Diabetes lecture for residents on our inpatient service
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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!

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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  • 1. Diabetes: A survival guide Joyce Lee, MD, MPH Twitter: @joyclee http://joyceisplayingontheinter.net/ Division of Pediatric Endocrinology Child Health Evaluation Research Unit University of Michigan
  • 2. This is not medical advice for patients with diabetes; These are rules of thumb shared with residents who have the right to call the endocrinology service anytime!
  • 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. 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. Bolus Insulin •  Covers food at meals & large snacks •  Lowers a high blood sugar •  Humalog or Novolog – Type of insulin used in pump
  • 6. -Must be given at a consistent time each day -Cannot be mixed with other insulins
  • 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. 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. 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. In hospital •  30 kg x 0.5 u/kg/day=15 units/day – Half basal (Lantus) – Half bolus (Humalog/Novolog)
  • 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. 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. •  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. •  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. 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. 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. 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. 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. Things to think about when dosing insulin: – Regimen? – Ketones? – Last dose of insulin? – Last meal?
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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