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Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
Insulin mgt
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Insulin mgt

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  • 1. Ellen Coonerty, RN, BSN, BA, CDE Clinical Diabetes Nurse Specialist In-Patient Diabetes Team: MSKCC – Main Campus August 14, 2013
  • 2. Healthy Insulin Profile Phase 1 and Phase 2 Insulin Response People without diabetes – typical insulin profile 8 am 12 noon 6 pm 10 pm
  • 3. Rapid - Fast Acting Insulins: Designed to mimic 1st phase insulin response– BOLUS Bolus insulin is also called ‘Nutritional or Prandial Insulin’ Name Onset Peak Duration Novolog Aspart 5-15 min 60 to 120 min 3-5 hrs Humalog Lispro 5-15 min 60-90 min 3-4 hrs Apidra Glulisine 5-15 min 60 to 90 min 3-4 hrs Regular (R) *Use for IV insulin use, TPN, Continuous Tube Feeds 30-60 min 2-4 hrs 6-8 hrs
  • 4. Intermediate Insulin Can be used as a Basal Insulin … “N” (NPH) insulin can last anywhere from 12-14-16-24 hours duration NPH and Prednisone and Methylprednisolone go perfectly together! Name Onset Peak Duration Novolin N No longer called NPH insulin 1 - 2 hrs 6 – 10 hrs 12 - 16 -20 hrs
  • 5. Long-Lasting Insulin Designed to mimic 2nd phase insulin response - BASAL Name Onset Peak Duration Lantus (Glargine) AACE, ADA, ACE: Lantus does not cause cancer! 1-2 hrs No Peak Reaches steady state ~ 6 hours 20-24 hrs Levemir (Detemir) 1-2 hrs Dose- dependent Dosing needs to be 0.3 to 0.4 units/kg/day to reach 24 hours duration. * Maximum effect of dose is within the first 12 hours of use.
  • 6. Pharmacokinetics of Insulin Preparations Short acting Analog Regular 8 AM 6 PMN 10 PM InsulinEffect 6-23 8 AM NPH Glargine Detemir
  • 7. Outcome/Goal: Maintain good to optimal glucose control throughout the hospitalization period without causing hypoglycemia Titrate DAILY Don’t do nothing … Inertia breeds inertia! Treat Hyperglycemia using pt. history, patient condition, calculations, and BG results Korytkowski, Mary MD Professor of Medicine, University of Pittsburgh School of Medicine 3-2011
  • 8. In the APACHE II trial . . . “even a single episode of severe hypoglycemia conferred an increased risk of mortality.”
  • 9. Hypoglycemia Order Set on CIS Every time you order insulin … order the Hypoglycemia Order Set
  • 10. Obtain patient weight in kg  T2DM: Calculate Total Daily Dose (TDD) as 0.2 to 0.5 units per kg/day (0.4 is this CDE’s safety #) *WILL NEED MORE INSULIN IF TAKING STEROIDS WILL NEED LESS INSULIN IF TYPE 1DIABETES  Choose the dosing schedule Give 50% of TDD as Basal Insulin Give 50% of TDD as Bolus Insulin (premeal or nutritional) and divide by 3 – for 3 meals  Adjust according to results of BGM Adjust dose for NPO status or changes in clinical status Korytkowski, Mary MD Professor of Medicine, University of Pittsburgh School of Medicine 3-2011
  • 11.  What are BG goals for MSKCC non-critical hospitalized patient? FBG: 90 to 150 mg/dl ac and HS: 90 to 180 mg/dl 
  • 12. John: T2DM x 5 years. Wgt = 150 Kg. BMI 42.00 Takes 3 oral diabetes meds at home. HBA1c = 9.4 % . Admitted to MSKCC for newly Dx Prostate Cancer  First, D/C all oral diabetes medication  Pt. with uncontrolled diabetes  Pt. is overweight – high BMI = Insulin Resistance  WGT = 150 Kg. Pt is naive to insulin.  150 Kg x 0.05 units/Kg = 75 units (TDD- Total Daily Dose)  Divide TDD by 2 for Basal/Bolus = 37 Basal and 37 Bolus  Divide the Bolus of 37 units by 3 meals = 12.3 units  Calculation = 37 units Lantus at HS  Target BG = 100 to 149 mg/dL
  • 13. Did you know that there are only 2 doses of Insulin???? Enough and Not Enough
  • 14. Let’s think … Insulin naïve – feels like a high dose – maybe scale back a little – make sure pt is eating! BG mg/dL Breakfast Novolog Lunch Novolog Dinner Novolog HS Novolog HS (9-10 PM) Lantus 70-99 8 8 8 0 (37?) 30 100-149 (12?)10 10 10 0 150 - 199 12 12 12 0 200-249 etc 14 14 0 250-299 16 16 0 300-349 18 18 0 350-399 20 20 0 > 400 mg/dL 22 22 0
  • 15. Patty: Age= 56. T2DM x 15 years. WGT= 122 Kg. Colon Cancer. Home insulin regimen= Lantus 80 units at HS. Takes 25 units Novolog before BKFT and Lunch, and 30 units ac Dinner. HBA1c = 10.3%. CURRENT INSULIN REGIMEN Breakfast Lunch Dinner Bedtime BG Level Lantus 40 units Novolog Novolog Novolog 70-99 12 12 12 100-149 14 14 14 150-199 16 16 16 200-249 18 18 18 250-299 20 20 20 300-349 22 22 22 350-399 24 24 24  400 26 26 26 BLOOD-GLUCOSE RESULTS Date Before Breakfast Before Lunch Before Dinner Before Bedtime How much is too much insulin???? 265 (20) 279 (20) 276 (20) 310 (L=40) 302 210 258 233 288 224 301 277
  • 16. Edward: 45 yrs old; T2DM x 10 yrs; Wgt = 100 Kg; BMI=35; PMHx- HTN, hyperlipids, pancreatitis. Admitted with newly Dx CLL. Induction chemotherapy. DECADRON 40 MG X 5 DAYS CURRENT INSULIN REGIMEN Breakfast Lunch Dinner Bedtime BG Level Novolog Novolog Novolog Lantus 10 units 70-99 0 0 0 100-149 2 2 2 150-199 4 4 4 200-249 6 6 6 250-299 8 8 8 300-349 10 10 10 350-399 12 12 12  400 14 14 14 BLOOD-GLUCOSE Results Date Before Breakfast Before Lunch Before Dinner Bedtime 10 PM 5-31-13 321 (10) 345 (10) 401 (14) 10 6-1-13 369 289 444 6-2-13 398 275 320
  • 17. Thomas: Type 2 DM x 8 years. Age-72; HBA1c – 7.3%. WGT – 74 Kg. Admitted with SOB 2/2 lung mass upper R lobe. No steroids yet. Lives alone. Eating. CURRENT INSULIN REGIMEN BG Level Breakfast Lunch Dinner Bedtime Novolog Novolog Novolog Lantus 10 units 70-99 0 0 0 100-149 0 0 0 150-199 4 4 4 200-249 6 6 6 250-299 8 8 8 300-349 10 10 10 350-399 12 12 12  400 14 14 14 BLOOD GLUCOSE LEVELS Date Before Breakfast Before Lunch Before Dinner Bedtime 10 P Lantus 10 units 6-14-13 133 (0) 204 (6) 177 (4) 181 (10) 6-15-13 151 189 153 142 6-17-13 154 161 189 191
  • 18. Steroid-Induced Hyperglycemia Think … Insulin … Insulin, …Insulin David Baldwin, MD – Endocrinologist at Rush Institute in Chicago Managing Hyperglycemia in Special Situations: What are the Pitfalls of QAM Prednisone? 1. Prednisone only raises the blood glucose for ~ 18 hours (in system about 36-48 hrs) 2. Generally sulfonylureas or metformin will have no effect on steroid-exacerbated hyperglycemia • Lantus (Glargine) will usually outlast QAM prednisone and so BG in the PM may be ok … but fasting BG in the AM will be hypoglycemic ______________________________________________________________________ Managing Hyperglycemia in Special Situations: Best Solution to the Pitfalls of QAM Prednisone • The Pharmacokinetic profiles of: QAM prednisone and QAM NPH insulin are very similar. • Therefore the safest and most efficacious therapy for hyperglycemia in patients treated with QAM prednisone is NPH and rapid-acting analog QAM and rapid- acting analog QPM • Avoid Lantus (Glargine) or sulfonylureas
  • 19. Jeff: 59 years; lung cancer. SOB. Wgt 96 Kg. T2DM: Takes Metformin and Glimepiride at home. HBA1c = 8.8 %. BGs running in 230+ . Ordered Prednisone 20 mg BID. (The same rules would apply for Methylprednisolone) BG mg/dL Breakfast NPH (2/3 and 1/3) Breakfast Novolog Lunch Novolog Dinner Novolog HS NPH 70-99 20 8 8 10 100-149 10 10 10 150 - 199 12 12 200-249 14 250-299 16 300-349 18 350-399 20 > 400 22
  • 20. A few hints:  Know your target and work daily to get there!  Titrate Insulin Daily  If pt. on insulin at home – order ½ their doses to start and titrate daily.  Routine insulin calculation: 0.04 to 0.05 units/Kg/day  Steroids: 0.07 units/Kg/day  Renal Failure: 0.3 units/Kg/day  Type 1 Diabetes or Pump: 0.1 or 0.15 or 0.2 (Call endocrine)  If YOU are not comfortable with the dose, go lower !  Please keep re-assessing your pt. Keep in mind the pt. condition, eating status, NPO, BG targets, titrate daily.

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