Transcript Insulin: Initiation and Management

Insulin Initiation and
Management:
Lessons from my first year of Diabetes Clinic
Kena K. Desai MS, MD
Disclosures: None
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Objectives
• Learn when and how to initiate basal insulin.
• Gain comfort initiating bolus insulin and modifying
the dose.
• Review sick day management of insulin.
• Learn how to treat short term hyperglycemia.
• Learn how to treat hypoglycemia.
Our Patient
• 82 year old male, with a MHx of obesity (BMI – 38
kg/m2), past alcohol abuse, HTN, Hyperlipidemia,
BPH and DMII.
• He has had diabetes for 3 years.
• He loves to exercise, but also loves to eat and is an
excellent cook.
• He lives by himself in a retirement community (but
has numerous lady friends and a grand-daughter that
visits him frequently) .
• He is able to do all ADL, including driving.
Set a Goal
• What is his HgBA1C goal?
a. 7% or less
b. Between 7-8%
c. Between 8-9%
d. He is to old to have a goal
Set a Goal
Set a Goal
• What is his HgBA1C goal?
a. 7% or less
b. Between 7-8%
c. Between 8-9%
d. He is to old to have a goal
• He is on Pioglitazone 45 mg PO daily and Glimepiride 2 mg PO
with breakfast and dinner.
• He is not checking any finger-stick glucose levels, but denies
any symptoms of hypoglycemia.
138
HgBa1c – 7.8%
3.8
98
17
1.1
25
180
GFR = 65 ml/min
What diabetes medication is notably missing?
Metformin
Why is he not on Metformin?
a.
b.
c.
d.
Age
Renal Function
Risk of hypoglycemia
He should be on metformin.
I asked the patient.
I started Metformin ER 1000 mg PO QHS.
He returns for follow-up in 2 months later…..
• After starting metformin he had nausea, vomiting and diarrhea 4
days. Therefore he stopped all medications and felt much better.
He has not resumed any medications because he continue to feel
great!!! He has lost 10 lbs in 2 months and affirms hardy appetite,
increased urination and thirst (5L water daily).
• V/S:
37.5 C / HR – 110 / RR – 22 / BP – 160/96 / BMI – 35 kg/m2
HgBA1C – 9.2%
131
92
32
4.0
18
1.6
462
GFR = 48 ml/min
What is your assessment of the patient?
#1 – Kick myself in the butt for starting metformin.
BUT I WOULD DO IT AGAIN, AGAIN, AGAIN!!! Why?
What medication do I start now?
a) Metformin
b) Glimepiride and Pioglitazone
c) Glimepiride, Pioglitazone and Basal Insulin
d) Pioglitazone and Basal Insulin
e) Just Basal Insulin
What are the different types of basal insulin?
Formulations
Of Basal Insulin
Onset
Peak
Duration
NPH (intermediate
Acting)
2-4 h
4-10 h
10-16 h
Levemir (long
acting)
2-4 h
6-14 h
16-20 h
Glargine (long
acting)
2-4 h
Bulk peak
20-24 h
Where on the body to inject?
M W
Initiation of Basal (long-acting) Insulin
Guidelines for Weight Based Dosing:
- HgBA1c less then 9% - 0.1 units/kg
- HgBA1c greater then 9% - 0.2 units/kg
HgBA1c:
My Rule of Thumb for Basal Insulin:
Less then 9%
10 units QHS
Between 9 – 11%
15 units QHS
More then 11%
20 units QHS
Plus Bolus Insulin with 1 to 2
largest meals.
Start Conservative -> with a plan for the patient to self titrate
the dose up.
Instructions for Titrating Basal Insulin
1. Start basal insulin QHS.
2. Increase basal insulin by 2-4 units every 4 days.
- Until: Fasting am finger-stick glucose levels are stably
between 80 to 130 mg/dl (younger, healthier patients) or
100-150 mg/dl (older, sicker patients).
- Or: A dose of 40 - 60 units (or weight kg/2) has been reached.
3. Follow-up in 4 to 6 weeks.
Why is basal insulin dosed QHS? For the ease of titration based on
am fasting finger-stick glucose levels.
• The patient returns for follow-up 6 weeks later. He is taking
Lantus 40 units QHS. His fasting am fingerstick glucose values
have been in the 80-130 mg/dl range. He complains of
occasional shaking and intense hunger when he wakes up. His
glucose levels on those mornings are below 90 mg/dl.
Average
Glucose
7 days
105
14 days
145
30 days
175
What is he experiencing?
a. Hypoglycemia
b. Relative Hypoglycemia
c. Normal response to starting Insulin
What is the difference between hypoglycemia and relative
hypoglycemia?
• What should I do with the Lantus dosing?
a. Decrease the Lantus dose by 4 units
b. Change to Q am dosing
c. Stop Lantus and start Glimepiride and Pioglitazone.
d. Do nothing. The patient will gradually adjust to the normal
blood glucose levels.
What can prevent the symptoms of relative hypoglycemia?
a. Longer durations of time between increasing the dose.
b. Smaller increments of titration.
c. Both
• The patient returns for 3 month follow-up. He reports that he is
doing very well. His grand-daughter has moved in with him for the
summer and she is a wonderful baker. He has been having waffles
for breakfast and cookies for dessert. He continues to take Lantus
40 units Q am and denies any symptoms of hypoglycemia. He
continues to check fasting am finger-stick levels.
Average Glucose
7 day
232
14 day
190
30 day
165
HgBA1c – 9.4%
What medication should I start now?
a. Glyburide
b. Metformin
c. Pioglitazone
d. Meal Associated Insulin
• I selected meal associated insulin.
What is the difference between rapid acting insulin and short
acting insulin?
Onset
Peak
Duration of Action
Regular Insulin
30-60 min
2-3 h
5-8 h
Aspart (Novolog)
Lispro (Humalog)
5-15 min
30-90 min
3-5 h
What dose do I start?
When do I ask the patient to dose the insulin?
a. Before meal
b. After meal
c. During meal
Simple Carbohydrate Counting
1. Serving Size
2. Carbohydrates in grams (Google)
3. Insulin to Carb ratio
- 1 unit – 15 grams (30 g = 2 units)
- 1 unit – 10 grams (30 g = 3 units)
- 1 unit – 5 grams (30 g = 6 units)
• The patient makes an emergency follow-up appointment 2 weeks
later. He has been taking Lantus 40 units Q am but his fasting am
levels are in the 250-350 mg/dl range. He is not feeling well. He has
fevers/chills and back pain. He denies dysuria, but does affirm new
urinary incontinence. He is still able to eat and drink, but has
decreased appetite. Because he is not eating much, he has not been
taking Novolog.
11.7
14.6
142
147
38.0
4.1
102
23
38
333
1.6
UA:
Epi 3
WBC 30
Nitrite +
Leukocyte esterase +
GFR – 45 ml/min
Why are his blood glucose levels high?
Sick Day Management of Insulin
Food
Liquid
Basal
Bolus
Yes
Yes
Take at usual dose.
Take at usual dose.
Decreased
Yes
Take at usual dose.
Take at usual dose.
Consider immediately after the
meal.
No
Yes
Take at usual dose.
High FSG – low calorie
liquids w/ electrolytes, +
correction insulin.
Low FSG – liquids with
calories.
No
No
Take at usual dose.
Consider decreasing by 1020% if not tolerating foods
and liquids for > 24 hrs and
having lower glucose levels.
No Calories => No
Meal Associated
Insulin.
Rapid acting insulin may still
be needed for corrections.
• Treatment of his Hyperglycemia:
1) Treatment of the underlying inflammatory process
(urinary tract infection) -> started antibiotics.
2) Treatment of his hyperglycemia -> started a correction
factor
Follow-up in 2 week…..
- He was doing much better
- FSG levels in the 150-180 mg/dl range
- He was no longer needing correction
factor
• 6 months later….
• The patient has missed several follow-up appointment. I
receive a call from his grand-daughter reporting that he has
started to drink again. He is intoxicated 3-4x/weekly. When he
wakes up he is irritable and confused, but improves after
drinking regular coke. He is not checking BG levels, but is taking
insulin because his lady friend has been very judicious about
make sure he takes his medications.
What is he most likely experiencing?
What does alcohol due to blood glucose levels?
a. Increases them
b. Decreases them
c. Screws them up…… completely.
Hypoglycemia
Mental Status
Treatment
Normal, Functional
(50-70 mg/dl)
Oral Glucose (15 grams of carbohydrates)
- hard candy (4-6 pieces)
- glucose tabs (4 pieces)
- 4 oz of juice, regular soda, whole milk
- Simple sugar or honey
(not chocolate bars)
Changed, Functional
(40-50 mg/dl)
Oral Glucose
- 40% Glucose Gels
Changed, Not Functional
(below 40 mg/dl)
40% Glucose Gel -> anal
Glucagon
D50 – IV (EMS)
Our Patient
• Has not made it to a diabetes appointment in over 9
months. His grand-daughter has been working hard to
get him into a rehab facility. He has been evaluated in
the ED on several occasions for alcohol withdrawal,
acute kidney injury and TIA symptoms…..
What is his HgBA1c goal now?
Glycemic goals must change with the patient’s changing
clinical picture.
Objectives
• Learn when and how to initiate basal insulin.
• Gain comfort initiating bolus insulin and modifying
the dose.
• Review sick day management of insulin.
• Learn how to treat short term hyperglycemia.
• Learn how to treat hypoglycemia.
Clinical Diabetes Team
Office Phone: 907-729-1125
Email: [email protected]
Dietitian and Insulin Pump Trainer – Angela Manderfeld RD, CDE
Pharmacist and Diabetes Director – Judy Thompson PharmD, CDE
Nurse Practitioner – Ann Marie Mayer MPH, NP
Physician – Kena K. Desai MS, MD