Insulin mgt

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Insulin mgt

  1. 1. Ellen Coonerty, RN, BSN, BA, CDE Clinical Diabetes Nurse Specialist In-Patient Diabetes Team: MSKCC – Main Campus August 14, 2013
  2. 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. 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. 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. 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. 6. Pharmacokinetics of Insulin Preparations Short acting Analog Regular 8 AM 6 PMN 10 PM InsulinEffect 6-23 8 AM NPH Glargine Detemir
  7. 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. 8. In the APACHE II trial . . . “even a single episode of severe hypoglycemia conferred an increased risk of mortality.”
  9. 9. Hypoglycemia Order Set on CIS Every time you order insulin … order the Hypoglycemia Order Set
  10. 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. 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. 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. 13. Did you know that there are only 2 doses of Insulin???? Enough and Not Enough
  14. 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. 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. 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. 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. 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. 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. 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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