Inpatient Diabetes

Question 1

Dx of DM

Answer 1

-Symptomatic hyperglycemia: symptoms of hyperglycemia (weight loss, polydipsia, polyuria, blurred vision with random glucose of 200 mg/dl or higher.
-Asymptomatic: -Fasting glucose greater or equal to 126 mg/dl following no intake for 8 hours. -Two-hour plasma glucose value of greater or equal to 200 mg/dl during a 75-gram OGTT.
-Hemoglobin A1c >or equal to 6.5%

Question 2

Type 1 DM

Answer 2

-auto immune destruction of beta-cell function, leading to absolute insulin deficiency. This may also include LADA.
-Diabetic ketoacidosis(DKA)may be the initial presentation.

Question 3

Type 2 DM

Answer 3

-loss of beta cell function frequently in the setting of insulin resistance

Question 4

Patients with poor oral intake and those who are NPO

Answer 4

Basal insulin or a basal plus bolus correction insulin regimen

Question 5

Non-critically ill patients regimen

Answer 5

“An insulin regimen with basal, prandial, and correction components is the preferred treatment for non–critically ill hospitalized patients with good nutritional intake”.

Question 6

Successful transition from IV insulin to Subq

Answer 6

-Stable and eating
-using average IV insulin rate over 6–8-hour period and then administering 40-80% of the this as basal insulin.

Question 7

Intermediate-Acting insulin

Answer 7

-NPH (Humulin-N, Novolin-NPH)
-Onset: 1 to 3 hrs
-Duration: up to 18 hrs

Question 8

Rapid Acting insulin

Answer 8

-Lispro (Humalog)
-Glullsine (Apidra)
-Aspart (NovoRapid)
-Onset 10-15 min
-Duration-3-5hrs

Question 9

Slow or long-acting insulin

Answer 9

-Glargine (Lantus)
-Detemir (Levemir)
-Onset: 90 min
-Duration: up to 24 hrs

Question 10

Basal/Bolus program components

Answer 10

-Basal insulin, dosed 1-2x/day
-Rapid acting w/ meals, prandial doses
-Rapid acting for correction of hyperglycemia

Question 11

Basal insulin

Answer 11

-Glargine
-Detemir (Levemir)
-Degludec (Tresiba)
-NPH

Question 12

Prandial and Correction

Answer 12

-Rapid acting insulin
-Aspart (Fiasp, NovoLog)
-Lispro (Admelog, Lyumjev)
-Glulisine (Apidra)
-Short acting (Humulin R and Novolin R)
-Inhaled insulin (Afrezza)
-Correction scale, based on hospital protocol
-Ideally basal and bolus should be 50/50 split.

Question 13

Dosing Insulin DM1

Answer 13

-Most newly dx is 0.2-0.5U/kg/day
-many will ultimately require 0.6-0.7U/kg/day
-Basal bolus 50/50 split

Question 14

Dosing Insulin DM2

Answer 14

-0.2U/kg/day (min of 10 units, up to 15 to 20 units) daily
-50/50 split basal bolus insulin

Question 15

Early Management of DKA and HHS

Answer 15

-Metabolic profile prior to IV fluids
-1L 0.9% NaCl in 1 hr
-K level should be >3.3 before initiation of insulin-supplemental replacement
-Initiate insulin therapy once first steps met
-Change IV fluid to 0.45% NaCl when indicated

Question 16

DKA

Answer 16

-Hyperglycemia, acidosis, ketonemia.

Question 17

Hyperosmotic hyperglycemia nonketotic state (HHS)

Answer 17

-Little to no ketone accumulation
-Glucose may be above 1000 mg/dl
-Plasma osmol/kg greater than 320
-Neurologic abnormalities which may include coma

Question 18

Resolution of DKA and HHS

Answer 18

-Ketoacidosis is resolved when serum anion gap is normalized as well as beta-hydroxybutyrate (if available at facility)
-HHS when patient is mentally alert and plasma osmolality is less than 315 mOsmol/kg
-Patient able to eat

Question 19

How to transition after DKA and HHS

Answer 19

-In DKA plan to transition to basal/bolus insulin. If patient will not be eating, consider continuation of insulin infusion.
-In HHS transition to basal/bolus insulin when serum glucose falls below 250-300 mg/dl.
-DC insulin infusion 2-4 hours following administration of subcutaneous insulin. This will help avoid hyperglycemia.