diabetes management

Types of insulin

  • short acting: regular; onset 30 min - 1 hour
  • rapid acting: NPH, lispro; onset 15 - 30 min
  • Lantus (glargine): given sometimes once and sometimes twice a day.
  • Levemir (detemir): does not last 24 hours, only lasts 12
  • NPH: 12 hours, give 2x/day
  • Humulin-R: 6 hours, give with meals, only use if can't afford others
  • U-500: 500 units of concentrated insulin, use when using more than 300 u/day. Use like humulin R but like a basal. 60% in morening, 40% at night or 40-30-30
  • 70/30: mixed
    • 70% basal (NPH), 30% short acting
    • start at 0.5/u/kg/day
    • dosed BID
    • only use if struggling with injections
    • You can convert to long acting by multiplying 70% of total 70/30
  • SSI: check glucose, then give insulin based on sugar and food given

Weight Based TDD

  • Type 1: 0.2-0.4
  • Type 2: 0.5-1.0

Outpatient Management

DM2

Goal:

  • 2 hours after meal (post prandial): 100-180
  • Fasting (FBG): 90-130

Start with metformin, then go to basal insulin (long acting), then add meal time insulin (short acting)

  1. start metformin and add oral agents
  2. start basal insulin if using 3 or more agents or if A1C > 10%. Target FBG
  3. once fasting is under controlled, recheck A1C in 3 months
    • A1C high: start meal time insulin with largest meal of day, then go up to 3x/day if needed

Meal time insulin:

  • 2 ways of calculating meal time:
    • 10% basal dose = meal time. E.g. 60 units basal insulin, 6 x 3 = 18 units / meal
    • 1/2 basal. E.g. 60 units basal, 30 units total / 3 = 10 units / meal
  • Can use GLP in place of meal time insulin

A1C to glucose conversion:

  • For each 1 point on A1C, BG goes up/down by 30
  • 8 = 180
  • 9 = 210

DM 1

  • start with basal bolus insulin
  • weight based dosing 0.2-0.4 u/kg
    • spit in 1/2
    • 50% basal
    • 50% bolus
  • count carbs
  • give pumps if uncontrolled

Inpatient management

  • Goal inpatient and ICU: 140-180
  • TF: use regular insulin q6h
  • SSI: Use correction factor TDD/1800 = how much glucose drop
    • e.g. 100/1800 = 18mg.dl drop
  • Insulin pump but not on pump: either use weight based or TDD from pump

Smogyi Effect and Dawn phenomenon

  • Smogyi effect: theory of hyperglycemia in early morning due to hypoglycemic events during late evening
  • Dawn phenomenon: morning hyperglycemia is due to the decreased levels of endogenous insulin secreted at night. Similar to Smogyi but without hypoglycemic events

charts