intensive insulin therapy for managing diabetic foot

1. Intensive insulin therapyIntensive insulin therapy
for managing diabeticfor managing diabetic
footfoot
Dr. Bipin Kumar SethiDr. Bipin Kumar Sethi

2. Intensified insulin therapy ..mythsIntensified insulin therapy ..myths
 Costly !Costly !
 Not for this patient !Not for this patient !
 Not yet ..not so soon !Not yet ..not so soon !
 Why this headache?Why this headache?
 Why another specialist ?Why another specialist ?
 Patient won’t accept !Patient won’t accept !

3.  Glycemic control is one of the important facets ofGlycemic control is one of the important facets of
management of diabetic foot & is complimentary to themanagement of diabetic foot & is complimentary to the
general care, antimicrobial therapy and surgerygeneral care, antimicrobial therapy and surgery
 Most hospitalised patients require insulin and theMost hospitalised patients require insulin and the
regimens depend uponregimens depend upon
 Route of nutritional delivery/sensoriumRoute of nutritional delivery/sensorium
 Hemodynamic statusHemodynamic status
 Co-morbid conditions esp. hepatic and renal insufficiencyCo-morbid conditions esp. hepatic and renal insufficiency
 Monitoring facilitiesMonitoring facilities
 Degree of hyperglycemia/ decompensationDegree of hyperglycemia/ decompensation
 Hyperglycemia in a hemodynamically stable patientHyperglycemia in a hemodynamically stable patient
should not be a deterrent to delivery of adequate footshould not be a deterrent to delivery of adequate foot
care (debridement, desloughing, amputation)care (debridement, desloughing, amputation)

4. Why does glycemic control worsen ?Why does glycemic control worsen ?
 Never checked before – natural courseNever checked before – natural course
 RecumbencyRecumbency
 InfectionInfection
 DietDiet
 Drugs- steroidsDrugs- steroids
 Hospital “schedules/protocols”Hospital “schedules/protocols”
 StressStress

5. Benefits of intensified insulinBenefits of intensified insulin
regimensregimens
 Quick(er) metabolic controlQuick(er) metabolic control
 Anabolic effectAnabolic effect
 Better insulinisationBetter insulinisation
 Lesser mismatchLesser mismatch
 Lesser hyposLesser hypos
 OthersOthers

6. For patients taking nutrients orallyFor patients taking nutrients orally
 MSIMSI
 R + R + R + Basal (N/L/G/D)R + R + R + Basal (N/L/G/D)
 S + S + S + Basal (N/L/G/D)S + S + S + Basal (N/L/G/D)
 Premixed + S/R + PremixedPremixed + S/R + Premixed

7. International Diabetes CenterInternational Diabetes Center
RelativeInsulinEffectRelativeInsulinEffect
Time (Hours)Time (Hours)
0 2 4 6 8 10 12 14 16
Long (Glargine)Long (Glargine)
18 20
Intermediate (NPH)Intermediate (NPH)
Short (Regular)Short (Regular)
Rapid (Lispro, Aspart)Rapid (Lispro, Aspart)
Insulin Time Action Curves

8. 220220
BloodsugarBloodsugar
(mg%)(mg%)
210210
200200
180180
160160
140140
6 am6 am 12 noon12 noon 6 pm6 pm 12 midnight12 midnight 5 am5 am
BreakfastBreakfast LunchLunch DinnerDinner
INSULIN
Biphasic Rapid insulin Monophasic
Blood sugar :Blood sugar :
Multiple Daily Insulin InjectionsMultiple Daily Insulin Injections

9. International Diabetes CenterInternational Diabetes Center
RA
RA
RA
Physiologic Insulin
S/R – S/R – S/R– G/D/N
Seruminsulin(mU/L)
Hours
S/R S/R S/R G/D/N
Glargine
0
10
20
30
40
50
0 2 4 6 8 10 12 14 16 18 20 22 24

10. For patients not taking nutrientsFor patients not taking nutrients
orallyorally
 Insulin infusionInsulin infusion
 GIKGIK
 Non GIKNon GIK
1.1. Infusion pumpInfusion pump
2.2. NeutralisedNeutralised
3.3. Pediatric dripPediatric drip

11. Short term NBM requiring procedureShort term NBM requiring procedure
 Insulin + Dextrose infusionInsulin + Dextrose infusion
 GIKGIK
 Non GIKNon GIK

12. AlgorithmsAlgorithms
1.1. Guidelines rather than sacrosanct rulesGuidelines rather than sacrosanct rules
2.2. Go by antecedent responses, memory andGo by antecedent responses, memory and
current blood glucosecurrent blood glucose
3.3. Revise if response is suboptimalRevise if response is suboptimal
Target BG 80-110mg/dl
Monitoring key to success
Don’t leave it to paramedics

13. Team approachTeam approach
 Not just numbers but interacting dedicatedNot just numbers but interacting dedicated
membersmembers
 Flexibility to change regimensFlexibility to change regimens
 Monitoring, record keepingMonitoring, record keeping

14. A chain is as strong as its weakest linkA chain is as strong as its weakest link
AnonymousAnonymous

15. Case scenarioCase scenario
 Mr. MRLS, 55yMr. MRLS, 55y
 T2DM 10y, Gliclazide + Mixtard 30 & 20 unitsT2DM 10y, Gliclazide + Mixtard 30 & 20 units
 HTNHTN
 No CVA, PVDNo CVA, PVD
 CAD ?CAD ?
 Cataract bilaterallyCataract bilaterally
 Neuropathy +, PVD +Neuropathy +, PVD +
 Admitted on 31.3.04Admitted on 31.3.04

16.  Foot infection on left side for 2 months, ulcer isFoot infection on left side for 2 months, ulcer is
located below the left great toe, redness, edemalocated below the left great toe, redness, edema
and tenderness extending up to forefoot.and tenderness extending up to forefoot.
 Disarticulation of 2Disarticulation of 2ndnd
toe with wide local excisiontoe with wide local excision
done on 9.4.04done on 9.4.04
 Continued to be febrile and hyperglycemicContinued to be febrile and hyperglycemic
 Wound remained unhealthy despite radicalWound remained unhealthy despite radical
excision of all sloughexcision of all slough
 15.4.04 endocrinology consultation taken,15.4.04 endocrinology consultation taken,
started on MSI with A20,20,20; M26unitsstarted on MSI with A20,20,20; M26units

17. DateDate FPGFPG PPGPPG RapidRapid BasalBasal MixMix
15.4.0415.4.04 293293 364364 20,20,2020,20,20 2626
16.4.0416.4.04 160160 28,28,2828,28,28 16,3016,30
18.4.0418.4.04 314314 384384 20,20,2420,20,24 2626
19.4.0419.4.04 176176 226226 24,24,2424,24,24 24,2424,24
20.4.0420.4.04 5454 136136 15,15,1515,15,15 1515
21.4.0421.4.04 183183 16,16,1616,16,16 1818
25.4.0425.4.04 7878 186186 24,2424,24

18.  Mid tarsal amputation done on 17.4.04, as his oral intakeMid tarsal amputation done on 17.4.04, as his oral intake
remained very poor after surgery he was given infusion of DNSremained very poor after surgery he was given infusion of DNS
with added insulinwith added insulin
 He experienced hypoglycemia on 20.4.04He experienced hypoglycemia on 20.4.04
 Below knee amputation on 4.5.04Below knee amputation on 4.5.04
 Post surgery intake remained poor and had vomitingPost surgery intake remained poor and had vomiting
 Surgery team would change to insulin as per sliding scale, insulinSurgery team would change to insulin as per sliding scale, insulin
would be stopped altogether whenever hypos occurredwould be stopped altogether whenever hypos occurred
 Parenteral nutrition was also given with no provision of insulinParenteral nutrition was also given with no provision of insulin
 Altered sensorium with hypotension on 11.5.04Altered sensorium with hypotension on 11.5.04

19. DateDate FPGFPG PPGPPG RapidRapid BasalBasal CommentsComments
5.5.045.5.04 203203 264264 10,10,1010,10,10 1010
7.5.047.5.04 078078 114114 8,8,88,8,8 88
8.5.048.5.04 123123 212212 12,1212,12 Nil orallyNil orally
9.5.049.5.04 253253 324324 12,12,1212,12,12 1212
10.5.0410.5.04 243243 16,16,1616,16,16 1616
11.5.0411.5.04 65,6365,63 9696

20. DateDate FPGFPG PPGPPG RapidRapid BasalBasal PrePre
MixedMixed
15.5.0415.5.04 134134 184184 10,10,1010,10,10 1010
19.5.0419.5.04 111111 161161 15,15,1515,15,15 1515
24.5.0424.5.04 7474 101101 35,2535,25

21.  Hyponatremia (Na112),Hypokalemia (K 2.8)Hyponatremia (Na112),Hypokalemia (K 2.8)
Hypotension 90/50 mmHg, Pyrexia, MetabolicHypotension 90/50 mmHg, Pyrexia, Metabolic
alkalosisalkalosis
 Blood culture grew Klebsiella,EnteococcusBlood culture grew Klebsiella,Enteococcus
speciesspecies
 Was managed in AMC, received IV insulinWas managed in AMC, received IV insulin
infusioninfusion
 Discharged on 25.5.04 !Discharged on 25.5.04 !

22.  Intensified insulin regimens work but are introducedIntensified insulin regimens work but are introduced
rather laterather late
 Insulin requirements fluctuate but hypos should notInsulin requirements fluctuate but hypos should not
deter from achieving the goaldeter from achieving the goal
 Shifting from oral to parenteral nutrition does occursShifting from oral to parenteral nutrition does occurs
and needs closer monitoring and better insulinisationand needs closer monitoring and better insulinisation
 Unplanned procedures often result in interruption ofUnplanned procedures often result in interruption of
insulininsulin
At all times provide for nutrient/fluid and insulinAt all times provide for nutrient/fluid and insulin

23. SummarySummary
 Most patients with diabetic foot ulcers have significantMost patients with diabetic foot ulcers have significant
hyperglycemia necessitating insulin therapyhyperglycemia necessitating insulin therapy
 Glycemic control is an important though not the onlyGlycemic control is an important though not the only
management tool in the care of diabetic foot ulcers ,sadly it ismanagement tool in the care of diabetic foot ulcers ,sadly it is
often neglectedoften neglected
 Regimens for glycemic control vary among other things with theRegimens for glycemic control vary among other things with the
severity of hyperglycemia ,monitoring facilities, co-morbidseverity of hyperglycemia ,monitoring facilities, co-morbid
conditions but are driven largely by the enthusiasm forconditions but are driven largely by the enthusiasm for
euglycemia of treating team and must ensure continuity of insulineuglycemia of treating team and must ensure continuity of insulin
therapytherapy
 Admission for diabetic foot offers an opportunity forAdmission for diabetic foot offers an opportunity for
salvaging/protecting the individual against further ravages ofsalvaging/protecting the individual against further ravages of
micro/macrovascular diseasemicro/macrovascular disease

24. AcknowledgementAcknowledgement

25. Thanks…if at all youThanks…if at all you
could keep awake!!could keep awake!!