Insulin

Question 1

When should insulin be considered?

Answer 1

• Initially when A1C > 10%
• Fasting glucose > 300 mg/dL
• After maxing out oral meds
• Symptoms of hyperglycemia
• Pregnancy

**Consider insulin early!!

Question 2

In what order are types of insulin usually initially ordered? When are they administered?

Answer 2

• Basal or NPH in the evening—then—
• Meal-time insulin with the biggest meal
  (Stop SU when initiating mealtime insulin)

Question 3

What are the pro’s and con’s of insulin?

Answer 3

Pro’s:
- long history of use
- decreased vascular events
- decreased BG levels

Con’s:
- weight gain
- hypoglycemia

Question 4

How much basal insulin should be ordered when initiating it?

Answer 4

10 units
—OR—
0.1 - 0.2 units/kg

Question 5

How often and in what increments should basal insulin be increased until the patient’s AM FBG is reached?

Answer 5

Frequency: around every 2-3 days

Increments:
2 - 4 units
—OR—
10% - 15% of current doses

Question 6

What actions should be taken if a DM patient whose basal insulin dose is being adjusted experiences hypoglycemia?

Answer 6

• Determine and address the cause
• Decrease basal dose by:
  
  • 4 units
    —OR—
  • 10% - 20% of present dose

Question 7

How much rapid insulin should be ordered when initiating mealtime insulin?

Answer 7

4 units
—OR—
0.1 units/kg
—OR—
10% basal dose

Question 8

How often and in what increments should rapid, meal-time insulin be increased until SMBG goal is reached?

Answer 8

Frequency: around every 2-3 days/week

Increments:
1 - 2 units
—OR—
10% - 15% of current dose

Question 9

What should be done if a DM patient who is taking basal and rapid, mealtime insulin experiences hypoglycemia?

Answer 9

Decrease basal or rapid insulin by:

2 - 4 units
—OR—
10% - 20% of present dose

Question 10

What is the next step when BG/A1C goals are not met by a patient on PO diabetic meds, as well as basal insulin and rapid insulin before the largest meal of the day?

Answer 10

Add 2 rapid insulin injections before meals (aka “basal-bolus”)

Question 11

How much insulin should be ordered when additional mealtime doses of rapid insulin are started or adjusted for a DM patient with unmet BG/A1C goals who is already on PO diabetes meds, basal insulin, and rapid insulin before the largest meal of the day? How should hypoglycemia be treated for this patient after rapid mealtime doses have been added?

Answer 11

Start at:
4 units
—OR—
0.1 units/kg
—OR—
10% basal dose

Adjust every 2-3 days/week at:
-increase by 1-2 units
—OR—
-increase by 10% - 15%

For hypoglycemia, decrease basal or rapid dose by:
2 - 4 units
—OR—
10% - 20%