1. *Load Coverage app. on your phone for workshop use.

2. Reference Packet – not required for use during workshop
Treatment Options for Hyperglycemia card
Pharmacologic Approaches to Glycemic Treatment, Diabetes Care, Jan 2019
Pearls for Prescribing Diabetes Medication 2019
Treat to Targets
Diabetes Clinic Update Questionnaire (2 pages)
Glucotoxicity Acute Temporary Insulin Start protocol
Instructions for using disposable pens for Diabetes
Hypoglycemia and How to treat (for the patient)
Blood Glucose log (2 pages)
WalMart low cost Diabetes supplies (2 pages)
Hypoglycemia Protocol (for office staff)
Pre-Meal Insulin Correction Scale 1:25 over 150
Use of Libre Continuous Glucose Monitor
Type 2 Diabetes & Unplanned Pregnancy – Acute plan options protocol

3. Managing Insulin & Non-insulin Medications for DM, case-based practice
Mary E. Steward, APRN-CNP, CDE Assistant Professor, Internal Medicine OU School of Community Medicine - Tulsa

4. Speaker Disclosure
I have no financial relationships or affiliations to disclose.

5. Prandial glucose excursion 1-3 hrs. after eating CHO
Prandial insulin 50%
50%
Prandial glucose excursion 1-3 hrs. after eating CHO

6. Pattern Observations Premeal targets 80-130, pp or HS 100-180.
Acceptable variability between premeal values < 30 mg/dL.
Acceptable variability between premeal
and 2 hrs. postprandial mg/dL.
Acceptable overnight change < 30mg/dL.
1 -2hrs
180
150
120
100
Breakfast
Lunch
Supper

7. Postprandial Pattern “stairstep”
HIGH
Excursions from AM, Lability
Postprandial Pattern “stairstep”
Fasting Pattern “wave”
HIGH
Baseline
Normal
1-2 hrs.
excursions B L S

8. Recognizing Patterns Postprandial Hyperglycemia
(Stair-step pattern with elevations >100 mg/dL over fasting level, increase with feeding, do not return to baseline)
Fasting Hyperglycemia
(Start high—stay high, <100 mg/dL variance through day from fasting level)
Normal meal to meal or overnight variations in BS +/- 30 mg/dL

9. Sample Patterns AM Noon PM Bedtime 185 224 279 312 215 290 343 298 147
218
325
360
220
243
278
251
195
222
244
260
247
239
250
301

10. Pattern Characteristics---- Always fix LOWs before correcting HIGHs.
POSTPRANDIAL
Fix the highest elevation first (usually meal prior), or where biggest jump in glucose occurs
FASTING
Fix the fasting first

11. Glucose Rxn = DME Joe Smith DOB 01/01/1950 XXX Brand glucose strip.
Test BS 3 times daily
E11.65, Z79.4 (insulin use)
Sue Jones, APRN-CNP
NPI xxxxxxxxx
Insulin using = 3 times daily, #100/1mos
Non-insulin using = 1 times daily, #100/3mos.

12. Approach to Hyperglycemia – A1c goal More Stringent Less Stringent
Attitude & Expected Tx Effort
Motivation
Adherent
self-care
Risks hypo
Disease duration
Life expectancy
Comorbidities
Vascular comp.
Resources, support
Motivation
adherent, self-care
High
Long-standing
Short
Severe
Limited
Low
Newly D
Long
Few, mild
None
Available
Diabetes Care, 19 April 2012

13. Hypoglycemia: Less Stringent Mgt
Hypoglycemia unawareness
Age >65 yrs/functional status
Limited life expectancy
Cardiovascular disease
Renal disease
Seizure disorder
Work safety
Live alone
ALWAYS FIX LOWS BEFORE HIGHS

14. Pre-T2 T2 Onset Metabolic Syndrome T2 Progression >10 yrs
Insulin resistance
Post meal BS
BEFORE meal BS
Insulin production
Incretin gut hormone
Metabolic Syndrome
T2 Progression >10 yrs

15. Pathophysiology

16. Action Fasting Both Liver Metformin Pancreas GLP-1, DPP4 Muscle TZD
Postprandial
Liver
Metformin
Pancreas
GLP-1, DPP4
Sulfonylurea
Muscle
TZD
Gut/Incretin
Insulin
Lantus, Basaglar, Toujeo, Tresiba; Levemir (BID)
ReliOn 10-11pm
Humalog 75/25 or Novolog 70/30 Mix insulin,
ReliOn 70/30
Humalog, Novolog.
Apidra, Fiasp,
ReliOn Regular
Kidney
SGLT-2
EXPENSIVE
CHEAPER
CV preferred

17. Case Practice How much A1c reduction do I need?
What is the BS pattern?
Fasting
Postprandial
What are my compelling indications?
ASCVD, CKD, HF; eGFR; Hypo tolerance, Wt concerns, Cost
Oral vs injectable, complexity of regimen, duration of diabetes diagnosis

18. Type 2 DM Insulin Candidates
Glucotoxicity (Fasting>300, Random>350)
Temporary use: illness, infection, surgery
Exceed BS targets on max. dose 2+ orals
Renal disease
Pregnancy (metformin used)
Contraindication to orals

19. Insulin Action Profiles

20. Type 2 DM Insulin Candidates, non-pregnant
A1c >10% = Basal/bolus (3-4 shots/d)
Mix BID or TID (2-3 shots/d)
Basal/GLP combo (1 shot/d)
(Xultophy, Soliqua)
+ metformin
A1c 8-9% = Basal insulin
+ combo drugs

21. INSULIN A GOOD solution to a COMMON problem— don’t hesitate
STRONG

22. New to Insulin DM2
Starting Basal only (A1c <9%) ONE SHOT Start 10% weight in pounds, usually in PM
GLP/Basal combo (Xultophy, Soliqua) ONE SHOT – Start per package units daily in AM, usually before first meal
Premix insulin TWO SHOTS – Start 10% weight in pounds, timed before meals
Basal/Bolus THREE to FOUR SHOTS – Start basal 10% weight in pounds, bolus 5% weight in pounds, timed before meals

23. Conservative Insulin Dose changes
10-20% of the dose
Bolus = 24 hrs. steady state,
daily adjusts
Basal = 3-5 day steady state,
1-2 time weekly adjusts
“Stacking” = giving doses too close together

24. DME needed for Insulin use
Pen needles 32g x 4 mm not more than daily use, if reusing
Syringes 31g x 5 mm 0.5 ml (50 units); 1.0 ml (100 units)
Wal-Mart sells generic brands for $12-20/100 no insurance

25. INSULIN Eval Criteria Insulin Dose for body Wt
u/kg for established Type 1
1.0 u/kg + for obese Type 2
Basal/Bolus Split 50/50 or 40/60
Insulin:Carb Ratio
Insulin:Food timing 0-15 min analog; min Regular
Hypoglycemia Minimization
Soft injection sites, new pen needles

26. Maintaining Proper Basal-Bolus Ratios
Periodically reevaluate the total insulin used:
Are the total daily insulin units appropriate for body weight? ( /kg for T1DM; 1.0+/kg obese T2DM) *Underinsulinization or Overrinsulinization
Is the ratio of basal to bolus insulin somewhere around 50:50 to 60:40?
Does your planned insulin dose change match pattern of blood sugars observed? Fasting vs Postprandial

27. FAMOS Issues? Food Activity Meds Other illness Stress
history-based problem-solving out of target BG
Food - Skip breakfast? Large supper? More CHO?
Activity – planned/unplanned? Added? (sensitizer)
Meds – SU timed to go before meals? Meal insulin timed with food? Using additional correction doses?
Other Illness – occult infections (skin, foot, dental, GU)? OTC meds (decongestants, cough meds)? Steroids? Atypical antipsychotics?
Stress – unusual?

28. 38 yrs. CF with PMH Gest DM 3 yrs. ago requiring insulin 3 shots/day
38 yrs. CF with PMH Gest DM 3 yrs. ago requiring insulin 3 shots/day. Glucose tolerance normal postpartum. Wt 187# (85kg), BMI 31.
Labs for chronic HCV w/mildly elev. LFTs show random glucose 211 on chemistry, no s/s DM at visit.
1 wk FU Fasting BS A1c 9.2% MPG 250.

29. 17 yrs. AAF with recurrent yeast infections, not cured w/OTC antifungals. Wt 229#, 104 kg, BMI 39.
Nocturia
No recent change in weight.
Strong maternal FH DM
Random BS 397, A1c of 13, MPG 386, urine ketones negative

30. 26yrs. CF with CC: fatigue, constant thirst, dry skin, losing weight
26yrs. CF with CC: fatigue, constant thirst, dry skin, losing weight. PMH negative. FH negative. Wt 117, 53 kg. Down from 135 lbs. 3 mos ago.
Glucose 346, Urine ketones 3+ moderate
Denies s/s infection.
No medications or allergies
Eats lunch & supper only. Drinks 3-4 cans Pepsi daily.
Single, no children, lives with boyfriend x 3 yrs., irreg condom use.

31. What did the past 3 new patients share demographically that needs to be addressed?

32. Need for PRECONCEPTION CARE Birth Control See Protocol: Type 2 Diabetes & Unplanned Pregnancy—Acute plan options in your workshop packet

33. 61 yrs. HISP Bedlam free clinic (no insurance), new onset polyuria, polydipsia, blurred vision worsening over last 2 mos. w/o wt loss.295 pounds (134 kg)
Office fingerstick fasting HI (over 600)
Fingerstick A1c 13.0%, MPG 386
FAMOUS
Food Activity Medicine Other illness (occult infection) Stress

34. 61 yrs. HISP female @ Bedlam clinic, 1 wk FU visit
Home blood sugars AM N PM HS

35. 28 yrs. CM with 3 mos hx onset fatigue, blurry vision, freq urination, nocturia, has lost 15 pounds, now 165 lbs, 75kg, BMI 25.
Random fingerstick BS am.
FH DM2 in paternal aunt

36. 28 yrs. CM with 3 mos hx onset fatigue, blurry vision, freq urination, nocturia, has lost 15 pounds, 248 lbs, 113kg, BMI 36.
Random fingerstick BS am.
FH DM2 in paternal aunt
A1c 8.4%, MPG 210

37. 28 yrs. CM with 1 wk onset nausea, vomiting, flu-like symptoms, has lost 15 pounds, now 165 lbs, 75kg, BMI 25.
Fasting glucose 379.
Urine ketones moderate
A1c 11.2%, MPG 320.
C-peptide 0.6 ( )

38. Diabetes Specialty Labs for Diagnostic Clarity
C-peptide (.8-3.1)
Autoantibodies (need if C-peptide <1)
GAD – 65 Glutamic Acid Decarboxylase-65
IA – 2 Insulinoma assoc. 2 autoantibodies
Zinc Transporter 8 (ZnT8)
ICA – Islet Cell Antibody
IAA – Insulin Autoantibody

39. 60 yrs. Cauc Female, DM2 since 2017, 192 pounds (87 kg)
A1c 8.5%, MPG 225
Metformin 1000 BID, Lantus 20 HS
Office fingerstick fasting 225
Recall home sugars AM presupper.

40. 35 yrs. CM, DM2 since 2012, 292 pounds (132 kg)
A1c 10.3%, MPG 289
Metformin 1000 BID, Lantus 100 HS
Humalog TID premeal, Stopped Humalog as “felt like a pin cushion”
Office fingerstick over 3 hrs. postprandial 302
Fasting at home today 181
Recall home sugars: AM presupper.
2 pieces whole wheat toast & SF drink for breakfast

41. 54 yrs. AA Male, DM2 since 2017, 192 pounds (87 kg)
A1c 11.0%, MPG 314
Metformin 1000 BID, Lantus 20 HS
Humalog TID premeal
Office fingerstick fasting 302
Fasting at home today 281
Recall home sugars AM presupper.

42. Illness creates insulin resistance & greater requirement esp for short-acting insulin (correction, nutritional, prandial) doses.

43. 40 yrs. Native American F presents to ER with cellulitis of leg, BS 407 random, 140 pounds (64 kg).
Hx DM2 x 15 yrs. A1c of 11.5% MPG Taking metformin 1000 BID, glipizide 10 BID premeal.
No home testing
Drinks occasional sugared pop, mostly water & unsweet tea

44. 71 yrs. AAM, with T2DM x 6 yrs, Wt 180#, (82kg, BMI 25), taking Novolog units premeal & 40 units Levemir HS.
Tx for pyoderma gangrenosa leg ulcer. Much improved blood sugars with insulin addition. Initially he had to drop the doses as abrupt change in lower sugar left him very symptomatic, he has been able to raise to recommended levels, keeping log of TID sugars with most values range.
AM 87, 117, 124, 121, 154, 125, 144, 101, 112
Presupper 155, 243, 243, 244, 167
Bedtime 249, 293, 239, 367, 275, 262
Had a few sips regular Sprite this AM as thought might be dropping, morning is when he is lowest.
Office BS 219 after breakfast; A1c 8.6% MPG 230

45. 61 yrs. CM with DM 2 x 16 yrs. , COPD with freq acute exacerb
61 yrs. CM with DM 2 x 16 yrs., COPD with freq acute exacerb. requiring steroid bursts pounds (80 kg).
Metformin 1000 BID, Glipizide 5mg in AM. Only eats lunch & supper meals.
Office BS 365 random, A1c 9.5%, MPG Just finished 5 days Prednisone 40 mg daily. Has agreed to go on inhaled steroids to minimize recurrences.

46. 56 yrs. AAF with T2DM & newly diagnosed polymyalgia rheumatic.
180 lbs., 82 kg.
Janumet XR 50/ tabs in AM, A1c has been stable at 6.5-7% last year.
Office BS 307 random, pt starts home checks once daily alternating with AM ; presupper ; HS 250
Expect need for higher dose steroids over next few months.

47. Insulin Prescriptions & Conversions
40 yrs. Hisp M with DM2, A1c of 12.4%, not on meds. Wt. 200 lbs. No insurance.
Prescription:
Timing:
Additional equipment rxn (include ICD 10 code if using insurance).

48. 25 yrs. CF with DM1, A1c of 9.5%, taking 8R/15N twice daily, now has insurance*, wants to use insulin pens. Wt. 120 lbs. *Load Coverage app.
Prescription: ? Novolog
(United Commercial insurance)
Preferred: Humalog & Basaglar or Tresiba
Timing:
Additional equipment (ICD10 code?)

49. 75 yrs. AAM with DM2, admit to hospital with diverticulitis, taking ReliOn 70/30, 35 units BID, A1c 7.8%
SQ Prescription while NPO:
SQ Prescription when resume oral feeding:
Discharge Prescription:

50. 21 yrs. CM, 132 pounds, 60 kg., with Type 1 DM, hx DKA, BS 500, neg ketones
EMR states he is on Lantus 45 units PM with Humalog 15 units TID premeal Last A1c 12.4%, MPG 360
Insulin dose for body wt?
Questions to ask?
Insulin prescription:

51. Suspect Insulin Omission Food Activity Medicine Other illness Stress
ASK about liquid carb intake.
I know it must be hard to get xx shots/day.
What dose are you most likely to miss? Which dose is next hardest?
How many days of the week are you likely to get at least xxx shots?
Are you covering meals AND snacks with short-acting insulin?
How often do you fall asleep or forget your long-acting insulin shot?
Frequency of low blood sugars/time of day/snacking to avoid
PALPATE injection sites for lipohypertrophy
Infection: Occult (skin, foot, dental, GU)
Other meds: Steroids, Atypical antipsychotics, OTC decongestants & cough meds

52. Overinsulinization
When the dose of insulin is high for body weight with a high A1c
Check omission, distribution basal/bolus, covering snacks & meals, frequency of insulin pentip changes, dates & storage home supplies.
Have your nurse call pharmacy for a 12 mos “fill history” on meds.
Type 1 /Thin, insulin sensitive patient - Recalculate a weight-based dose (.6-.9 u/kg), distribute basal/bolus with carb coverage. New injection sites. Consider DM education/nutrition referral for accurate carb counting.
Type 2/Obese, insulin resistant patient – Recalculate, lower dose, consider adding a sensitizer like metformin, TZD and a GLP-1 drug that hits other sites contributing to hyperglycemia. If poor control on over 100 units/day, consider use of u-200 or u-300 (over 200 u/d, consider u-500) insulin pens for better absorption/action.

53. 60 yrs. CF with DM2, taking Humalog Mix 75/25 20 units TID premeal, having lows at bedtime, highs in AM.
Prescription:
Timing:

54. Pathophysiology

55. Action Fasting Both Liver Metformin Pancreas GLP-1, DPP4 Muscle TZD
Postprandial
Liver
Metformin
Pancreas
GLP-1, DPP4
Sulfonylurea
Muscle
TZD
Gut/Incretin
Insulin
Lantus, Basaglar, Toujeo, Tresiba; Levemir (BID)
ReliOn 10-11pm
Humalog 75/25 or Novolog 70/30 Mix insulin,
ReliOn 70/30
Humalog, Novolog.
Apidra, Fiasp,
ReliOn Regular
Kidney
SGLT-2
EXPENSIVE
CHEAPER
CV preferred

56. Pre-T2 T2 Onset Metabolic Syndrome T2 Progression >10 yrs
Insulin resistance
Post meal BS
BEFORE meal BS
Insulin production
Incretin gut hormone
Metabolic Syndrome
T2 Progression >10 yrs

57. Incretin Drugs—GLP-1 & DPP4
Victoza (daily), Trulicity (weekly) preferred CV
Ozempic (semaglutide) (weekly) best A1c & weight data, CV data pending, oral daily pill in 2020, good Medicare formulary coverage
Nausea primary side effect GLP-1, titrate slowly; Do not use w/chronic pancreatitis, gastroparesis/Reglan
DPP4 not as strong, A1c lowering <1%, well-tolerated; Tradjenta (linagliptin) in CKD5

59. 28yrs. CM with DM2 x 2 yrs, schizophrenia. Wt 330, 150kg.
Taking Zyprexa, Metformin 1000 BID, Glipizide 10 mg BID.
A1c rise from 7.2% to 9.4%, MPG 255, in past 3 mos. with 15 pound wt. gain.
Does not test home sugar, lives in group home, little outside supervision/support.

60. 20 yrs. Nat Amer F, taking metformin 1000 BID, Novolog 45 TID meals, Lantus 85 BID, wt 300 lbs., A1c 13%.
Insulin dose for body wt?
Questions to ask?
Prescription:
Timing:

61. 48 yrs. AAM, 284 lbs, FH DM2
A1c 9.8%, MPG 240
Fasting fingerstick glucose 195 in office
Total Chol 299, LDL 165, Tg 444, HDL 38
Office BS last 2 visits 138/88, 146/9

62. Just discharged from alcohol abuse treatment center
What concerns do you have about metformin use?

63. Metformin concerns
eGFR >45 = 2 grams/day; Write for max dose if A1c is over 8%, tell patient how to titrate.
eGFR = 1 gram/day
eGFR <30 = contraindicated
Caution starting with age >80 yrs.
GI side effects – use metformin ER 500 after meals
Binge drinking – metabolic acidosis
B12 deficiency

64. SGLT-2 use Best CV data = Jardiance eGFR <45---don’t start
eGFR <30----stop
Caution yeast > UTI—uncircumcised, obese, tight fitting nylon clothing; keep the perineum/penis tip clean & dry.
May need to decrease diuretic if tight BP control
Risk for complications in dehydration states

65. 55 yrs. CF, DM2 dx 2 yrs. ago but untreated until past 3 mos.
recently lost from 150 down to 137 lbs.
severe neuropathy pains in legs
Taking metformin ER tabs daily with good GI tolerance
A1c dropped from 9.7 to 8.2% in past 3 months

66. 86 yrs. frail CF, 130 lbs. Lives alone, family checks her once daily
Erratic food/meal consumption. Likes sweets, reluctant to give up jelly, cookies, ice cream, etc.
Several UTIs recently, likely linked to untreated hyperglycemia
A1c increase 8.1% to 9.0% over past year.
Weight is stable.

67. 41 yrs. CM 268 lbs, DM2 x 5 yrs.
PMH: Disabled due to knee & hip problems. Depression. Htn.
A1c 8.4% on metformin 850 TID, glyburide 10 BID.
Returns for DM FU w/o complaints.
BS log:
AM Noon Supper Bed
New A1c 9.4%

68. Wal-Mart Discounted Meds
Metformin ER /$4 360/$10
Metformin /$4 180/$10
Pioglitazone 15, 30, 45 mg 30/$9 90/$24

69. TZDs – pioglitazone/Actos 15, 30, 45 mg
Effective A1c lowering up to 1.5%
Slow onset 4-10 weeks
ALT <3x ULN prior to use
No eGFR adjust
Edema, weight gain, heart failure, upper body fracture risk (women), macular edema, ? Bladder cancer
WEEKLY weights to monitor
Avoid the 45 mg dose with insulin

70. 55 yrs. AAF 147 lbs., Strong FH DM2, new onset hyperglycemia sx.
Office chemistry BS 247 random, fasting 143 in past week.
Follows a low sugar/low fat diet
Walks 3-4 days/week for at least 45 min.

71. 62 yrs. CM 220 lbs., DM 2 x 8 yrs.
Recently had 2 cardiac stents, hx CAD in past
Taking metformin 1000 BID
A1c is 7.6% MPG Office fasting is 143.
States home sugars usually s range premeal.

72. LOW RISK for HYPO Metformin
GLP-1 drugs: Ozempic, Victoza, Trulicity, etc
SGLT-2 drugs: Jardiance, etc
TZD drug: Pioglitazone/Actos

73. Hyperglycemia—Be Ready to Respond

74. Managing Insulin & Non-insulin Medications for DM, case-based practice
Mary E. Steward, APRN-CNP, CDE Assistant Professor, Internal Medicine OU School of Community Medicine - Tulsa