days. In the “review” section, total daily basal rate should be assessed. Then, 80% of that dose should be given as insulin glargine once a day. Prandial insulin review should inform prandial rapid-acting insulin analog dosing. Again, the starting dose should be 80% of the customarily used dose to avoid hypoglycemia. Finally, “insulin sensitivity” can be used for the generation of an individualized supplemental bolus scale.
The second question is imprecise. If it pertains to converting a patient from oral medications to insulin, we recommend weight-based dosing of 0.2 units/kg glargine per day and 0.07 units/kg prandial insulin. If it pertains to starting insulin in addition to oral medications, we recommend starting with a basal insulin such as insulin glargine or insulin detemir at a low dose of 10-15 units daily and up-titrating every 2-4 days by 10% based on fasting blood glucose levels [Strange P. J Diabetes Sci Technol. 2007;1:540-548].