Van Bockern - Inpatient DM Flashcards
when should a1c be checked (2)
bg > 140 (w.o dm dx)
not done in prev 3 mo
bg target for most pt’s
140-180:
premeal < 140
random < 180
preferred IP insulin regimens
basal-bolus
basal-prandial-correction if pt is eating
what type of insulin is rarely used in IP setting
prandial
most important thing to avoid w. DM in hospital setting
hypoglycemia
underdosing is much better than overdosing
what should you do if a pt becomes hypoglycemic
change orders
always have hypoglycemia orders in place
4 conditions that increase risk for hypoglycemia
renal insufficiency
liver dz
altered nutrition
hx severe hypoglycemia
what do you need to do if you make a pt npo
change insulin orders
2 meds that increase risk for hypoglycemia
sulfonylureas
insulin
what med should you never prescribe to a pt w. underlying renal dz
sulfonylureas
3 rf for hypoglycemia in the hospital setting
changes in renal fxn
changes in meds
changes in nutrition/npo
3 options for hypoglycemia tx
oral glucose - juice
IVD50W
IM/SC glucagon
when would glucagon be given for hypoglycemia
no IV access
most hypoglycemic pt’s respond to __
oral glucose
basal-bolus insulin regimen includes what 2 types of insulin
basal - long acting
bolus - rapid acting
sliding scale insulin regimen includes what type of insulin
rapid acting only -> correction/sliding scale
basal-bolus insulin ex
lantus 10 u hs
PLUS
lispro 3 u q AC
PLUS
lispro correction scale q AC
insulin dosing is meant to mimic
non DM physiologic insulin
3 rapid acting insulins
aspart
lispro
glulisine
2 basal insulins
glargine
detemir
5 steps in insulin dosing
- know your pt - ex. renal dz?
- calculate total daily dose (tdd)
- dose basal insulin (50% of tdd)
- dose bolus insulin (50% of tdd)
- ongoing adjustment
when should insulin be evaluated/adjusted
every day
7 factors you must know about pt before dosing insulin
a1c
type 1 vs type 2
home meds
bmi
renal fxn
liver fxn
estimated insulin sensitivity
indications for insulin-resistant/medium insulin dosing (4)
t2dm
bmi 24-30
steroids
home tdd 40-80 u/day
indications for extra-resistant/high insulin dosing (3)
t2dm
bmi > 30
home tdd > 80
tdd low - high
low: 0.3-0.5 u/kg/day
med: 0.5-1.0 u/kg/day
high: 1.0 u/kg/day
30 y/o M, T2DM being admitted for PNA. His home meds include Metformin, Glimepiride, and Januvia. His wt is 100kg (BMI 30). His CMP is normal. A1c 9.0
how do you figure out his insulin dosing
calculate basal insulin
adjust w. SSI
why do you d.c metformin in IP setting (2)
AKI
lactic acidosis s.e
why do you d.c glyburide in IP setting
risk of hypoglycemia
30 y/o M, T2DM being admitted for PNA. His home meds include Metformin, Glimepiride, and Januvia. His wt is 100kg (BMI 30). His CMP is normal. A1c 9.0
how do you calculate his basal insulin
- insulin “resistant”/med dose -> 0.5-1.0 u/kg/day =
50-100 u/day - use 50/50 rule to figure out starting dose:
basal = 50% of tdd –> 25-50 u of glargine/day w. resistant SSI - 50 total u/day:
-25 u lantus
-25 u lispro
-divided tid
how do you figure out resistant SSI dosing
~8-17 u of lispro/meal
OR
calculate: 0.1 u/kg/meal = 10 u lispro/meal
adjust basal insulin based on __ glucose
fasting
basal insulin needs to be adjusted if bg is < __ or > __
< 80 OR > 120
50 y/o M, T2DM, wt 150kg
Home meds: glargine 50 units BID; lispro: “I dose it myself”
A1c 14.1%
what dose of glargine do you start with?
start w. 75 u daily (50% of tdd)
50 y/o M, T2DM, wt 150kg
Home meds: glargine 50 units BID; lispro: “I dose it myself”
A1c 14.1%
calculate tdd
- “extra resistant” patient –> 1.0 u/kg/day needed = 150 u/day
- basal = 50% tdd (150) –> 75% u glargine/day
target bg range for most patients on insulin and steroids
140-180
when do you need to repeat a1c for pt on insulin and steroids
a1c results < 6.5 (non DM) w.in past 3 mo
new sx dm (polyuria, polydipsia, rapid wt loss)
when should you check bg for patients on dex who do not have pre-DM or DM
qd
as long as it remains < 180
what type of insulin is preferred in pt who is also on steroids
nph bid (intermediate/long acting)
what condition do you think of when you see a hospitalized pt on steroids
covid pna
why is nph insulin better for pt on steroids
shorter duration of action -> faster dose modification
dex makes bg spike at all times of day
how do you manage insulin for pt on steroids who was previously on insulin
-increase basal insulin dose by 20% and give as nph insulin
-2/3 daily dose AM
-1/3 daily dose PM
management of rapid acting insulin for pt on steroids who was previously on insulin
- home basal insulin < 50 u: sensitive scale
- home basal insulin 50-100 u: moderate scale
- home basal insulin > 100 u: high resistance scale
management of insulin for pt on steroids who was not previously on insulin
- start w. totaly daily dose of nph insulin at 0.3 u/kg/day
- 2/3 AM
- 1/3 afternoon
- sensitive scale lispro
how do you adjust nph insulin for pt on steroids
- increase or decrease dose by 10-20% based on bg prior to next scheduled dose
ex adjust AM dose based on PM bg
Pt is a 63 year old male with pmh of Type II DM admitted for COVID PNA due to AHRF. Pt is started on Dex/RDV. Pt has not been taking insulin at home. He weighs 70kg. His blood sugar is 220.
What dose of NPH should he be started on?
70 kg x 0.3 u/kg = 21 u total
with NPH we do 2/3 AM and 1/3 PM –>
2/3 of 21 = 14u q AM
1/3 of 21 = 7u q PM
d.c consideration for inpt on dex
make take several days for insulin resistance to fall back to baseline -> make sure pt is back to baseline before d/c
up to __ of pt’s w. steroid induced hyperglycemia and no previous dx may later develop DM
1/3
most important d.c instruction for inpt DM pt
close PCP f.u 2 weeks after d.c
target bc in the hospital
140-180
the 50/50 rule is used to dose
basal bolus
