Inpatient Diabetes (Final) Flashcards
When should I check an A1c?
- Hyperglycemia > 140 mg/dL without diagnosis of diabetes
- Not already checked in last 3 months
Glucose target
- Glucose target is 140-180 mg/dL for most Pts
- She recommended goal of keeping it below 200
- Also mentioned of IP settings it is safer to have the BS run high instead of low
Preferred insulin regimens in IP?
- Basal-bolus insulin is preferred treatment
- If Pt is eating, use basal-prandial-correction
- Check BS Q4
What should be done to respond to hypoglycemia
- Always have hypoglycemia orders in place
- If hypoglycemia occurs change your insulin orders
Risk factors for hypoglycemia
- Renal insufficiency
- Insulin is renally cleared
- Liver disease
- Altered nutrition
- History of severe hypoglycemia
- Sulfonylureas
- Do not give to Pts with underlying renal disease
Common things in the hospital environment that can make managing of blood sugars difficult
- Changes in Pt renal function
- Changes in Pt medications
- Changes in Pt nutritional/NPO status
Treatment for hypoglycemia
- Oral glucose
- IM/SC glucagon
- Max effect a few minutes after administration
- IV D50W
- Need IV access
- Hyperosmolar
- Tissue necrosis if infiltrated
- Some orders call for fast-acting carbohydrates if BG 50-79
- Orange juice is a popular choice
A diabetic Pt is admitted to your unit should they continue on their oral diabetes medications?
No, in most IP situations hold oral diabetes medications until Pt discharges.
What is Basal-Bolus insulin dosing?
- Basal
- Long-acting insulin
- Bolus
- Rapid-acting insulin
- Example
- Lantus 10 units QHS
- Lispro 3 units QAC
- +Lispro correction scale QAC
- Lantus 10 units QHS
What is sliding scale insulin dosing?
- NO basal insulin
- ONLY rapid-acting insulin with correction scale
- Think scale for how much insulin based on Pts BG pre-meal
- Example
- Lispro correction scale QAC
Name some common insulin medications and their length of effect
- Long-acting
- Glargine
- Detemir
- Intermediate acting
- NPH
- Short-acting
- Aspart
- Lispro
- Glulisine
Approach to dosing Basal-Bolus insulin
- Know your Pt
- A1c
- Type 1 vs 2
- Home meds
- BMI
- Renal function
- Liver function
- Estimate insulin sensitivity
- Calculate total daily dose (TDD)
- Dose basal insulin (50% TDD)
- Dose bolus insulin (50% TDD)
- Ongoing adjustment
What factors may help you determine that a Pt has insulin resistances requiring a medium total daily dose of insulin?
- T2DM
- BMI 24-30
- Corticosteroids
- Home TDD 40-80 units/day
What factors may help you determine that a Pt has extra-resistant insulin resistance requiring a high total daily dose of insulin?
- T2DM
- BMI > 30
- Home TDD > 80 units/day
Total Daily Dosinfgs
- Low dose
- 0.3-0.5 units/kg/day
- Medium dose
- 0.5-1.0 units/kg/day
- High dose
- 1.0 units/kg/day
30 y/o M, T2DM being admitted for PNA. His home meds include Metformin, Glimepiride, and Januvia. His wt is 100kg (BMI 32). His CMP is normal. A1c 9.0
What should you order for his DM IP?
- A. Continue his home meds Metformin, Glyburide, and Januvia
- B. Order SSI
- C. Calculate his basal insulin and adjust with SSI
- D. Hold everything he is being admitted for PNA, who cares about his DM
- C. Calculate his basal insulin and adjust with SSI
- “resistant”
- Use medium-dose since he is young, don’t want to cause hypoglycemia
- TDD calculation would give 0.5-1.0 units/kg/day
- 50-100 units/day
- “resistant”
30 y/o M, T2DM being admitted for PNA. His home meds include Metformin, Glimepiride, and Januvia. His wt is 100kg (BMI 32). His CMP is normal. A1c 9.0. You choose to calculate his basal insulin (using medium dose) and adjust with sliding scale insulin (SSI), what should you start with?
- TDD = 50-100 units/day
- Basal = 50% of TDD
- 25-50 units of glargine per day
- Order:
- 25 units of Glargine with resistant SSI
- Resistant SS is different per institution but typically follows a pattern
- i.e. about 8-17 units of lispro per meal or new to insulin calculation: 0.1 units/kg/meal: gives 10 units of lispro per meal.
When should insulin be adjusted?
- Always look at glucose log daily and adjust
- Adjust basal
- Based on fasting glucose < 80 or > 120
- Adjust bolus
- Low/medium/high
- Immediate adjustment if hypoglycemic event
50 y/o M, T2DM, wt 150kg
Home meds: glargine 50 units BID; lispro: “I dose it myself”
A1c 14.1%
What does of Glargine should you start?
- a.) Let him dose himself. He knows his body best
- b.) Continue home dose of 50 units BID
- c.) Calculate TDD (~150units) so 150units QHS
- d.) Start with 75 units daily (50% of total TDD)
- d.) Start with 75 units daily (50% of total TDD)
- “Extra-resistant”
- Age
- High weight
- TDD calculation would be 1.0 units/kg/day
- 150 units/day
- Basal
- 50% of TDD
- 75 units of glargine per day
- 50% of TDD
- “Extra-resistant”
Managing hyperglycemia in Pts on steroids
- Repeat A1c in Pts who have results that are non-DM range (< 6.5%) within the past 3 months who have new symptoms of DM
- Polyuria
- polydipsia
- Rapid weight loss
- A target glucose range of 140-180 is appropriate for most Pts on insulin
- In Pts on Dex who do not have pre-DM or DM, blood glucose can be checked once daily as long as it remains < 180
Choice of antihyperglycemic agents in the setting of steroids
Insulin NPH twice daily is preferred over Glargine/Lantus as an intermediate/long-acting agent due to NPH’s shorter duration of action which allows for faster dose modification.
For Pts on steroids who were previously on Insulin, what adjustments should you make?
- Basal insulin
- Increase basal insulin dose by 20% and give as NPH insulin.
- ⅔ daily dose in the morning and ⅓ of the basal daily dose in the evening
- Meal time insulin
- Lispro
- If home basal insulin < 50 units per day, start sensitive scale
- If home basal insulin is 50-100 units per day, start moderate scale
- If home basal insulin is > 100 units per day, start high resistance scale
- Lispro
For Pts on steroids experiencing hyperglycemia who were NOT previously on insulin, what dosage should you use?
- Basal
- Start with total daily does of NPH insulin
- 0.3 units/kg/day
- Give ⅔ in the morning and ⅓ in the afternoon
- 0.3 units/kg/day
- Start with total daily does of NPH insulin
- Meal time
- Start with sensitive Lispro scale
- Want to avoid hypoglycemia!!
- Start with sensitive Lispro scale
When adjusting insulin in Pts on steroids what should you do?
- NPH
- Increase of decrease dose by 10-20% based on blood glucose prior to next scheduled dose
- ie change AM dose based on evening blood glucose
- Increase of decrease dose by 10-20% based on blood glucose prior to next scheduled dose
What happens to insulin resistance after Dexamethasone therapy is terminated?
- Insulin resistance will begin to fall after DEX is stopped but may take several days to get back to baseline
What should you consider when preparing a Pt who was on steroids for discharge?
- Up to ⅓ of Pts with steroid-induced hyperglycemia and no previous diagnosis of DM may later develop DM.
- Patients with prior history of DM should be transitioned back to their home DM medications as soon as possible.
- Close PCP follow-up ideally in 2 weeks.
