1. 1 Module 5 Pharmacologic Management of Hospital Hyperglycemia: Insulin Management Part 2 Diabetes Special Interest Group Georgia Hospital Association

2. 2 In this module you will practice applying principles of insulin therapy in the hospital Learning Modules Module no.Topic 1Hyperglycemia and hospital outcomes 2Challenges and opportunities for care improvement 3Initial recognition, triaging, and management 4Principles of pharmacologic management: Insulin 1 5Principles of pharmacologic management: Insulin 2 6Review of policies and procedures 7Getting patient ready for discharge

3. 3 Calculate basal-bolus insulin dose in a 52 year old man with type 2 diabetes, glucose values in the 200’s, with weight of 100 kg who is eating –First estimate total daily insulin requirements: Total daily insulin = 0.5 unit x 100 kg = 50 units –Second, estimate basal insulin amount: Basal insulin amount = 0.5 x 50 = 25 units –Third, estimate prandial (or bolus) insulin: Prandial insulin = (0.5 x 50)/3 = 8 units per meal –Fourth, create a scale using a CF = 30 (next slide)

4. 4 Calculate His Corrective Insulin Program GlucoseCF = 30 70-140Target range 141-199 200-250 251-300 301-350 351-400 (170-110)/30 = 2 (225-110)/30 = 4 (275-110)/30 = 5 (325-110)/30 = 7 (375-110)/30 = 9

5. 5 A 65 year old 82 kg woman with metastatic breast cancer is admitted for mental status changes. She has a 10 year history of diabetes on glipizide. Her A1c is 8.3%. She is not eating and you hold her glipizide. You monitor q 6h bedside glucose. You start her on a “mild sliding scale” but after 24 h her values range from 200 to 275 mg/dL. What would you do? A. Increase her sliding scale to “aggressive” B. Start scheduled basal insulin with corrective insulin C. Start a basal-prandial insulin program with corrective insulin D. Restart glipizide Answer: B

6. 6 Calculate your patient’s initial insulin doses –Estimate total daily insulin requirement: Total daily insulin = 0.5 unit x 82 kg = 41 units –Estimate basal insulin amount: Basal insulin amount = 0.5 x 41 ~ 20 units –Construct a corrective insulin program using a CF = 20 You will want a lower CF– she is probably pretty insulin resistant GlucoseCF = 20 70-140Target range 141-199 200-250 251-300 301-350 351-400 (170-110)/20 = 3 (225-110)/20 = 6 (275-110)/20 = 8 (325-110)/20 = 11 (375-110)/20 = 13

7. 7 A 90 kg 70 year old man with advanced COPD is admitted with pneumonia and bronchospasm. He has no history of diabetes but his admission glucose is 281 mg/dL. You will have to start steroids. You check the A1c and it is 7.3%. He is eating. During the first 24 h his bedside glucose values are in the high 200’s. You decide to put him on a scheduled insulin program. Calculate the doses. –First estimate total daily insulin requirements: Total daily insulin = 0.5 unit x 90 kg = 45 units –Second, estimate basal insulin amount: Basal insulin amount = 0.5 x 45 ~ 22 Units –Third, estimate meal time insulin: Prandial insulin = (0.5 x 45)/3 ~ 7 Units per meal –Fourth, continue corrective insulin program

8. 8 You have started your 70 year old man on the scheduled insulin program, but after 24 h his glucose values are still in the 250 to 300 range. He is on Prednisone. Pseudomonas grew out of his sputum and blood. You have become reconciled to the fact that he will be with you a few more days. How much should you increase his insulin? Calculate the new doses. Insulin regimenOld dose units New dose units Basal22 Prandial Breakfast7 Lunch7 Supper7 29 9 9 9 Daily glucose mg/dL % increase total daily insulin 70 - 1400 141 - 19910 200 - 24920 250 - 29930 300 - 34940 >350Insulin infusion

9. 9 After another 24 h your 70 year old man’s blood glucose values are improving, but are still in the 200 to 249 range. How much would you increase his insulin? Calculate the new doses. Insulin regimenOld dose units New dose units Basal29 Prandial Breakfast9 Lunch9 Supper9 35 11 Daily glucose mg/dL % increase total daily insulin 70 - 1400 141 - 19910 200 - 24920 250 - 29930 300 - 34940 >350Insulin infusion

10. 10 After another 24 h your 70 year old man’s blood glucose values are now in the 160 to 190 mg/dL range. While they are now much improved, knowing the importance of good glucose in the hospital, and being the OCD person you are, you are still not happy and want to get him to a 120 to 150 mg/dL target. How much would you increase his insulin now? Calculate the new doses. Insulin regimenOld dose units New dose units Basal35 Prandial Breakfast11 Lunch11 Supper11 Congratulations, he is now at target. 38 12 Daily glucose mg/dL % increase total daily insulin 70 - 1400 141 - 19910 200 - 24920 250 - 29930 300 - 34940 >350Insulin infusion