This preparation is made to explain drawbacks of sliding scale insulin therapy and explain pharmacological properties of various types of Insulin

1. Insulin Therapy
In Hospital Settings
By Dr Raj Thorat
HAL Hospital,Ojhar
11/09/2012

2. A Natural Hormone,produced by Beta cells of
Pancreas,
{unlike OHA’s which are chemicals n synthetic in
nature (may damage liver n kidney) }
A Natural Hormone,produced by Beta cells of
Pancreas,
{unlike OHA’s which are chemicals n synthetic in
nature (may damage liver n kidney) }
What is Insulin?

3. Insulin
The King of Diabetes Treatment
Insulin
The King of Diabetes Treatment

4. Discovery of Insulin
• Dr. Frederick Banting
(right) and Dr. Charles
Best(left)
• Nobel Prize in 1923

5. First Clinical Use of insulin
• Leonard Thompson
• In 1922 January 11

7. Summary of Bioavailability of
Insulin
Summary of Bioavailability of
Insulin
Type Of Insulin Onset Peak Duration
Rapidly Acting
(Lispro,Aspart,
Glulisine)
5- 15 mins 1-1.5 hrs 3-4 hrs
Short Acting
(Regular)
30-60 mins 2 hrs 6-8 hrs
Intermediate
Acting (NPH)
2-4 hrs 6-7 hrs 10-20 hrs
Long Acting
(Glargine)
(Detemir)
1.5 hrs
1 hr
Flat
Flat
Approx 24 hrs
17 hrs

9. Human Regular Insulin
(Actrapid Human Insulin)
Human Regular Insulin
(Actrapid Human Insulin)
• Short Acting,Soluble,Crystalline Zinc Insulin
• Insulin Recommended for Intravenous Use in
Emergencies like Diabetic Ketoacidosis
• Quaternary Hexamer Structure  Dissolution 
Monomer  Absorption
• Lag Phase 30 mins before entering circulation
after S/C Injection

10. Biostatistics of Regular InsulinBiostatistics of Regular Insulin
Type Of Insulin Onset Peak Duration
Short
Acting
(Regular)
30-60
mins
2-3 hrs 6-8 hrs

11. BSL Management for Indoor
Patients with Regular Insulin
BSL Management for Indoor
Patients with Regular Insulin
• (What are we Doing) : -
• Sliding Scale
RBSL 6-8 hrly,Regular Insulin according to BSL
VIZ. RBSL <200 mg%.... NO Insulin
200-250 4 Units
250-300 6 units
300-350 8 units
……….and so on
• (What are we Doing) : -
• Sliding Scale
RBSL 6-8 hrly,Regular Insulin according to BSL
VIZ. RBSL <200 mg%.... NO Insulin
200-250 4 Units
250-300 6 units
300-350 8 units
……….and so on

12. DrawbacksDrawbacks
• Pre-Prandial Hypoglycaemia
• Post-Prandial Hyperglycaemia
• -------------------------------------------------------------
• WHY?
• Rbsl and Insulin Injections given irrespective
of Meal Timings of Patients

13. Examples(RBSL Charts of Indoor patients
on Insulin)
Examples(RBSL Charts of Indoor patients
on Insulin)
Glucose
EXCURSIONS

14. Pre-meal
hypo-
Glycaemia

15. Inadequate
Insulin
doses

16. What can be Done to Avoid it?What can be Done to Avoid it?
• Monitor BSL according to Meal
Timings (Pre-meal)
• Give Insulin before Meals

17. Inj Actrapid Human
(Regular Insulin)
Inj Actrapid Human
(Regular Insulin)

18. Biostatistics of Regular InsulinBiostatistics of Regular Insulin
Type Of Insulin Onset Peak Duration
Short
Acting
(Regular)
30-60
mins
2-3 hrs 6-8 hrs

19. Blood Sugar
Level
(Regular Insulin )
Pre-Breakfast Pre-Lunch Pre-Dinner
Day I- BSL
Insulin to be
Given
Monitor BSL Before MealsMonitor BSL Before Meals

20. Blood Sugar
Level
(Regular
Insulin )
Pre-Breakfast Pre-Lunch Pre-Dinner
Day I- BSL
Insulin to be
Given
4 units 8 units 4 units
How to Titrate Insulin Doses?How to Titrate Insulin Doses?

21. Day IIDay II
Blood Sugar
Level
(Insulin to be
given)
Pre-Breakfast Pre-Lunch Pre-Dinner
Day I- BSL 299 mg % 222 mg% 333 mg%
Insulin Given 4 units 8 units 4 units
Day II- BSL 159 mg%
Insulin

22. 1 Unit of Insulin approx reduces 25 mg% of BSL in
Obese and 50 mg% BSL in thin patient
1 Unit of Insulin approx reduces 25 mg% of BSL in
Obese and 50 mg% BSL in thin patient
Blood Sugar
Level
(Insulin to be
given)
Pre-Breakfast Pre-Lunch Pre-Dinner
Day I- BSL 299 mg % 222 mg% 333 mg%
Insulin Given 4 units 8 units 4 units
Day II- BSL 159 mg%
Insulin to be
Given
6 units 12 units 6 units

23. Day IIIDay III
Blood Sugar
Level
(Insulin to be
given)
Pre-Breakfast Pre-Lunch Pre-Dinner
Day I- BSL 299 mg % 222 mg% 333 mg%
Insulin Given 4 units 8 units 4 units
Day II- BSL 159 mg% 202 mg % 244 mg%
Insulin Given 6 units 12 units 6 units
Day III-BSL 108 mg%
Insulin to be
Given

24. Increase Insulin Doses GraduallyIncrease Insulin Doses Gradually
Blood Sugar
Level
(Insulin to be
given)
Pre-Breakfast Pre-Lunch Pre-Dinner
Day I- BSL 299 mg % 222 mg% 333 mg%
Insulin Given 4 units 8 units 4 units
Day II- BSL 159 mg% 202 mg % 244 mg%
Insulin Given 6 units 12 units 6 units
Day III-BSL 108 mg%
Insulin to be
Given
10 units 14 units 6 units

25. Day IVDay IV
Blood Sugar
Level
(Insulin to be
given)
Pre-Breakfast Pre-Lunch Pre-Dinner
Day I- BSL 299 mg % 222 mg% 333 mg%
Insulin Given 4 units 8 units 4 units
Day II- BSL 159 mg% 202 mg % 244 mg%
Insulin Given 6 units 12 units 6 units
Day III-BSL 108 mg% 122 mg% 200 mg%
Insulin Given 10 units 14 units 6 units
Day IV-BSL 113 mg%

26. Target = To bring pre-meal bsl to
100-120 mg%
Target = To bring pre-meal bsl to
100-120 mg%
Blood Sugar
Level
(Insulin given)
Pre-Breakfast Pre-Lunch Pre-Dinner
Day I- BSL 299 mg % 222 mg% 333 mg%
Insulin Given 4 units 8 units 4 units
Day II- BSL 159 mg% 202 mg % 244 mg%
Insulin Given 6 units 12 units 6 units
Day III-BSL 108 mg% 122 mg% 200 mg%
Insulin Given 10 units 14 units 6 units
Day IV-BSL 113 mg%
Insulin to be
Given
10 units 16 units 6 units

27. Satisfactory BSL Control
(Time to Shift type of Insulin)
Satisfactory BSL Control
(Time to Shift type of Insulin)
Blood Sugar
Level
(Insulin given)
Pre-Breakfast Pre-Lunch Pre-Dinner
Day I- BSL 299 mg % 222 mg% 333 mg%
Insulin Given 4 units 8 units 4 units
Day II- BSL 159 mg% 202 mg % 244 mg%
Insulin Given 6 units 12 units 6 units
Day III-BSL 108 mg% 122 mg% 200 mg%
Insulin Given 10 units 14 units 6 units
Day IV-BSL 113 mg% 133 mg% 165 mg%
Insulin to be
Given
10 units 16 units 6 units

28. Shifting from Regular to Pre-
mixed(Short + Intermediate acting
Insulin)
Shifting from Regular to Pre-
mixed(Short + Intermediate acting
Insulin)
2/3rd
of Total requirement of
Insulin….Before Breakfast
1/3rd
of Total requirement of
Insulin….Before Dinner
2/3rd
of Total requirement of
Insulin….Before Breakfast
1/3rd
of Total requirement of
Insulin….Before Dinner

29. Inj Human Mixtard (30/70)-Pre Mixed
(30% regular + 70% NPH)
Dual Peak
Inj Human Mixtard (30/70)-Pre Mixed
(30% regular + 70% NPH)
Dual Peak

30. Blood Sugar
Level
(Insulin to be
given)
Pre-Breakfast 2 hours PP-
Lunch
Pre-Dinner
Day I- BSL
Insulin units ----------- units
Inj Human Mixtard (30/70)Inj Human Mixtard (30/70)

31. Earlier Patient required total 32
units of Regular Insulin
Earlier Patient required total 32
units of Regular Insulin
Blood Sugar
Level
(Insulin to be
given)
Pre-Breakfast 2 hours PP-
Lunch
Pre-Dinner
Day I- BSL
Insulin to be
given
20 units
(2/3rd
)
----------- 10 units
(1/3rd
)

32. Blood Sugar
Level
(Insulin given)
Pre-Breakfast 2 hours PP-
Lunch
Pre-Dinner
Day I- BSL 148mg% 188 mg% 165 mg%
Insulin given 20 units ----------- 10 units
Day II-BSL 138 mg%

33. Blood Sugar
Level
(Insulin given)
Pre-Breakfast 2 hours PP-
Lunch
Pre-Dinner
Day I- BSL 148mg% 188 mg% 165 mg%
Insulin given 20 units ----------- 10 units
Day II- BSL 138 mg %
Insulin to be
given
22 units 10 units

34. Blood Sugar
Level
(Insulin given)
Pre-Breakfast 2 hours PP-
Lunch
Pre-Dinner
Day I- BSL 148mg% 188 mg% 165 mg%
Insulin 20 units ----------- 10 units
Day II- BSL 138 mg % 155 mg% 118 mg%
Insulin 22 units ----------- 10 units
On Discharge advice------
Inj H.Mixtard (30/70)
20 units (BBF)……….08 Units(Before Dinner)

35. Inj Human Mixtard 30/70 (another
Example)
Inj Human Mixtard 30/70 (another
Example)
Blood Sugar
Level
(Insulin to be
given)
Pre-Breakfast 2 hours PP-
Lunch
Pre-Dinner
Day I- BSL 248mg% 228 mg% 265 mg%
Insulin to be
given
20 units ----------- 10 units

36. Blood Sugar
Level
(Insulin to be
given)
Pre-Breakfast 2 hours PP-
Lunch
Pre-Dinner
Day I- BSL 248mg% 228 mg% 265 mg%
Insulin to be
given
20 units ----------- 10 units
Day II BSL 208 mg%
Inj Human Mixtard 30/70Inj Human Mixtard 30/70

37. Inj Human Mixtard 30/70Inj Human Mixtard 30/70
Blood Sugar
Level
(Insulin given)
Pre-Breakfast 2 hours PP-
Lunch
Pre-Dinner
Day I- BSL 248mg% 228 mg% 265 mg%
Insulin given 20 units ----------- 10 units
Day II-BSL 208 mg %
Insulin to be
given
24 units ----------- 12 units

38. Blood Sugar
Level
(Insulin given)
Pre-Breakfast 2 hours PP-
Lunch
Pre-Dinner
Day I- BSL 248mg% 228 mg% 265 mg%
Insulin 20 units ----------- 10 units
Day II-BSL 208 mg % 199 mg% 128 mg %
Insulin 24 units ----------- 12 units
Day III-BSL 168 mg %
Insulin

39. Inj Human Mixtard 30/70Inj Human Mixtard 30/70
Blood Sugar
Level
(Insulin given)
Pre-Breakfast 2 hours PP-
Lunch
Pre-Dinner
Day I- BSL 248mg% 228 mg% 265 mg%
Insulin 20 units ----------- 10 units
Day II-BSL 208 mg % 199 mg% 128 mg %
Insulin 24 units ----------- 12 units
Day III-BSL 168 mg %
Insulin 26 units ----------- 14 units

40. Watch for Hypo-GlycaemiaWatch for Hypo-Glycaemia
Blood Sugar
Level
(Insulin given)
Pre-Breakfast 2 hours PP-
Lunch
Pre-Dinner
Day I- BSL 248mg% 228 mg% 265 mg%
Insulin 20 units ----------- 10 units
Day II-BSL 208 mg % 199 mg% 128 mg %
Insulin 24 units ----------- 12 units
Day III-BSL 168 mg % 145 mg % 78 mg%
Insulin 26 units ----------- 14 units
Day IV-BSL 79 mg%
Insulin

41. If Bsl is < 80 mg%,reduce Insulin
by 2 unit
If Bsl is < 80 mg%,reduce Insulin
by 2 unit
Blood Sugar
Level
(Insulin given)
Pre-Breakfast 2 hours PP-
Lunch
Pre-Dinner
Day I- BSL 248mg% 228 mg% 265 mg%
Insulin 20 units ----------- 10 units
Day II-BSL 208 mg % 199 mg% 128 mg %
Insulin 24 units ----------- 12 units
Day III-BSL 168 mg % 145 mg % 78 mg%
Insulin 26 units ----------- 14 units
Day IV-BSL 79 mg%
Insulin 24 units 12 units

42. HypoglycemiaHypoglycemia
Signs
• Diaphoresis
• Altered Consiousness
• Tachycardia
• Pallor
Symptoms
• Sweating
• Palpitations
• Tremors
• Headache
• Hunger
• Behavioral Changes
• Seizure
• Coma

43. Treatment Goals for DM in Adults
(ADA Recommendations)
Treatment Goals for DM in Adults
(ADA Recommendations)

44. EducationEducation
• Motivation
• Insulin Injection Technique
• Rotation of site of Injection
• Frequent Meals and Diabetic Diet
• Symptoms of Hypoglycemia
• Self Monitoring of Blood Glucose
Doctor’s Role Patient

45. Special SituationsSpecial Situations
Pregnancy and Diabetes
• GD – Diet………..
• FBSL < 105 mg%
• RBG(most Samples)<120mg
%
• Weight Loss not
recommended
• GD – Insulin……
• FBSL upto 120 mg%
• PPBSL > 150 mg%
• Target Mean Plasma
Glucose = 100 mg% (70-
130)
• A Single NPH may Suffice

46. IDDM with PregnancyIDDM with Pregnancy
• Basal Insulin(NPH) + Pre-Meal Insulins (Short
Acting)
• Ideal Goals Of BSL…….
FBSL = 65 – 90 mg%
PPBSL = 100 – 135 mg%

47. Pregnancy and DiabetesPregnancy and Diabetes
During DeliveryDuring Delivery
• Vaginal Route Preferred till
TERM (HBA1C < 7%)
• Exceptions
-- Large Baby
--Hydramnios
--HBA1C >10%
Induce @ 37-38 weeks
During LabourDuring Labour
• Maintain BSL = 75 – 105
mg% ( To prevent
Neonatal
Hypoglycaemia)
• IV Insulin @ 2
Units/hour with 10%
Dextrose (Monitor RBSL
hrly and adjust drip
rate)

48. Surgery (Elective and Major)Surgery (Elective and Major)
• Schedule in Morning Hours
• 1/4th
total daily requirement of Insulin…S/C 1
hour prior to Anaesthesia
• After 30 mins, D 5% @ 150-200 ml/hr
• Following Induction of Anaesthesia…Insulin in NS
@ 1-2 U/hr and Maintain BSL = 140-180 mg%
• Following Surgery…150gms Glucose + 3 lit fluid
over next 24 hrs (Add KCL 10 mEq to every 1 lit D
5%)

49. Minor SurgeriesMinor Surgeries
• NIDDM on OHA’s with good BSL control(who
don’t require GA)…NO Need Of Insulin
• If Surgery is such that Oral Intake cant be
resumed from same Evening ==) Shift from
OHA to Insulin 8-10 days Prior to Sx and
control BSL
• Insulin to be continued through
Convalescence (4-5 weeks)

50. Take Home PointsTake Home Points
.Monitor BSL according to meal timings i.e.
PRE-MEALS ….Pre-BF,PRE-Lunch,Pre-
Dinner
• Ask patient to have meals after 20-30 mins of
taking Regular Insulin
• Adjust Pre-BF Insulin Doses based on Pre-
Lunch BSL
• Adjust Pre-lunch Insulin based on pre-dinner
BSL
• Adjust Pre-dinner insulin based on Pre-BF
(Fasting) BSL

51. Take Home Message
Change is the
sign of Life,
Stagnation-a sign
of Decay
And if Change is
for the
Better,Embrace
it with Open
Arms

54. Correct your sugar level…
ENJOY !!!
