1. Inpatient Insulin Management on the Wards
Kevin Bechler, MD
Clinical Assistant Professor of Medicine
Keck School of Medicine of USC
LAC+USC Medical Center

2. Objectives Know target inpatient glucose values
Know the insulin types available at LAC/USC
Develop a weight based insulin regimen and know how to make adjustments
Manage insulin in patient’s with atypical PO intake

3. Goal Why do we care? FS Goal: 140-180 Why not more aggressive?
Effects on immune function/ wound healing, osmotic diuresis, inflammation/oxidative stress
FS Goal:
Why not more aggressive?
NICE SUGAR Trial
Hypoglycemia symptoms

4. Diabetes Medications In general stop PO DM meds
Metformin- risk of lactic acidosis, especially with renal/hemodynamic impairment
Sulfonylureas- unreliable absorption, risk of severe/prolonged hypoglycemia
Others simply not studied well or exert effect mainly post-prandially (GLP-1 agonists, DPP-4 inhibitors) or risk dehydration/GU infections (SGLT 2 inhibitors)

5. Insulin types at LAC/USC
Onset
Peak
Duration
Glargine 1h
None
24h
NPH
1-2h
4-8h
8-12h
Regular
30 min 2h
4-6h
Humalog
15 min
2-4h
Premixed combo: 70/30: 70% NPH with 30% Regular

6. What is their the FS? Below or at goal (<140-180): observe
Slightly above goal: single dose long acting vs weight based
Significantly above goal: weight based
Avoid sliding scale to “evaluate requirements”

7. Insulin Regimen Options
Basal/bolus options:
NPH/Regular: given together before breakfast and dinner
Glargine/Humalog: Humalog given before each meal and glargine before bed
Sliding scale is not the answer
Worse glycemic control and increased complications compared with basal/bolus
Reactive vs proactive

8. Deal with the Home Regimen
What to do with patient’s home insulin regimen
Continue
Reduce by 25-50% due to difference in food and PO intake
Start from scratch with new weight based
Controlled on PO meds
D/c PO meds, start weight based insulin
On no meds but hyperglycemic on admission
Weight based, check A1C

9. Weight based Weight based regimen:
Calculate total daily dose of insulin
Weight in Kg X correction factor
Correction Factor: based on insulin sensitivity/resistance
0.3 for elderly, slightly above goal, renal disease
0.5 good starting point for most
0.8-1 significant insulin resistance, high dose insulin at home

10. Weight based Decide on type of insulin
No significant difference between Glargine/Humalog vs NPH/Regular
Glargine/Humalog- mimics physiology but 4 injections per day
NPH/Regular- 2 injections per day
Avoid 70/30 as inpatient, increased hypoglycemia

11. Glargine/Humalog Total insulin dose split in half between 2 types
Glargine to be given before bed
Humalog component split into thirds to be given before meals

12. Practice
65 yo man with DM2 on insulin at home (forgot regimen) admitted for DM foot ulcer. Weighs 72kg and initial FS 300.

13. Practice
85 yo man with DM2 and CKD2 on oral meds at home admitted for PNA. Weighs 60kg and initial FS 225.

14. Practice
40 yo man with DM2 on insulin at home admitted for DM foot ulcer. Weighs 100kg and initial FS 450.

15. NPH/Regular Total insulin dose split 2/3, 1/3 for AM and PM
AM insulin split 2/3, 1/3 for NPH and Regular to be given together before breakfast
PM insulin split ½, ½ for NPH and Regular to be given before bed

16. Practice
65 yo man with DM2 on PO meds (forgot regimen) admitted for ACS r/o. Weighs 72kg and initial FS 300.

17. Practice
85 yo man with DM2 and CKD2 on no meds at home admitted for PNA. Weighs 60kg and initial FS 190.

18. Practice
40 yo man with DM2 on insulin at home admitted for DM foot ulcer. Weighs 100kg and initial FS 450.

19. Adjustments Regimen is a starting point
Daily adjustments of insulin based on corresponding Finger stick values AM, lunch, PM, HS until at goal
Adjust based on differences in PO intake depending on meal

20. Adjustment Guidelines
If all FS elevated, increase long acting
If single value elevated, adjust corresponding insulin
Increase by ~ 10-20% but can exceed depending on level of control
Use rule to 1800/TDD to estimate effect of a unit of insulin

21. Adjustment Scenario
40 yo man with DM2 on insulin at home admitted for DM foot ulcer. Weighs 100kg and initial FS 450.
FS: 350, 400, 275, 300
FS: 150, 450, 170, 250
FS: 300, 160, 180, 130

22. Diet changes NPO: Half long acting, hold short acting Enteral feeds:
Bolus: used the same basal/bolus strategy timed with boluses
Continuous: Single dose lantus or BID NPH
TPN: insulin often added to TPN so work with pharmacy

23. Troubleshoot
Several days to increase regimen to reach goal, then FS start fall below goal consistently
Stable regimen with FS at goal, then sudden hypoglycemic event
Inconsistent PO intake, lots of very elevated FS as well as hypoglycemic events

24. Sliding Scale
Additional insulin to cover hyperglycemic events, given at each FS check
Makes it difficult to interpret how your regimen is doing
Should be used as a reminder to adjust the regimen not as a solution to hyperglycemia

25. 70/30 Simplest regimen with basal/bolus insulin
Only 2 injections/ day with no mixing
Calculate TDD then 2/3, 1/3 in AM, PM

26. Type 1 DM Always need basal insulin
Often carb count and adjust their own insulin
Consider working with patient and nursing to facilitate acceptable plan

27. Discharge Use A1C to help guide need for outpatient insulin
If previously controlled on PO meds, resume without insulin
If continuing insulin, keep in mind changing insulin sensitivity and changes in diet
Choose an insulin regimen that is realistic for the patient