Diabetes:
A survival guide
Joyce Lee, MD, MPH
Twitter: @joyclee
Division of Pediatric Endocrinology
Child Health Evaluatio...
This is not medical advice for
patients with diabetes;
These are rules of thumb shared
with residents who are usually
taki...
Lilly Novo Nordisk Start Peak End
Humalog Novolog 10 min 1.5 hr 3 hr
Humulin N
(NPH)
Novolin N
(NPH)
1.5 hr 4-6 hr 12 hr
H...
Basal Insulin
•  Controls blood sugar between meals and
overnight
•  Beginning Dose: 50% of Total Daily
Dose (TDD) of all ...
Bolus Insulin
•  Covers food at meals & large snacks
•  Lowers a high blood sugar
•  Humalog or Novolog
– Type of insulin ...
-Must be given at a consistent time each day
-Cannot be mixed with other insulins
We used to manage diabetes like this:
Breakfast Lunch Supper BT snack
7 Novolog 13 NPH pre breakfast
5 Novolog dinner
5 NP...
Now we use Basal/Bolus “Flex” regimens
Breakfast Lunch Supper BT snack
-10 U Lantus at bedtime; Novolog before meals
-Pump...
New onset diabetes:
Generally start with a total daily dose
of 0.5 U/kg/day and bump it down or
up based on clinical prese...
In hospital
•  30 kg x 0.5 u/kg/day=15 units/day
– Half basal (Lantus)
– Half bolus (Humalog/Novolog)
Lantus and Novolog/Humalog
(Basal/Bolus “Flex” regimens)
•  50% TDD=Lantus
•  50% TDD=Novolog/Humalog
– Carb ratio “500 ru...
Lantus and Novolog/Humalog
(Basal/Bolus “Flex” regimens)
•  Lantus=7.5 units (Pump 0.3 units/hr)
•  Humalog
– Carb ratio 5...
•  Regimen is:
– 7.5 U Lantus; Carb ratio 1:30;
Correction ratio 1:120
•  BS was 240 pre lunch
•  Child plans to eat 60 gm...
•  Regimen is:
– 7.5 U Lantus; Carb ratio 1:30;
Correction ratio 1:120
•  BS was 240 pre lunch
•  Child plans to eat 60 gm...
Regimen: 7.5 U Lantus; Carb ratio 1:30;
Correction ratio 1:120
Carbs (g) Insulin (u) BS range Insulin (u)
30 gm +1 121-240...
Regimen: 7.5 U Lantus; Carb ratio 1:30;
Correction ratio 1:120
2AM Bef bk Bef lun Bef din qhs
105 280 210 180 160
Lantus d...
Regimen: 7.5 U Lantus; Carb ratio 1:30;
Correction ratio 1:120
2AM Bef bk Bef lun Bef din qhs
105 110 320 180 160
High BS ...
Pearls
•  Patients must always get their Lantus!
•  Avoid dextrose in IVF for diabetics
–  Exception: Aggressive insulin t...
Things to think about when dosing
insulin:
– Regimen?
– Ketones?
– Last dose of insulin?
– Last meal?
What dose of insulin do you give to your 8
yo patient with T1D with BS 480 at bedtime?
– Regimen? 7.5 L, 1:30, 1:120
– Ket...
What dose of insulin do you give to your 8
yo patient with T1D with BS 480 at bedtime?
– Regimen? 7.5 L, 1:30, 1:120
– Ket...
What dose of insulin do you give to your 8
yo patient with T1D with BS 480 at bedtime?
– Regimen? 7.5 L, 1:30, 1:120
– Ket...
What dose of insulin do you give to your 8
yo patient with T1D with BS 480 at bedtime?
– Regimen? 7.5 L, 1:30, 1:120
– Ket...
What dose of insulin do you give to your 8
yo patient with T1D with BS 480 at
bedtime?
– Regimen? 7.5 L, 1:30, 1:120
– Ket...
What dose of insulin do you give to your 8
yo patient with T1D with BS 480 at
bedtime?
– Regimen? 7.5 L, 1:30, 1:120
– Ket...
What dose of insulin do you give to your 8
yo patient with T1D with BS 480 at bedtime?
– Regimen? 7.5 L, 1:30, 1:120
– Ket...
What dose of insulin do you give to your 8
yo patient with T1D with BS 480 at bedtime?
– Regimen? 7.5 L, 1:30, 1:120
– Ket...
What dose of insulin do you give to your 8
yo patient with T1D with BS 120 at bedtime?
– Regimen? 7.5 L, 1:30, 1:120
– Ket...
What dose of insulin do you give to your 8
yo patient with T1D with BS 120 at bedtime?
– Regimen? 7.5 L, 1:30, 1:120
– Ket...
What dose of insulin do you give to your 8
yo patient with T1D with BS 120 at bedtime?
– Regimen? 7.5 L, 1:30, 1:120
– Ket...
What dose of insulin do you give to your 8
yo patient with T1D with BS 120 at bedtime?
– Regimen? 7.5 L, 1:30, 1:120
– Ket...
Your 8 yo pt with T1D has a BS of 120 and
is
NPO for an Abd US in the AM.
Insulin? IVF?
– Regimen? 7.5 L, 1:30, 1:120
– Ke...
Your 8 yo pt with T1D has a BS of 120 and
is
NPO for an Abd US in the AM.
Insulin? IVF?
– Regimen? 7.5 L, 1:30, 1:120
– Ke...
Pearls
•  Patients must always get their Lantus!
•  Avoid dextrose in IVF for diabetics
–  Exception: Aggressive insulin t...
Pearls
•  Hyperglycemia
–  hyperglycemia + mod/lg ketones-> give insulin
–  hyperglycemia + tr/sm ketones-> change
doses f...
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Diabetes lecture for residents on our inpatient service

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This is not medical advice for patients with diabetes; these are rules of thumb shared with inpatient residents who have the right to call the endocrinology service at anytime!

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Diabetes lecture for residents on our inpatient service

  1. 1. Diabetes: A survival guide Joyce Lee, MD, MPH Twitter: @joyclee Division of Pediatric Endocrinology Child Health Evaluation Research Unit University of Michigan
  2. 2. This is not medical advice for patients with diabetes; These are rules of thumb shared with residents who are usually taking care of new onset patients who have the right to call the endocrinology service anytime!
  3. 3. Lilly Novo Nordisk Start Peak End Humalog Novolog 10 min 1.5 hr 3 hr Humulin N (NPH) Novolin N (NPH) 1.5 hr 4-6 hr 12 hr Humulin R (Regular) Novolin R (Regular) 20 min 3-4 hr 6 hr Humalog Mix 70/30 Novolog Mix 70/30 70% NPH +30% Novolog Humulin Mix 70/30 Novolin Mix 70/30 70% NPH +30% Regular Lantus 1 hr - 24 hr The suffix hints at the onset and duration of action
  4. 4. Basal Insulin •  Controls blood sugar between meals and overnight •  Beginning Dose: 50% of Total Daily Dose (TDD) of all insulins •  e.g. TDD = 15 units, ~7.5 Lantus or 0.3U/hr on insulin pump
  5. 5. Bolus Insulin •  Covers food at meals & large snacks •  Lowers a high blood sugar •  Humalog or Novolog – Type of insulin used in pump
  6. 6. -Must be given at a consistent time each day -Cannot be mixed with other insulins
  7. 7. We used to manage diabetes like this: Breakfast Lunch Supper BT snack 7 Novolog 13 NPH pre breakfast 5 Novolog dinner 5 NPH bedtime
  8. 8. Now we use Basal/Bolus “Flex” regimens Breakfast Lunch Supper BT snack -10 U Lantus at bedtime; Novolog before meals -Pump (Basal rate 0.4 units/hr x 24 hr); Novolog before meals (only Novolog in the pump)
  9. 9. New onset diabetes: Generally start with a total daily dose of 0.5 U/kg/day and bump it down or up based on clinical presentation 0.5 U/kg/d0.3 0.7 Younger Older No ketones DKA
  10. 10. In hospital •  30 kg x 0.5 u/kg/day=15 units/day – Half basal (Lantus) – Half bolus (Humalog/Novolog)
  11. 11. Lantus and Novolog/Humalog (Basal/Bolus “Flex” regimens) •  50% TDD=Lantus •  50% TDD=Novolog/Humalog – Carb ratio “500 rule” • 500/TDD – Correction factor “1800 rule” • 1800/TDD
  12. 12. Lantus and Novolog/Humalog (Basal/Bolus “Flex” regimens) •  Lantus=7.5 units (Pump 0.3 units/hr) •  Humalog – Carb ratio 500/15=33 -> • 1 unit insulin: 30 gm CHO – Correction 1800/15=120 -> • 1 unit insulin to drop BS by 120 pts (correct to 120)
  13. 13. •  Regimen is: – 7.5 U Lantus; Carb ratio 1:30; Correction ratio 1:120 •  BS was 240 pre lunch •  Child plans to eat 60 gm carb You are on call, how much insulin do you give to your patient?
  14. 14. •  Regimen is: – 7.5 U Lantus; Carb ratio 1:30; Correction ratio 1:120 •  BS was 240 pre lunch •  Child plans to eat 60 gm carb You are on call, how much insulin do you give to your patient? 2 for Carbs, 1 for correction=3
  15. 15. Regimen: 7.5 U Lantus; Carb ratio 1:30; Correction ratio 1:120 Carbs (g) Insulin (u) BS range Insulin (u) 30 gm +1 121-240 +1 60 gm +2 241-360 +2 90 gm +3 361-480 +3 120 gm +4 481-600 +4
  16. 16. Regimen: 7.5 U Lantus; Carb ratio 1:30; Correction ratio 1:120 2AM Bef bk Bef lun Bef din qhs 105 280 210 180 160 Lantus dose affects AM BS (bump up Lantus to make AM BS better for next day?)
  17. 17. Regimen: 7.5 U Lantus; Carb ratio 1:30; Correction ratio 1:120 2AM Bef bk Bef lun Bef din qhs 105 110 320 180 160 High BS may require increases in insulin at the previous meal (consider changing carb ratio to 1:25)
  18. 18. Pearls •  Patients must always get their Lantus! •  Avoid dextrose in IVF for diabetics –  Exception: Aggressive insulin tx with hypo/ normoglycemia (SQ, Insulin Drip) •  Mod/large ketones=insulin deficiency –  Mod/large ketones-give extra insulin –  Small/trace ketones-drink more water •  In the hospital hypoglycemia is worse than hyperglycemia –  As long as there are no ketones
  19. 19. Things to think about when dosing insulin: – Regimen? – Ketones? – Last dose of insulin? – Last meal?
  20. 20. What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? Large – Last dose of insulin? 3U Novolog at dinner – Last meal? Dinner (5 PM)
  21. 21. What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? Large – Last dose of insulin? 3U Novolog at dinner – Last meal? Dinner (5 PM) Large ketones: 2x correction dose or 20%TDD Moderate ketones: 1.5 x correction dose or 10%TDD 6 units Novolog + Lantus
  22. 22. What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? Trace-small – Last dose of insulin? 3U Novolog at dinner – Last meal? Dinner (5 PM)
  23. 23. What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? Trace-small – Last dose of insulin? 3U Novolog at dinner – Last meal? Dinner (5 PM) Consider half or no insulin correction dose at bedtime; no correction at 2 AM Give Lantus!
  24. 24. What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? Moderate – Last dose of insulin? Novolog 4U 1hr ago – Last meal? Dinner (5 PM)
  25. 25. What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? Moderate – Last dose of insulin? Novolog 4U 1hr ago – Last meal? Dinner (5 PM)Reassess for ketones 3 hours after last insulin dose No Novolog yet (just got some 1 hr ago!) Give Lantus
  26. 26. What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? Moderate – Last dose of insulin? Lantus qhs – Last meal? Dinner (5 PM)
  27. 27. What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? Moderate – Last dose of insulin? Lantus qhs – Last meal? Dinner (5 PM) Large ketones: 2x correction dose or 20%TDD Moderate ketones: 1.5 x correction dose or 10%TDD Try 4.5 units Novolog. Check for ketones q3 hrs.
  28. 28. What dose of insulin do you give to your 8 yo patient with T1D with BS 120 at bedtime? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? Trace-small – Last dose of insulin? 3U Novolog at dinner – Last meal? Dinner (5 PM)
  29. 29. What dose of insulin do you give to your 8 yo patient with T1D with BS 120 at bedtime? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? Trace-small – Last dose of insulin? 3U Novolog at dinner – Last meal? Dinner (5 PM) Give Lantus
  30. 30. What dose of insulin do you give to your 8 yo patient with T1D with BS 120 at bedtime? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? Large – Last dose of insulin? 3U Novolog at dinner – Last meal? Dinner (5 PM)
  31. 31. What dose of insulin do you give to your 8 yo patient with T1D with BS 120 at bedtime? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? Large – Last dose of insulin? 3U Novolog at dinner – Last meal? Dinner (5 PM) Large ketones: 2x correction dose or 20%TDD Moderate ketones: 1.5 x correction dose or 10%TDD 6U Novolog. Give glucose through IV or make pt eat something. Check BS q 2 O/N. Give Lantus!
  32. 32. Your 8 yo pt with T1D has a BS of 120 and is NPO for an Abd US in the AM. Insulin? IVF? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? none – Last dose of insulin? 3 at dinnertime
  33. 33. Your 8 yo pt with T1D has a BS of 120 and is NPO for an Abd US in the AM. Insulin? IVF? – Regimen? 7.5 L, 1:30, 1:120 – Ketones? none – Last dose of insulin? 3 at dinnertime Pts always need their Lantus, even if NPO! Give Lantus, no dextrose in IVF
  34. 34. Pearls •  Patients must always get their Lantus! •  Avoid dextrose in IVF for diabetics –  Exception: Aggressive insulin tx with hypo/ normoglycemia (SQ, Insulin Drip) •  Mod/large ketones=insulin deficiency –  Mod/large ketones-give extra insulin –  Small/trace ketones-drink more water •  In the hospital hypoglycemia is worse than hyperglycemia –  As long as there are no ketones
  35. 35. Pearls •  Hyperglycemia –  hyperglycemia + mod/lg ketones-> give insulin –  hyperglycemia + tr/sm ketones-> change doses for next day •  Hypoglycemia –  hypoglycemia + mod/lg ketones-> give insulin and dextrose (IV, juice) –  hypoglycemia + tr/sm ketones-> change doses for next day
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