Insulin Regimens for Noobs
Really brief guide on starting insulin on patients you are admitting to the hospital. Not the most exciting topic I know but hopefully there's some helpful info here or at least can start a nice discussion. Again please post any comments/suggestions/feedback if you have any and thanks :)
You probably already know most of this, but for a quick refresher:
Discontinue all outpatient anti-hyperglycemics
Metformin = risk of lactic acidosis, CHF exacerbation
Sulfonylureas = risk of hypoglycemia
TZDs = risk of CHF
GLP-1 agonists = risk of GI symptoms, pancreatitis
SGLT2 inhibitors = risk of UTI
Can consider restarting some of them if patient is eating well and preparing for discharge per the article I'm linking about halfway down the page (this isn't done much though)
• Goal blood glucose while inpatient = 140-180 mg/dL per NICE-SUGAR (2009)
Was done in ICU level patients but now kind of extrapolated to all inpatients
You should add the "endocrine" or "glycemic management" tab to your patient summary if you haven't already (if you're on Epic). Your institution should probably have something similar along these lines. It gives you a very clear look at their glucoses and number of units of insulin given during the hospitalization. Example
If fasting AM glucose is elevated, you need to increase their basal insulin. If premeal and bedtime glucose are elevated, you need to increase their mealtime insulin. Will discuss more below.
If they ARE NOT on insulin outpatient:
0.3 units/kg/day for patients who are lean, on hemodialysis, frail and elderly, insulin-sensitive, or at risk for hypoglycemia
0.4 units/kg/day for patient at normal weight
0.5 units/kg/day for overweight patients
0.6 units/kg/day for obese patients, on high-dose steroids, or insulin-resistant
These numbers typically underestimate how much the patient will need Once you have calculated the total daily insulin dose, remember to split it to 50% basal glargine at night and 50% divided up three times a day with meals. Eg, if patient needs 60 units of insulin daily, they should get 30 units glargine qhs and 10 units aspart tid ac. Basal-bolus is the way to go per RABBIT-2 (2007)
I have always felt nervous "blindly" giving diabetic patients high doses of insulin when their insulin requirement is not known, however this study is very reassuring that the risk of hypoglycemia is pretty low with these ranges.
To be fair, if they do have AKI or there is any strong worry of precipitating hypoglycemia, I would err on the side of caution and just give sliding scale insulin for the first 24 hours. Then you can calculate their total daily insulin requirement and change them to basal-bolus the following day.
If they ARE on insulin outpatient:
Usually, take 75-80% of their insulin dose and start with that while they're in the hospital
• Remember to put everyone on sliding scale insulin (sensitive, moderate, or resistant) in addition to basal-bolus
• Remember to add hypoglycemia protocol so nurses can give juices/D50/glucagon if needed for hypoglycemia
Titrating up while inpatient:
Oftentimes while your patients are admitted, you will notice their sugars consistently hanging out around the 200s or something, and you will need to adjust their total insulin dose.
If morning glucose is 180-200, increase basal dose by 10%. If 200-300, increase by 20%. If >300, increase by 30%
If premeal glucose is 180-200, increase nutritional dose by 10%. If >200, increase by 20%. >300, increase by 30%
If ALL glucose measurements are elevated, then just calculate their total daily dose and add 10-20% and split it again
• If your patient is going NPO, discontinue mealtime short-acting insulin and check blood glucose q4h. Continue their long-acting basal insulin
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