1

Module 5Pharmacologic Management

of Hospital Hyperglycemia:Insulin Management Part 2

Diabetes Special Interest GroupGeorgia Hospital Association

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In this module you will practice applying principles of insulin therapy in the hospital

Learning Modules

Module no. Topic

1 Hyperglycemia and hospital outcomes

2 Challenges and opportunities for care improvement

3 Initial recognition, triaging, and management

4 Principles of pharmacologic management: Insulin 1

5 Principles of pharmacologic management: Insulin 2

6 Review of policies and procedures

7 Getting patient ready for discharge

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Calculate basal-bolus insulin dose in a 52 year old man with type 2 diabetes, glucose values in the 200’s, with weight of 100 kg who is eating

– First estimate total daily insulin requirements:Total daily insulin = 0.5 unit x 100 kg = 50 units

– Second, estimate basal insulin amount:Basal insulin amount = 0.5 x 50 = 25 units

– Third, estimate prandial (or bolus) insulin:Prandial insulin = (0.5 x 50)/3 = 8 units per meal

– Fourth, create a scale using a CF = 30 (next slide)

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Calculate His Corrective Insulin Program

Glucose CF = 30

70-140 Target range

141-199

200-250

251-300

301-350

351-400

(170-110)/30 = 2

(225-110)/30 = 4

(275-110)/30 = 5

(325-110)/30 = 7

(375-110)/30 = 9

5

A 65 year old 82 kg woman with metastatic breast cancer is admitted for mental status changes. She has a 10 year history of diabetes on glipizide. Her A1c is 8.3%. She is not eating and you hold her glipizide. You monitor q 6h bedside glucose. You start her on a “mild sliding scale” but after 24 h her values range from 200 to 275 mg/dL. What would you do?

A. Increase her sliding scale to “aggressive”

B. Start scheduled basal insulin with corrective insulin

C. Start a basal-prandial insulin program with corrective insulin

D. Restart glipizide

Answer: B

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• Calculate your patient’s initial insulin doses– Estimate total daily insulin

requirement:Total daily insulin = 0.5 unit x 82 kg =

41 units

– Estimate basal insulin amount:Basal insulin amount = 0.5 x 41 ~ 20

units

– Construct a corrective insulin program using a CF = 20

• You will want a lower CF– she is probably pretty insulin resistant

Glucose CF = 20

70-140 Target range

141-199

200-250

251-300

301-350

351-400

(170-110)/20 = 3

(225-110)/20 = 6

(275-110)/20 = 8

(325-110)/20 = 11

(375-110)/20 = 13

7

A 90 kg 70 year old man with advanced COPD is admitted with pneumonia and bronchospasm. He has no history of diabetes but his admission glucose is 281 mg/dL. You will have to start steroids. You check the A1c and it is 7.3%. He is eating. During the first 24 h his bedside glucose values are in the high 200’s. You decide to put him on a scheduled insulin program. Calculate the doses.

– First estimate total daily insulin requirements:Total daily insulin = 0.5 unit x 90 kg = 45 units

– Second, estimate basal insulin amount:Basal insulin amount = 0.5 x 45 ~ 22 Units

– Third, estimate meal time insulin:Prandial insulin = (0.5 x 45)/3 ~ 7 Units per meal

– Fourth, continue corrective insulin program

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You have started your 70 year old man on the scheduled insulin program, but after 24 h his glucose values are still in the 250 to 300 range. He is on Prednisone. Pseudomonas grew out of his sputum and blood. You have become reconciled to the fact that he will be with you a few more days. How much should you increase his insulin? Calculate the new doses.

Insulin regimen Old dose

units

New dose

units

Basal 22

Prandial

Breakfast 7

Lunch 7

Supper 7

29

9

9

9

Daily glucose

mg/dL

% increase total daily insulin

70 - 140 0

141 - 199 10

200 - 249 20

250 - 299 30

300 - 349 40

>350 Insulin infusion

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After another 24 h your 70 year old man’s blood glucose values are improving, but are still in the 200 to 249 range. How much would you increase his insulin? Calculate the new doses.

Insulin regimen Old dose

units

New dose

units

Basal 29

Prandial

Breakfast 9

Lunch 9

Supper 9

35

11

11

11

Daily glucose

mg/dL

% increase total daily insulin

70 - 140 0

141 - 199 10

200 - 249 20

250 - 299 30

300 - 349 40

>350 Insulin infusion

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After another 24 h your 70 year old man’s blood glucose values are now in the 160 to 190 mg/dL range. While they are now much improved, knowing the importance of good glucose in the hospital, and being the OCD person you are, you are still not happy and want to get him to a 120 to 150 mg/dL target. How much would you increase his insulin now? Calculate the new doses.

Insulin regimen Old dose

units

New dose

units

Basal 35

Prandial

Breakfast 11

Lunch 11

Supper 11

Congratulations, he is now at target.

38

12

12

12

Daily glucose

mg/dL

% increase total daily insulin

70 - 140 0

141 - 199 10

200 - 249 20

250 - 299 30

300 - 349 40

>350 Insulin infusion