Endocrine - Online MedEd - Insulin management Flashcards
Always basal insulin… as you eat 3 meals… what happens to glucose
Glucose levels rise with meals
Will have post-prandial insulin spikes!
Causes glucose to be controlled
Type 2 diabetes pancreas burns out… called
insulin insensitivity
If to replace insulin… the same physiology would occur
what is the best strategy?
Basal bolus
- Basal - long acting insulin given at night
- Bolus - a rapid acting insulin given in the day with meals
What are the different insulin types? Will be using trade names and generic names
1) Long acting insulins: lantus, lever (L’s)
2) Rapid acting (bolus): novo, huma - novolog and humalog
3) Mixed (70-30, 50-50), these are a mix of long acting and short acting insulin: novolin, humalin
4) NPH
Long-acting insulins
Basal coverage
Lantemir, lantus
Rapid-acting insulins
Novolog, humalog
Mixed insulins
Novolin, humalin - mix of NPH and regular insulin
NPH - long acting, BID
Regular insulin - rapid, really long half life
When to pick NPH and regular
Cheap
Pick novolin and humalin mixes?
Easy to use
But not great
Best regimen of insulin is basal-bolus
Lantus/lentemir once a day and novolog/humalog with meals
So when you have decided to go with insulin what is the first drug/dose? This is in the clinic setting.
Long-acting insulin 0.1 unit/kg –> start once daily ingestion –> check sugar before breakfast –> titrate based on fasting glucose in morning –> continue to increase basal until AM sugar is normal
Up to 15 units
*Eventually will get to a basal bolus strategy
Let’s say you have started insulin and a long-acting insulin titration… what to do next?
Measure A1C goal
Not at goal… start a second insulin at the biggest meal time
What does the basal-bolus regimen look like?
Breakfast - bolus –> steps are: check glucose, give insulin, then eat (If do not eat, then don’t give insulin –> will cause hypoglycaemia)
Lunch - bolus - same steps repeat for each meal time
Dinner - bolus
Bedtime - long-acting
*Glucose at current meal time is dependent on how much glucose eaten in previous meal and how much insulin given in previous meal (so always remember PREVIOUS!)
Ex. AM check titrates the long-acting bedtime glucose/insulin
If glucose at lunch is high, adjust insulin at breakfast
*4 glucose checks; use 2 types of insulins
Other options of insulin regimens are:
Easy way:
Give a combination of long and short BID
- BID mixed
- Ideal for patients who are unwilling to check sugars frequently
- But glucose control not as great! Not as physiologic
Sliding scale insulin in hospital is considered the wrong way
Check sugar and give insulin based on sugar right now!
But this is wrong… but sugar now is based on insulin previously!
What happens is that you get swings of up and down… you are being reactive not proactive
Hospital want to do what regimen…
Basal bolus + supplemental sliding scale
-Supplemental: at am, at bedtime, and q4h if npo
In the hospital… how would you pick the insulin…
Basal bolus regimen –> Total daily insulin: Either 0.5 units/kg or 0.3 units/kg
Total daily insulin will be divided up:
50% into basal, 50% into bolus, bolus is divided into 3 meals
Mixed bolus regimen –> Total daily insulin will be 2/3 AM and 1/3 PM
So at the end of the day* tally up how much extra insulin needed on insulin sliding scale
Then add it to the total daily insulin the same ratio –> 50/50 for example**That way you increase insulin control until glucose is under control
Types of insulin management regimens
1) Basal bolus - best
2) Mixed - okay
3) Sliding scale - on its own - do not use
4) Okay to use sliding scale in addition to other regimens in the hospital. Allows you to identify how much insulin they need and add it to current regimen
