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Greg Cook, MD Endocrinology Fellow Slide 2 Objectives Become familiar with different types of insulin and their actions Understand how various insulin regimens compare and contrast with endogenous insulin production Become comfortable initiating and managing insulin in the outpatient setting Learn basics of inpatient insulin therapy Learn how to use insulin to help address hyperglycemia caused by glucocorticoids or enteral nutrition Slide 3 Case I 45 yo man with 12 year history of DM type II presents for initial visit to outpatient clinic. He is currently on metformin 1 gram BID and glipizide 10mg BID. He monitors his glucoses infrequently and reports fasting values of 200-250. His mother recently died from diabetic complications, and he is very concerned about developing similar problems himself. Exam: Wt 242 lb (110 kg), BP is controlled Obese, +acanthosis nigricans on neck Labs: Serum glucose 286, Cr 1.3, Hgb A1c 9.6 In addition to encouraging dietary and lifestyle changes, how would you manage his diabetes? Slide 4 Acanthosis Nigricans Derm Atlas www. dermatlas.med.jhmi.edu Slide 5 Types of Insulin Onset (h)Peak (h)Effective Duration (h) Rapid Acting Insulin lispro (Humalog) Inpatient Management of Diabetes Basal insulin: 0.2-0.4 units/kg in 2 divided doses for NPH. Glargine can be given in AM or bedtime Prandial Insulin: MCV meals contain 60 g of CHO Use rule of 500 to calculate, or can start with between 4 (CHO 1:15) to 6 (CHO ratio of 1:10) units AC meals Correction Dose: Would at least provide correction for glucoses >300 Aspart 6 units for glucoses >300 is reasonable for most patients Use rule of 1500 to adjust. For example, if correction factor is 1:20 and glucose is 350, with target glucose of 150, the difference is 200. 200/20 = 10 units. 10 units of Aspart should lower glucose of 350 to 150 range Slide 31 Case IV Total Daily Dose (TDD) : 0.6 units/kg = 0.6 x 102 = 60 Units Basal Insulin: 50% of TDD = 30 units or 0.3 units/kg x 102 = 30 NPH 15 units AM and HS Glargine 30 units Prandial Insulin: A. 50 % of TDD = 30 units Aspart 10 units AC meals B. Rule of 500 = 500/60 = 8.33. For 60g CHO/meal. 60/8.3 =7 Aspart 7 units AC meals Correction Dose: A. Aspart 6 units prn for glucose > 300. B. Rule of 1500: 1500/60 = 25. 1 U of insulin lowers glucose by 25 Slide 32 Case IV Correction Dose Glucose InsulinGlucoseInsulin < 70Assess patient, treat