diabetes lecture for residents on our inpatient service

Diabetes: A survival guide

Joyce Lee, MD, MPH Twitter: @joyclee

http://joyceisplayingontheinter.net/ Division of Pediatric Endocrinology

Child Health Evaluation Research Unit University of Michigan

This is not medical advice for patients with diabetes;

These are rules of thumb shared with residents who have the right to call the endocrinology service

anytime!

Lilly Novo Nordisk Start Peak End

Humalog Novolog 10 min 1.5 hr 3 hr

Humulin N (NPH)

Novolin N (NPH)

1.5 hr 4-6 hr 12 hr

Humulin R (Regular)

Novolin R (Regular)

20 min 3-4 hr 6 hr

Humalog Mix 70/30

Novolog Mix 70/30

70% NPH +30% Novolog

Humulin Mix 70/30

Novolin Mix 70/30

70% NPH +30% Regular

Lantus 1 hr - 24 hr

The suffix hints at the onset and duration of action

Basal Insulin

•  Controls blood sugar between meals and overnight

•  Beginning Dose: 50% of Total Daily Dose (TDD) of all insulins

•  e.g. TDD = 15 units, ~7.5 Lantus or 0.3U/hr on insulin pump

Bolus Insulin

•  Covers food at meals & large snacks

•  Lowers a high blood sugar

•  Humalog or Novolog – Type of insulin used in pump

-Must be given at a consistent time each day -Cannot be mixed with other insulins

We used to manage diabetes like this:

Breakfast Lunch Supper BT snack

7 Novolog 13 NPH pre breakfast 5 Novolog dinner 5 NPH bedtime

Now we use Basal/Bolus “Flex” regimens

Breakfast Lunch Supper BT snack

-10 U Lantus at bedtime; Novolog before meals -Pump (Basal rate 0.4 units/hr x 24 hr); Novolog before meals (only Novolog in the pump)

New onset diabetes: Generally start with a total daily dose of 0.5 U/kg/day and bump it down or up

based on clinical presentation

0.5 U/kg/d 0.3 0.7

Younger Older No ketones DKA

In hospital

•  30 kg x 0.5 u/kg/day=15 units/day – Half basal (Lantus) – Half bolus (Humalog/Novolog)

Lantus and Novolog/Humalog (Basal/Bolus “Flex” regimens)

•  50% TDD=Lantus •  50% TDD=Novolog/Humalog

– Carb ratio “500 rule” • 500/TDD

– Correction factor “1800 rule” • 1800/TDD

Lantus and Novolog/Humalog (Basal/Bolus “Flex” regimens)

•  Lantus=7.5 units (Pump 0.3 units/hr) •  Humalog

– Carb ratio 500/15=33 -> • 1 unit insulin: 30 gm CHO

– Correction 1800/15=120 -> • 1 unit insulin to drop BS by 120 pts (correct to 120)

•  Regimen is: – 7.5 U Lantus; Carb ratio 1:30;

Correction ratio 1:120 •  BS was 240 pre lunch •  Child plans to eat 60 gm carb

You are on call, how much insulin do you give to your patient?

•  Regimen is: – 7.5 U Lantus; Carb ratio 1:30;

Correction ratio 1:120 •  BS was 240 pre lunch •  Child plans to eat 60 gm carb

You are on call, how much insulin do you give to your patient?

2 for Carbs, 1 for correction=3

Regimen: 7.5 U Lantus; Carb ratio 1:30; Correction ratio 1:120

Carbs (g) Insulin (u) BS range Insulin (u)

30 gm +1 121-240 +1

60 gm +2 241-360 +2

90 gm +3 361-480 +3

120 gm +4 481-600 +4

Regimen: 7.5 U Lantus; Carb ratio 1:30; Correction ratio 1:120

2AM Bef bk Bef lun Bef din qhs

105 280 210 180 160

Lantus dose affects AM BS (bump up Lantus to make AM BS better for next day?)

Regimen: 7.5 U Lantus; Carb ratio 1:30; Correction ratio 1:120

2AM Bef bk Bef lun Bef din qhs

105 110 320 180 160

High BS may require increases in insulin at the previous meal (consider changing carb ratio to 1:25)

Pearls •  Patients must always get their Lantus! •  Avoid dextrose in IVF for diabetics

–  Exception: Aggressive insulin tx with hypo/normoglycemia (SQ, Insulin Drip)

•  Mod/large ketones=insulin deficiency – Mod/large ketones-give extra insulin –  Small/trace ketones-drink more water

•  In the hospital hypoglycemia is worse than hyperglycemia – As long as there are no ketones

Things to think about when dosing insulin:

– Regimen? – Ketones? – Last dose of insulin? – Last meal?

What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? Large – Last dose of insulin? 3U Novolog at dinner – Last meal? Dinner (5 PM)

What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? Large – Last dose of insulin? 3U Novolog at dinner – Last meal? Dinner (5 PM)

Large ketones: 2x correction dose or 20%TDD Moderate ketones: 1.5 x correction dose or 10%TDD

6 units Novolog + Lantus

What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? Trace-small – Last dose of insulin? 3U Novolog at

dinner – Last meal? Dinner (5 PM)

What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? Trace-small – Last dose of insulin? 3U Novolog at

dinner – Last meal? Dinner (5 PM) Consider half or no insulin correction dose

at bedtime; no correction at 2 AM Give Lantus!

What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? Moderate – Last dose of insulin? Novolog 4U 1hr ago – Last meal? Dinner (5 PM)

What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? Moderate – Last dose of insulin? Novolog 4U 1hr ago – Last meal? Dinner (5 PM)

Reassess for ketones 3 hours after last insulin dose No Novolog yet (just got some 1 hr ago!)

Give Lantus

What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? Moderate – Last dose of insulin? Lantus qhs – Last meal? Dinner (5 PM)

What dose of insulin do you give to your 8 yo patient with T1D with BS 480 at bedtime?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? Moderate – Last dose of insulin? Lantus qhs – Last meal? Dinner (5 PM)

Large ketones: 2x correction dose or 20%TDD Moderate ketones: 1.5 x correction dose or 10%TDD

Try 4.5 units Novolog. Check for ketones q3 hrs.

What dose of insulin do you give to your 8 yo patient with T1D with BS 120 at bedtime?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? Trace-small – Last dose of insulin? 3U Novolog at

dinner – Last meal? Dinner (5 PM)

What dose of insulin do you give to your 8 yo patient with T1D with BS 120 at bedtime?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? Trace-small – Last dose of insulin? 3U Novolog at

dinner – Last meal? Dinner (5 PM)

Give Lantus

What dose of insulin do you give to your 8 yo patient with T1D with BS 120 at bedtime?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? Large – Last dose of insulin? 3U Novolog at

dinner – Last meal? Dinner (5 PM)

What dose of insulin do you give to your 8 yo patient with T1D with BS 120 at bedtime?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? Large – Last dose of insulin? 3U Novolog at

dinner – Last meal? Dinner (5 PM)

Large ketones: 2x correction dose or 20%TDD Moderate ketones: 1.5 x correction dose or 10%TDD

6U Novolog. Give glucose through IV or make pt eat something. Check BS q 2 O/N. Give Lantus!

Your 8 yo pt with T1D has a BS of 120 and is NPO for an Abd US in the AM. Insulin? IVF?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? none – Last dose of insulin? 3 at dinnertime

Your 8 yo pt with T1D has a BS of 120 and is NPO for an Abd US in the AM. Insulin? IVF?

– Regimen? 7.5 L, 1:30, 1:120 – Ketones? none – Last dose of insulin? 3 at dinnertime

Pts always need their Lantus, even if NPO! Give Lantus, no dextrose in IVF

Pearls •  Patients must always get their Lantus! •  Avoid dextrose in IVF for diabetics

–  Exception: Aggressive insulin tx with hypo/normoglycemia (SQ, Insulin Drip)

•  Mod/large ketones=insulin deficiency – Mod/large ketones-give extra insulin –  Small/trace ketones-drink more water

•  In the hospital hypoglycemia is worse than hyperglycemia – As long as there are no ketones

Pearls •  Hyperglycemia

–  hyperglycemia + mod/lg ketones-> give insulin –  hyperglycemia + tr/sm ketones-> change doses

for next day

•  Hypoglycemia –  hypoglycemia + mod/lg ketones-> give insulin

and dextrose (IV, juice) –  hypoglycemia + tr/sm ketones-> change doses

for next day