This document provides information on different types of insulin, including their onset, peak times and durations of action. It discusses using rapid-acting insulin to mimic the first phase insulin response and long-acting insulin to mimic the second phase. Formulas for calculating total daily insulin doses for patients with type 2 diabetes are presented. The importance of titrating insulin doses daily based on blood glucose results is emphasized to maintain good glucose control without hypoglycemia for hospitalized patients.

1. Ellen Coonerty, RN, BSN, BA, CDE
Clinical Diabetes Nurse Specialist
In-Patient Diabetes Team: MSKCC – Main Campus
August 14, 2013

3. Healthy Insulin Profile
Phase 1 and Phase 2 Insulin Response
People without diabetes – typical insulin profile
8 am 12 noon 6 pm 10 pm

4. 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

5. 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

6. 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.

7. Pharmacokinetics of Insulin Preparations
Short acting Analog
Regular
8 AM 6 PMN 10 PM
InsulinEffect
6-23
8 AM
NPH
Glargine
Detemir

8. 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

9. In the APACHE II trial . . .
“even a
single episode of severe hypoglycemia
conferred an increased risk of mortality.”

10. Hypoglycemia Order Set on CIS
Every time you order insulin …
order the Hypoglycemia Order Set

11. 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

12. 
What are BG goals for MSKCC non-critical hospitalized
patient?
FBG: 90 to 150 mg/dl
ac and HS: 90 to 180 mg/dl


13. 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

14. Did you know that there are only 2
doses of Insulin????
Enough
and
Not Enough

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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.