internal medicine resident’s fundamentals of medicine lecture series managing diabetes mellitus in...
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Internal Medicine Resident’s Fundamentals of Medicine Lecture Series
Managing Diabetes Mellitus in Hospitalized Patients
Steven Ing, MD MSCEDivision of Endocrinology, Diabetes and Metabolism
7/26/2010
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Some Factors Destabilizing Glucose Control during Hospitalization
Stress of illness, surgeryGlucocorticoid therapyIV dextrose, TPNDecreased physical activityStopping DM medications
Decreased caloric intakeContinued sulfonylureaInappropriate “sliding scale” insulin“Tight” control
Glucose ↑ ↓ Glucose
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Nuts & Bolts: 10 Ten List
1. Diet-controlled T2DM2. T2DM: what to do with oral DM meds3. What are the Glycemic Targets in Hospitalized
Patients?4. When to Consider IV Insulin Therapy5. How to Calculate an Initial Basal Insulin Dose
(and transitioning from IV insulin)
6. How to Manage Basal Insulin Dosing in Patients Already on Insulin
7. How to Calculate an Initial Prandial Insulin Dose8. How to Individualize the Premeal “Correction
Dose”9. When and Which Diabetes Consultant 10. Discharge Orders
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1. Diet-controlled T2DM
• Who have minor surgery, imaging, procedure, or non-critical acute illness that is expected to be short-lived– will not usually need specific anti-hyperglycemic
therapy• Monitor glucose to detect serious
hyperglycemia (e.g. steroids in COPD exacerbation)
• Insulin therapy should be instituted if the preprandial blood glucose concentration >200 mg/dL
• Inform patient that insulin may not be necessary after the episode is over
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2. T2DM: What to do with oral meds• Sulfonylureas
– glipizide (Glucotrol)– glyburide (Diabeta, Micronase, Glynase PresTab)– glimepiride (Amaryl)
• Meglitinides – repaglinide (Prandin)– netaglinide (Starlix)
• Biguanide– metformin (Glucophage, Glucophage XR, Fortamet, Glumetza,
Riomet)– Metaglip, Glucovance
• Thiazoladinediones– rosiglitazone (Avandia): Avandaryl, Avandamet– pioglitazone (Actos): Duetact, Actoplus Met
• Alpha-glucosidase inhibitors– acarbose (Precose)– miglitol (Glyset)
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• Contraindicated if hemodynamic status or renal function is impaired or threatened– Acute cardiac or pulmonary decompensation – Surgery (with potential compromise of circulation) – Acute renal failure– IV iodinated contrast studies (with potential for
contrast-induced ARF)– Dehydration– Sepsis
• Should be held at least temporarily in most hospitalized acutely ill patient until renal function and circulation can be established, e.g. 48 hours after IV contrast
Metformin
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Thiazoladinedione (TZD)
• Associated with edema, fluid retention– Contraindicated in advanced heart failure (NYH
class III, IV)– If there is question of ventricular dysfunction
during hospitalization, hold TZD until the situation is clarified
– Since the anti-hyperglycemic effect extends for several weeks after discontinuation, temporary interruption should have little effect on glucose lowering effect
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Sulfonylureas
• Associated with hypoglycemia that may be severe and prolonged
• Changes in renal function may increase the risk for hypoglycemia (decreased clearance)
• Consider discontinuation during the hospitalization in the patient with erratic meal schedules and missed meals to lower the likelihood of hypoglycemia
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Meglitinides
– repaglinide (Prandin)– netaglinide (Starlix)– Non-sulfonylurea insulin secretagogues– Prandial administration– Shorter duration of action – Theoretical advantage in hospitalized
patients, but should also be used cautiously
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Newer Diabetic Meds• exenatide (Byetta)
– GLP-1 analog – ↑ insulin, ↓ gastric emptying, ↓ appetite, ↓ glucagon– Nonformulary, SQ injection– Hold as inpatient
• sitagliptan (Januvia) – DPP4 inhibitor, oral– OK to continue except in ARF– Janumet = Januvia + metformin– Saxagliptan (Onglyza)
• pramlintide (Symlin)– Amylin analog – ↓ gastric emptying, ↓ appetite, ↓ glucagon– Nonformulary, SQ injection– Hold as inpatient
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3. What are the Glycemic Targets in Hospitalized Patients?
AACE Guidelines• ICU: 140-180 mg/dL • Noncritical care:
< 140 mg/dl preprandial< 180 mg/dL postprandial
• Values > 180 mg/dL indicate need to monitor glucose levels more frequently to determine the direction of any glucose trend and the need for more intensive intervention
American Association of Clinical Endocrinologists. Available at:
http://www.aace.com/pub/ICC/inpatientStatement.php.
OSUICU: 110-150Noncritical care: 110-180
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Insulin Therapy in Managing Hospitalized Persons With Diabetes
• Intravenous insulin– continuous variable-rate infusion– regular insulin
• Subcutaneous Insulin– basal/bolus therapy– long-acting and rapid-acting insulin
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4. When to Consider IV Insulin Therapy
• Diabetic ketoacidosis (DKA)• Hyperglycemia hyperosmolar state (HHS)• Critical care illness • Myocardial infarction (MI) or cardiogenic shock• Postoperative period following heart surgery• Labor and delivery• NPO status in Type 1 diabetes• General pre-, intra-, and postoperative care• Organ transplantation• Total parenteral nutrition• Exacerbated hyperglycemia during high-dose glucocorticoid
therapy• Dose-determining strategy prior to initiation of subcutaneous
insulin
American Association of Clinical Endocrinologists. Available at:http://www.aace.com/pub/ICC/inpatientStatement.php.
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IV Insulin Protocol
• When to initiate: – consider initiating if 3 consecutive accuchecks or
blood glucose values > 200 mg/dL and if NPO >24 hours
• Insulin solution: – regular insulin 100 units in 100 ml of 0.9% saline– piggy-backed with D5W– If initial glucose > 250 mg/dl: start D5W @ 25
ml/hr and increase to 100 ml/hr after glucose drops below 250 mg/dl.
– If initial glucose < 250 mg/dl: start D5W @ 100 ml/hr
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IV Insulin Protocol
• OSU target glucose range: 110 -150• Assessment:
– Serum or capillary glucose q1 hour– May transition to q 2 hours if glucose
values are within goal range x 3 consecutive measurements
– Convert back to q1 hour for major change in clinical condition or with any measurement out of goal range
• For patient who is eating, provide prandial rapid-acting insulin
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IV Insulin Protocol
• STEP 1: Consider consulting the Diabetes Team 292-3800• STEP 2: Patient must receive dextrose CONTINUOUSLY
during insulin infusion • STEP 3: Measure the patient's serum or capillary glucose
q1 hour.• STEP 4: Initiate insulin infusion at 2 units/hr• STEP 5: Monitor glucose and adjust the insulin infusion
rate as directed in following table • STEP 6: Frequency of glucose checks can be reduced to
q2 hours. Convert back to q1 hour for major change in clinical condition or with any measurement out of goal range
• STEP 7: Rate of decline of glucose should not be > 100 mg/dl/hour
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Insulin Drip Guideline
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OSU IV Insulin Protocol: Doctor-initiated and Nurse-driven
Current Glucose
Δ in Glucose from Prior Measure
Decreased by≥ 50 mg/dl
Change <50 mg/dl (↑ or ↓) Increased by ≥50 mg/dl
400 mg/dl Contact the Prescriber
301-400 mg/dl
↑ infusion rate by 2 units/hr ↑ infusion rate by 2-4 units/hr ↑ infusion to 2x current rate
201-300 mg/dl
↑infusion rate by 1 unit/hr ↑ infusion rate by 1-2 units/hr ↑ infusion rate by 1-3 units/hr
151-200 mg/dl
No Change ↑ infusion rate by 0-1 units/hr ↑ infusion rate by 1-2 units/hr
110-150 mg/dl
↓infusion rate by 2units/hr [minimum rate=0.5-1unit/hr]
If blood glucose is increasing then ↑ infusion rate by 0-1 units/hr.
If blood glucose is decreasing then ↓ infusion rate by 0-2 units/hr
[minimum rate=0.5 unit/hour]
↑ infusion by 0-1 units/hr
65-109 mg/dl Stop infusion of insulin and contact the Prescriber
If rate is < 3 units/hr, ↓infusion by 1-2 units/hrIf infusion stopped, contact the Prescriber
If rate 3-7 units/hr ↓ by 1-3 units/hr.If rate >7 units/hr ↓ rate by ≤50%
[minimum rate=0.5-1 unit/hr]
No Change
< 65 mg/dl
Stop infusion of insulin and contact the PrescriberDouble current infusion rate of dextrose solution. If not receiving dextrose IV infusion, start D5W at 50 ml/hr.
Consider giving 12.5g D50% x 1 (1/2 ampule). Recheck glucose in 15 minutes. When glucose > 150mg/dl, reduce the dextrose infusion back to previous rate
and resume drip at 0.5-1unit/hr. Resume drip protocol
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1. If patient is eating on IV insulin, cover mealtime carbohydrates
• On order set for CHO:insulin ratio, delete the correction factor
2.When transitioning off IV to basal insulin, overlap by 6 hours
• E.g. 9 PM give lantus, 3AM stop insulin drip
• Lantus typically but not necessarily at HS
3.Lowering insulin rate @ 0/hr ≠ stop insulin protocol
IV Insulin: Miscellaneous
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Take 80% of insulin drip rate in fasting patient with stable glucose
e.g. IV insulin rate @ 2 units/hr for past 8 hours
2 Units/hr x 24 hr x 0.8 = 38 Units glargine
5. How to Calculate an Initial Basal Insulin Dose: Converting from insulin drip
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Example: IV to SQ Insulin
Time Gluc U/hr11:20 342 2
12:30 298 23
13:30 288 3
14:30 279 3
15:30 244 34
16:30 219 45
17:30 155 54
18:30 138 43
19:30 161 3
20:30 196 34
22:00 173 43
Time Gluc U/hr00:00 114 32
01:00 130 2
02:00 97 21
03:00 96 1
04:00 97 1
05:00 155 13
06:30 189 34
07:30 145 41
08:30 144 1
09:30 179 2
10:30 272 24
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Insulin Glargine
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6. How to Manage Basal Insulin Dosing in Patients Already on Insulin
• Patients already on basal insulin, continue some basal insulin
• Food intake is diminished or stopped completely,– if glucose is well controlled in hospital, continue Rx– If hyperglycemic, can increase basal– if you suspect patient is on too much basal and too little
bolus, decrease lantus 20%, decrease NPH 50%
• NPO for test/procedure– Decrease prior PM glargine, detemir or NPH by 20%– Decrease AM NPH by 50%– After test/procedure, resume usual evening if eating
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6. How to Manage Basal Insulin Dosing in Patients Already on Insulin (cont’d)
• Insulin requirements often higher due to illness: infection, MI, steroids
• Consider IV insulin, until glucose reasonably stable– If basal insulin requirement was high (e.g. 100 U/day),
IV insulin rate should be higher (e.g. 5 U/hr)• Adjust basal insulin (often upwards) based on prior
day’s glucose data• Basal insulin requirement changes with improvement
of stress state, caloric intake, steroid dose, etc.
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7. How to Calculate an Initial Bolus Insulin Dose
1. Prandial dose • Insulin:carbohydrate ratio
– E.g. 1:15 = 1 unit lispro per 15 gm carbs, or 1:10, 1:20, etc.– Pro: flexible– Con: requires carbohydrate counting and calculation
• Fixed dose insulin– E.g. 5 units each meal– Ideally accompanied by fixed carbs each meal
(essentially same as insulin:carb ratio)
2. Correction factor– needed for either method– corrects for current glucose level, i.e. “Sliding Scale”
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10 Carbs(grams) = 1 unit insulin
Std: 10 Carbs(grams) = 1 unit insulinLow: 20 Carbs(grams) = 1 unit insulinHigh: 5 Carbs(grams) = 1 unit insulin
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“Sliding Scale” Insulin Alone Is Discouraged (in insulin-requiring diabetic)
• “Sliding Scale” is considered anti-intellectual
• Sliding scale only without basal insulin results in high rates of hyperglycemia, hypoglycemia, or iatrogenic diabetic ketoacidosis in hospitalized patients with T1DM
American Association of Clinical Endocrinologists. Available at:http://www.aace.com/pub/ICC/inpatientStatement.php.
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Carbohydrate Counting
• Grams of carbohydrates are listed on the menu tray ticket
• PCA/Nurse– calculate total carbs eaten – calculates prandial insulin dose– determines correction factor insulin dose– gives insulin as soon as possible post-meal
• At home patients take insulin pre-meal
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8. How to Individualize a Premeal “Correction Factor”?
Premeal BG Additional
Insulin
150-199 1 unit
200-249
2 units
250-299 3 units
300-349 4 units
>349 5 units
“Standard Dose” Algorithm Individualized Dose Algorithm
Premeal BG Additional Insulin
150-199 ___ units
200-249 ___ units
250-299 ___ units
300-349 ___ units
> 349 ___ units
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Must document against all occurrences regardless of whether product given or not given.
Insulin I:Cho+Cfact Lispro Sub Q Qachs
Nursing Documentation
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2) In “VS/Lab info” document grams of carbs eaten and premeal glucose e.g. 30:151
Cho(grams): B.S.(mg/dl)I:Cho(unit)+Cfact(Unit)
Insulin I:Cho+Cfact Lispro Sub Q Qachs 1) Document administration time/date
3) In “Rate/Dose” document units given for carb intake and units given per Correction factor. e.g. 3+1
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Insulin I:Cho+Cfact Lispro Sub Q Qachs Insulin I:Cho+Cfact Lispro Sub Q Qachs Insulin I:Cho+Cfact Lispro Sub Q Qachs
RN # 1 (user id = RNCHEM) documents administration 3+1 = units given for I:Cho and Correction factor30:151 = Cho (grams) and B.S. (mg/dl)Select F12 Save
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Cho(grams): B.S.(mg/dl)Ins:Cho(unit)+Cfactor(Unit)
Document actual Admin Tm/Dt blood sugar checked• In VS/Lab info document Cho intake in grams and Correction factor (Blood Glucose in mg/dl) i.e. 0:100• In Rate/Dose document units given per I:Cho intake and units given per Correction factor. i.e. 0+0•Select F5 Not Admin
Insulin I:Cho+Cfact Lispro Sub Q Qachs
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* Indicates Not Admin0+0 = units given for I:Cho and Cfactor0:100 = Cho (grams) and Cfactor (mg/dl)Select F12 Save
Insulin I:Cho+Cfact Lispro Sub Q Qachs
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Adjusting Insulin Doses
Breakfast Lunch Dinner Bedtime
Date BS
(mg/dl)
Carbs
(g)
Insulin
(Units)
BS
(mg/dl)
Carbs
(g)
Insulin
(Units)
BS
(mg/dl)
Carbs
(g)
Insulin
(Units)
BS
(mg/dl)
Carbs
(g)
Insulin
(Units)
7/22
7/23
7/24
Organize data into table: glucose, carbs, insulin by meal each day
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9. When and Which Diabetes Consult?
1. Staff Nurse– Review insulin self-administration: syringe and pen devices– Provide basic survival skills: video, written materials– Review DM regimen and insulins– CAPI: #15 Patient Care Teaching/Educate Self Injections or
Diabetic Teaching (enter specific info into comments field, e.g. “video/book review”
2. Nutritionist:– Provide carbohydrate counting education– Review ADA diet– CAPI: #13 Anc Services
3. Diabetes Clinical Nurse Specialist (C.N.S.)– Complex patient– Newly diagnosed diabetic– Needle phobia– Insulin pump– Review blood glucose monitoring technique– CAPI: #13 Anc Services
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INSULIN PENS Quick, Discreet, and
Convenient
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10. Discharge Orders: Basics• Insulin plus Supplies
• Ketostix• BD Ultra-Fine Insulin Syringes
size: 1 ml (100 units), 0.5 ml (50 units), 0.3 ml (30 units)100-count box, refills x ___
• BD Ultra-Fine Syringe Needles, 31 gauge x 5/16” (8 mm), 100-count box, refills x ___
• Pen insulin: 1 box of 5 cartridges (300 ml per cartridge)• BD Ultra-Fine Pen Needles, 100-count box, refills x ___
– 31 gauge x 5/16” (8 mm) - short– 31 gauge x 3/16” (5mm) - mini
• Glucometer• Lancets: BD Ultra-Fine Lancets, 33 gauge, 100-count box, refills x ___• Test strips for glucometer: sig, #, refills
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Diabetes Med Set: ease of use for DI
At discharge generate prescription/med list
Select “Add/Modify Discharge Meds”
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Diabetes Med Set: Ease of Use at Discharge
Select “New Med”
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Diabetes Med Set: Ease of Use at Discharge
Select “Med Sets”
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Diabetes Med Set: Ease of Use at Discharge
Select “Diabetes: Insulin And Supplies”
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Diabetes Med Set: Ease of Use at Discharge
You may select specific dosing of “Insulin Products” without Sliding Scales Here.
Page down for more options!
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Diabetes Med Set: Ease of Use at Discharge
You may select “Insulin Products” with “STD”, “HI”, or “LO” Sliding Scales Here.
You can choose just CF or CF with Carb Counting (I:CHO) based on patient needs.
Page down for more options!
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Diabetes Med Set: Ease of Use at Discharge
You may select patient “Diabetic Supplies” for Insulin Administration at home.
Page down for more options!
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Diabetes Med Set: Ease of Use at Discharge
Be sure to take advantage of the “DIABETES MED SET”
Saves time
Provides instructions to transition diabetic care to home
Customize the basal insulin, prandial insulin, and diabetic supplies that are specific to your patient
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Insulin Cost10 ml Vial 5 Pens (1500ml)
Lantus $114.99 $237.99
Levemir $132.99 $231.99
Humalog $122.99 $245.99
Novolog $132.99 $259.99
Humulin R $54.99 NA
Novolin R $62.99 $107.99
Humalog 75/25 $122.99 $245.99
Novolog 70/30 $132.99 $245.99
Humulin 70/30 $54.99 $172.99
Novolin 70/30 $62.99 $93.98
Syringe (10) $3.39 NA
Pen Tips (100) NA $38.99
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Glucometer Strip Cost
Pharmacy FreeStyle Lite 50 Count
FreeStyle Lite Promise Program
True Track
50 Count
CVS $67.99 $42.99 $31.99
Walgreen’s $69.99 $44.99 $31.99
CostCo $63.09 $38.09 $34.00Discount Drug Mart $59.99 $34.99 $29.99
Kroger $62.99 $37.99 $31.59
Target $59.99 $34.99 $$26.49
Giant Eagle $62.99 $37.99 $31.59
Wal-Mart $57.99 $32.99 $26.22
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Freestyle Lite Promise Program
• For extra $5 the patient can accurately dose their insulin
• Never need to code strips (wastes a strip)• Receive other perks:
– Free Batteries– Free Meter Upgrades– Free Access to Certified Diabetes Educators– Patient Education Materials– Insurance Help Line– Meter Tech Support
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Conclusion: Some Recommendations • Don’t be afraid of IV insulin
• Provide basal insulin (glargine, detemir, or NPH)
• Provide bolus insulin (rapid acting insulin) based on – carbohydrate intake (prandial dose)– premeal glucose (correction factor)
• Individualized dietary management
– fixed insulin (fixed carbs) vs. insulin:carb ratio
• Involve: Staff Nurse, Nutritionist, Diabetes CNS
• Schedule procedures and surgery in early AM
–insulin and food can simply be shifted later in the day
• Use the Med Sets
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END
???
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Management with Subcutaneous Insulin
Basal/Bolus Concept
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InsulinInsulin(µU/mL)(µU/mL)
GlucoseGlucose(mg/dL)(mg/dL)
Physiologic Insulin Secretion
24-Hour Profile
150150
100100
5050
0077 88 99 1010 1111 1212 11 22 33 44 55 66 77 88 99
A.M.A.M. P.M.P.M.
Basal GlucoseBasal Glucose
Time of DayTime of Day
5050
2525
00 Basal InsulinBasal Insulin
Breakfast Lunch DinnerBreakfast Lunch Dinner
Bolus Insulin
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Basal Insulins
Insulin Onset of Action Peak Action
Duration of Action
NPH
Formulary
1-2 hours 4-8 hours 10-20 hours
glargine (Lantus)
Formulary
1-2 hours Flat ~ 24 hours
detemir (Levemir)
Formulary 7/07
? Flat ~ 14 hours
Lente
Ultralente
2-4 hours Unpredictable 16-20 hours
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Bolus InsulinsInsulin Onset of Action Peak Action Duration of Action
Regular
Short-acting
Formulary - vial
30-60 minutes 2-4 hours 6-10 hours
lispro (Humalog)
Rapid-acting
Formulary - pen
5-15 minutes 1-2 hours 4-6 hours
aspart (Novolog)
Rapid-acting
Formulary - pen
5-15 minutes 1-2 hours 4-6 hours
glulisine (Apidra)
Rapid-acting
Nonformulary
5-15 minutes 1-2 hours 4-6 hours
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NPH/regular 70/30 Nonformulary
50/50 Nonformulary
NPH/lispro 75/25 Nonformulary
NPH/aspart 70/30 Formulary
Premixed Insulins
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Twice-daily Split-mixed Regimens
Regular
NPH
B SL HS
Insu
lin E
ffec
t
B
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Multiple Daily Injections:NPH + Regular
Regular NPH
NPH at breakfast and HS + Regular breakfast and dinner
NPH at HS + Regular qAC
Insu
lin
Eff
ect
B SL HS B
Insu
lin
Eff
ect
B SL HS B
Regular NPH
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Multiple Daily Injections:NPH + Lispro
NPH at breakfast and HS + Regular breakfast and dinner
NPH at HS + Lispro qAC
Insu
lin
Eff
ect
B SL HS B
Insu
lin
Eff
ect
B SL HS B
LisproNPH
LisproNPH
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Pros:Pros:• Postprandial control at each mealPostprandial control at each meal• Improve fasting glucoseImprove fasting glucose• Provides basal coverage Provides basal coverage
throughout the daythroughout the day
Cons:Cons:• Inconvenient, multiple dosingInconvenient, multiple dosing• Cannot mix glargine (or Cannot mix glargine (or
detemir) with other type of detemir) with other type of insulininsulin
B B LL SS HsHs BBMealsMeals
GlargineGlargineInsulin EffectInsulin Effect
Multiple Daily Injections:Glargine + Premeal Rapid Acting Insulin
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Locating “ADM 72 HOUR FAST”Order Set in CAPI
1. After selecting a patient from any service go to ordering screen above.
2. Select Order Sets button.
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Locating “ADM 72 HOUR FAST”Order Set in CAPI
1. If patient is on a service other than Diabetes…..
2. Select another service….
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Locating “ADM 72 HOUR FAST”Order Set in CAPI
1. Select Diabetes Service …..
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Locating “ADM 72 HOUR FAST”Order Set in CAPI
1. Select “ADM 72 Hour Fast” Order Set …..