Presentation on theme: "Insulin Use In Outpatient and Inpatient Settings"— Presentation transcript:
1 Insulin Use In Outpatient and Inpatient Settings Greg Cook, MDEndocrinology Fellow
2 ObjectivesBecome familiar with different types of insulin and their actionsUnderstand how various insulin regimens compare and contrast with endogenous insulin productionBecome comfortable initiating and managing insulin in the outpatient settingLearn basics of inpatient insulin therapyLearn how to use insulin to help address hyperglycemia caused by glucocorticoids or enteral nutrition
3 Case I45 yo man with 12 year history of DM type II presents for initial visit to outpatient clinic. He is currently on metformin 1 gram BID and glipizide 10mg BID. He monitors his glucoses infrequently and reports fasting values of His mother recently died from diabetic complications, and he is very concerned about developing similar problems himself. Exam: Wt 242 lb (110 kg), BP is controlled Obese, +acanthosis nigricans on neck Labs: Serum glucose 286, Cr 1.3, Hgb A1c 9.6 In addition to encouraging dietary and lifestyle changes, how would you manage his diabetes?
9 Terminology Basal Insulin: Prandial (Nutritional) Insulin: Long acting insulin. Required in all type I patients, and patients over glycemic target. Required even when NPOPrandial (Nutritional) Insulin:Scheduled short acting insulin given in anticipation of carbohydrate induced hyperglycemic excursionAdjust amount given if nutrition is diminished or interruptedCorrection Insulin:Short acting insulin given in addition to scheduled insulin as a response to unexpected hyperglycemia. If this is used extensively, then scheduled insulin should be adjusted or addedSubcutaneous Insulin Order Sets and Protocols: Effective Design and Implementation Strategies. Journal of Hospital Medicine: Vol 3, Issue 5, supplement 5 – S29-S41Subcutaneous Insulin Order Sets and Protocols: Effective Design and Implementation Strategies. Journal of Hospital Medicine:Vol 3, Issue 5, supplement 5 – S29-S41
11 Case I - Treatment Initiate basal therapy with insulin glargine or NPH Calculation of basal insulin:Initiate with units/kg and higher for patients with known insulin resistanceWould start with 0.3 units/kg, or more, in this patient with obesity and acanthosisWeight: 110kg0.3 x 110 = 33 units, rounded to nearest even # = 34 units.Written instructions to self-titrate dose by 2-4 units every 4 days for fasting glucoses > 130.Would also suggest he stop at 60 units (0.5 units/kg).Consider fast to evaluate basal doseAdd prandial insulin coverage, starting with largest meal
12 Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy Diabetes Care 2006, Vol 29, numberManagement of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation andAdjustment of Therapy Diabetes Care 2006, Vol 29, number
13 Case II32 yo overweight man with DM type II currently on Novolin 70/30 insulin, 30 units with breakfast and 20 units with dinner. Review of glucose log shows fasting glucoses around 200’s and pre-dinner glucoses (220’s), with frequent hypoglycemia occurring predominately before lunch, mainly on days that he eats a late lunch. He always eats a substantial bedtime snack due to a memorable episode of nighttime hypoglycemia. He has gained 10 pounds in last 3 months and is now 220 pounds. He wants to minimize number of insulin injections. What adjustments would you make?
14 Glucose Levels and Insulin physiology in Non-Diabetics
15 Mixed Insulin Regimens Diabetes Education Online – University of California San Francisco (www.deo.ucsf.edu/.../graph_sliding_premixed2.gif)
16 Case II - Treatment Current regimen: 30 units 70/30 in AM = 21 units N, 9 units R20 units 70/30 in PM = 14 units N, 6 units RCalculation of total daily insulin dose:0.4 – 0.8 units x weight (kg), based on insulin sensitivityCase II: 0.5 x 100 = 50 units/day50% as basal, 50% as bolusBasal = 25, Bolus = 25Could change to:NPH 18 units in AM mixed with Aspart 8 units AC breakfastAdditional NPH at breakfast will help cover lunchtime hyperglycemiaAspart 10 units AC dinner (his biggest meal)NPH 12 units HS
17 NPH and Rapid Acting Insulin NPH AM and AC dinnerNPH AM and HSCME medscape
18 Case III24 yo man presented 3 days ago with DKA and was diagnosed with type I diabetes. He is currently on an insulin infusion. He has received 40 units of insulin over the last 24 hours (avg = 1.67 units/hr), is eating a regular diet, and is ready for transfer to the floor. Exam: Wt 176 lbs (80kg) How would you transition him to SC Insulin?
21 Case III Calculation of Total Daily Dose (TDD) of Insulin 1. Using Insulin Infusion Information80% of total dose: 0.8 x 40 = 32 unitsAvg rate x 20: 1.67 x 20 = 32 unitsMay represent only basal amount if pt was NPO during infusion2. Calculation based on body weightunits/kg for patients without significant insulin resistance: 0.4units/kg x 80kg = 32 unitsCalculation of basal insulin:50% of TDD = 16 units or 0.2 units/kg x 32kg = 16 unitsBe sure to give basal insulin at least 2 hours prior to stopping insulin infusion
22 Case III continued Calculation of prandial insulin: % of TDD divided between 3 meals: 16 units – approximately 5 units/meal2. Carbohydrate ratio: (“Rule of 500”)500/TDD of insulin = how many grams of CHO 1 unit of insulin will coverExample: 500/32 units = – round to 15One unit of meal-time insulin for every 15 grams of carbohydratesMeals at MCV contain approx. 60 grams of CHO. For our patient, 4 units for each meal would be a starting pointCalculation of Correction Factor: (“Rule of 1500”)1500/ Total Daily Dose of Insulin = how many mg/dl 1 unit of insulin will lower blood sugarExample: 1500/32units = – rounded up 50One unit of insulin should lower glucose by 50 mg/dlFor glucose of 350, 4 units of Aspart should lower level to 150
23 Examples of Standardized Correction Doses ** Note that HS correction dose is significantly less and maybe zero **Subcutaneous Insulin Order Sets and Protocols: Effective Design and Implementation Strategies. Journal of Hospital Medicine: Vol 3, Issue 5, supplement 5 – S29-S41
24 Case III -ContinuedPatient does not like hospital food and eats varying amounts of meal. What you should do?Patient is going to be made NPO for procedure. What should you do?
25 Case III - Continued NPO status If diabetic, especially type I, is to be NPO, be sure to continue basal insulinCan decrease dose by 10% or 20% if uncertain of true basal needsChange glucose monitoring to Q 6 hoursIf patient’s appetite or PO intake is uncertainGive mealtime Aspart after the mealCan give ½ dose (2 units, for example) if about 50% of meal is eatenIf patient is able to count carbohydrates, he/she could tell nurse how much insulin to give after the meal, based on amount eaten
26 Case III GlucosesInsulin regimen Basal Insulin: Glargine 16 units QAM Prandial Insulin: Aspart 5 units AC meals Correction Factor: 1 unit/50 mg/dl above 150 Glucoses What adjustments would you make to insulin regimen?DateAC BAC LAC DHS7/101751221891157/11192101210120
27 Case IV55 yo with DM type II, admitted with pneumonia. Meds: Glyburide 10mg daily Metformin 1 gram BID Exam: Wt 225 pounds (102 kg) Labs: Serum Glucose 285 Cr 1.5 (baseline of 1.2) Hgb A1c two months ago was 8.1 How would your manage his diabetes?
28 Hyperglycemia in the Hospital Management of Hyperglycemia in the Hospital Setting NEJM 335:18 Nov 2006Management of Hyperglycemia in the Hospital Setting NEJM 335:18 Nov 2006
29 Inpatient Management of Diabetes Every diabetic patient should have recent A1c to assess control on diabetic regimen. If unknown or not recent, order A1c on admitIf A1c is <8%, outpatient regimen can be considered. If on oral meds, will need to verify there are no contraindications (renal, liver, and cardiac function, other medications, procedures, nutritional status, etc)If A1c is >8% will need basal insulin, if on oral meds. If on insulin, will need adjustments to prior insulin regimenOrder Accuchecks AC meals and HS. Q6 hours if NPO
30 Inpatient Management of Diabetes Basal insulin: units/kg in 2 divided doses for NPH. Glargine can be given in AM or bedtimePrandial Insulin: MCV meals contain 60 g of CHOUse “rule of 500” to calculate, or can start with between 4 (CHO 1:15) to 6 (CHO ratio of 1:10) units AC mealsCorrection Dose:Would at least provide correction for glucoses >300Aspart 6 units for glucoses >300 is reasonable for most patientsUse rule of 1500 to adjust. For example, if correction factor is 1:20 and glucose is 350, with target glucose of 150, the difference is /20 = 10 units. 10 units of Aspart should lower glucose of 350 to 150 range
31 Case IV Total Daily Dose (TDD) : 0.6 units/kg = 0.6 x 102 = 60 Units Basal Insulin: 50% of TDD = 30 units or 0.3 units/kg x 102 = 30NPH 15 units AM and HSGlargine 30 unitsPrandial Insulin:A. 50 % of TDD = 30 unitsAspart 10 units AC mealsB. Rule of 500 = 500/60 = For 60g CHO/meal. 60/8.3 =7Aspart 7 units AC mealsCorrection Dose:A. Aspart 6 units prn for glucose > 300.B. Rule of 1500: 1500/60 = U of insulin lowers glucose by 25
32 Case IV Correction Dose Glucose Insulin Glucose Insulin < 70 Assess patient, treat <70 Assess + treatNo additional insulin Noneunit unitsunits unitsunits unitsunits unitsunits unitsunits units + callunitsunitsunitsunits and call MD
33 Case V65 yo with DM type II and COPD admitted with COPD exacerbation. Home regimen was NPH 20 units AM, HS and Aspart 10 units AC breakfast and AC dinner. He is to be on prednisone 60mg daily as an inpatient and then will receive prednisone taper over 10 days on discharge Exam: Weight 80 kg How would you adjust his insulin regiment to account for hyperglycemic effects of corticosteroid?
34 Case V Corticosteroids induce insulin resistance Although prednisone is dosed every 24 hours, hyperglycemic effect is only a little over 12 hoursOnce above 40mg, increasing doses of prednisone do not have added hyperglycemic effectsNPH’s has a duration of action to cover this effectNPH 0.1 units/kg for every 10mg of prednisone up to 40 mg
35 Case VFor our 80 kg patient: Dose of prednisone NPH to be added home regimen 60mg 0.4 U/kg x 80kg = 32 units 40mg 0.4 U/kg x 80kg = 32 units 20mg 0.2 U/kg x 80kg = 16 units 10mg 0.1 U/kg x 80 kg = 8 units For 60 mg of prednisone, he would take 20 U NPH + 32 U NPH = 52 U NPH in AM at the same time as prednisone He will continue 20 U NPH at bedtime and same mealtime Aspart insulin He may likely need more dinner Aspart while on prednisone
36 Case VI60 yo with DM type II, laryngeal cancer, s/p surgery. He is currently on continuous TFs with Two Cal HN at 60 ml per hour. He is unsure of his home diabetes regimen. Exam: Weight 85 kg Labs: Hgb A1c is 8.4 How would you control his glucoses while on the TFs?
37 Case VI1. Calculate Total Daily Dose of Insulin 0.6 x 85 kg = 51 Units (50 units) 2. Calculate basal needs: 0.3 units/kg x 85 = 25.5 units (25 units) 2. Rule of 500 to calculate carbohydrate ratio 500/50 = 10 1 unit will cover 10g of carbohydrates 3. Calculate total grams of carbohydrates to be covered -1st calculate total amount (volume) of TFs 60 ml/hr x 24 hours = 1440 ml/day -Next calculate how many grams of carbohydrates (CHO) this gives/day Two cal HN has 52 g of CHO per 8 fl oz can (236ml) or 0.22 g CHO/ml 0.22 g CHO/ml x 1440 ml/day = 317 g CHO/day -Finally calculate how much insulin is needed to cover CHO content of TFs 317 g CHO/day x 1U/10g CHO = 31.7 or 32 units 4. Basal insulin + Insulin to cover TFs = 25 U + 32 U = 57 Units
38 Case IV Options for TF coverage: Glargine daily, Regular every 6 hr, Aspart every 4 hr, or NPH every 8 hrTube feeds tend to be interrupted often (i.e. for procedures or because the patients pull them out)For our patient, we would choose NPH every 8 hours57 units total/ 3 = 19 units NPH Q 8 hours*If TFs are stopped, he will need D10 infusion to cover NPH
39 Key Points Individualize insulin therapy based on Etiology of diabetes Weight, BMI and anticipated insulin resistanceClinical setting- inpatient vs outpatientPatient’s diet or nutritional statusTreatment goals