Building and Implementing Effective Subcutaneous Insulin Orders and Protocols

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Building and Implementing Effective Subcutaneous
Insulin Orders and Protocols

• Greg Maynard MD, MS
• Professor of Clinical Medicine and Chief,
  Division of Hospital Medicine
• University of California, San Diego

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Insulin Terminology

• Basal insulin
• Long-acting, all Type 1 and most Type 2 DM
  patients should have basal insulin whether they
  are eating or not (insulin glargine, insulin
  detemir, or NPH)
• Nutritional or pre-meal / prandial insulin
• Short-acting insulin given with meals in
  anticipation of carbohydrate load glycemic spike
  (scheduled insulin aspart, insulin lispro,
  insulin glulisine, regular insulin)
• Correction or supplemental insulin
• Short-acting insulin given to cover high glucose
  if substantial use, it should drive adjustment of
  basal and nutritional insulins

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Insulin Terminology

• Sliding scale insulin
• This is a dirty word we dont use dirty words at
  UCSD
• Mindless medicine, paralysis of thought,
  action without benefit, insulin insanity
• Evidence does not support this technique without
  basal insulin unacceptably high rates of
• Hyperglycemia
• Hypoglycemia and insulin stacking
• Iatrogenic DKA in patients with type 1 DM

Umpierrez G et al. J Hosp Med. 2006 1141-4.
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Steps for Successful Implementation

• Identify best practices and preferred regimens
• Integrate into a protocol, summarize in one page.
  
• Place protocol guidance into flow of work
• Structured order sets, documentation tools,
  prompts
• Use high reliability design, layer on other
  improvement methods (including special teams)
• Proactively identify and mitigate outliers.
  Refine and redesign your educational efforts,
  order set design, and implementation strategies
  accordingly.

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Integrate Best Practice into protocols, order
sets, documentation

• Actionable glycemic target
• Constant carbohydrate / dietary / consult
• A1c
• Specify hyperglycemic diagnosis
• Education plan
• Hypoglycemia protocol
• Guidance for transitions (linked protocols)

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Integrate Best Practice into protocols, order
sets, documentation

• Coordinated insulin / nutrition / monitoring.
• Insulin preferred - DC oral agents
• Basal / Nutrition / Correction terminology
• Dosing adjustment guidance
• Specific regimens for different situations
• NPO
• Eating
• Tube feeds
• Steroids, etc

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Problems with Oral Agents in the Hospital

• Sulfonylureas (e.g., glyburide, glipizide, etc.)
• Hypoglycemia (long acting)
• ? CAD
• Metformin
• Lactic acidosis risk
• Renal insufficiency, hypotension, heart failure)
• Gastrointestinal
• Nausea, abdominal pain, diarrhea
• Thiazolidinediones (TZDs or glitazones) (e.g.,
  rosiglitazone)
• Possible liver toxicity
• Fluid overload, heart failure
• Inability to titrate (very slow onset of action)

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Physiologic Insulin SecretionBasal-Bolus
Concept
Nutritional (prandial) insulin
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Insulin (µU/mL)
Suppresses glucose production
between meals and overnight
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0
Basal insulin
Breakfast Lunch Supper
150
Nutritional glucose
The 50/50 rule (or maybe 40/60)
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Glucose (mg/dL)
50
Basal glucose
0
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A.M.
P.M.
Time of Day
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Which Patients Need Basal Insulin in the Hospital?

• Insulin-deficient patients should always have
  basal insulin (even NPO)
• Type 1 DM or DKA, pancreatic insufficiency
• A history of type 2 DM for 10 years or more
• On any insulin for 5 years or more
• Wide fluctuations of glucose values
• Preprandial glucose gt ?130, 150 mg/dL
• Any glucose gt 180 mg/dL

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Constructing a Profile for Scheduled Subcutaneous
Insulin .
Glulisine Lispro Aspart
Regular
NPH
Glargine Detemir
6 am 12 pm 6 pm 12 am
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SHM Glycemic Control Task ForcePreferred Insulin
Regimens

• See handout
• In interest of standardization, narrow down
  choices.
• Eliminating other acceptable choices, but also
  many unacceptable ones!
• Allow variation, while encouraging standardization

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Common Features Increasing Risk of Hypoglycemia
in an Inpatient Setting

• Malnutrition and low body weight
• Chronic renal failure
• Decreased oral intake, failure to provide
  nutrition or dextrose infusion
• Advanced age
• Liver disease
• Beta-blockers
• Iatrogenic Risk Factors SSI, distractions, poor
  regimens disconnect between testing,
  administration of insulin, and nutrition

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Calculating Insulin Dosage (Total Daily Dose)

• Calculate from insulin infusion amount
• Recent steady state hourly rate x 20, for example
• Add up insulins taken at home, adjust for
  glycemic control and other factors
• Calculate from weight, body habitus, other factors

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Starting Basal-Bolus from Scratch

• Calculate starting total daily dose (TDD)
• 0.3 units/kg/day (hypoglycemia risk factors,
  naïve patient)
• 0.4 units/kg/day (conservative for most
  patients)
• 0.5 0.6 units/kg/day (overweight to obese)
• Adjust TDD up or down based on
• Past response to insulin
• Presence of hyperglycemia inducing agents, stress
• This Is very conservative and safe (adjust up as
  needed)
• Basal insulin 40-50 of TDD
• Glargine q HS or q AM, detemir in 1 or 2 doses
• Goal FBS and pre-meal glucose 80-110 mg/dL

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Case 1 Initiating Subcutaneous Insulin in an
obese patient eating regular meals

• 56 year old man admitted with diabetic foot
  infection, eating regular meals.
• Obese, weighs 100 kg
• Home regimen
• 2 OHGs and 20 units of NPH q HS
• Baseline Control
• HbA1c of 10, POC glucose in ED 240 mg/dL
• What are your initial orders for insulin?
• What change would you make if he had to go to the
  OR the next morning?

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Eating Patient (or Bolus TF)
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Case 1 Solutions for Obese, eating patient

• Accuchecks AC and HS
• TDD 100 kg x 0.6 units/kg/day 60 units
• Glargine (Lantus) Alternative
• Basal Glargine 30 units q HS
• Nutritional Lispro 10 units q ac
• Correction Lispro per scale q ac and HS
• For NPO p MN and OR the next AM
• Hold nutritional dose, continue adjustment dose
• Give the full dose of Glargine q HS No change.

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Adjust, Adjust, Adjust

• If glucoses going lt 70 mg / dL, use 80 of TDD as
  next days TDD
• If glucose readings gt 150 and no hypoglycemic
  values, use 120 of yesterdays total as new TDD
  (or 130, depending on the uniformity and degree
  of poor control)

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Case 2 Patient in IMU on Continuous TF

• 65 year old you are seeing for the first time in
  the IMU, no outpatient history available except
  on insulin. Glucose gt 200 in ED, HbA1C pending.
  
• 80 kg overweight woman started on continuous TF
  yesterday (HD3), with serum glucose in 200-250
  mg/dL range
• What would you order?

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TPN or Continuous Tube Feedings
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Continuous Tube Feeding Insulin Regimen
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Case 2 Solutions in a patient on continuous TF
or TPN

• Accuchecks q 6 hours
• TDD is 0.5 units/kg/day x 80 kg 40 units
• Basal Glargine 16 units q hs (or q am)
• Nutritional 6 units regular insulin q 6 h
• Correction regular insulin q 6 h per scale
• Patients being started on TPN do better with
  separate insulin infusions initially (with y
  connector) to find dose.
• Conversion then can be made to insulin in TPN
  (80 of TDD), or subcutaneous regimen.

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Case 3 Transition from IV to subcutaneous
insulin

• 60 yo man with DM 2, well controlled in ICU on
  insulin infusion and continuous TF at 40 ml/hour.
• Insulin Infusion rate 80 units in the last 24
  hours, 3 units / hour over last 6 hours.
• Prior to hospitalization, baseline HbA1c was 8.7
  on 40 units of 70/30 insulin per day and OHGs.
• Plan Transfer to ward, continue enteral
  nutrition
• How do you transition this patient to a
  subcutaneous insulin regimen?

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Stepwise approach to moving from IV to SC insulin

• Calculate how much IV insulin the patient has
  been requiring. Modify down for safety cushion.
• Was this insulin supplying Basal requirements, or
  Basal and Nutritional requirements? Translate
  into the subcutaneous regimen.
• Consider any nutritional changes that may be
  implemented at the time of the transition off of
  the drip
• Make sure SC insulin is given before
  discontinuation of the IV insulin

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Case Transition to subcutaneous insulin(enteral
nutrition to continue)

• Safe Estimate of 24 hour requirement
• 3 units / hour x 20 60 units
• 60 units represents the TDD Basal and
  nutritional insulin
• 5050 Rule Example
• Glargine 30 units Basal
• Regular 7 units q 6 h Nutritional
• Correction dose of regular insulin also given
  along with nutritional dose as needed.
• Glargine / Nutritional should be given BEFORE IV
  insulin stopped

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What if??? Enteral to PO

• Instead of continuing enteral nutrition on the
  floor, you opt to stop enteral nutrition and
  start patient on a mechanical soft diet?
• Glargine 30 units Basal
• RAA 10 units q AC Nutritional / Prandial
• (IF you expect them to eat a full meal! )
• If po intake suspect at first, use CHO counting,
  or empirically reduce nutritional RAA dose and
  give the dose just AFTER the meal instead of just
  BEFORE the meal.
• CORRECTION dose RAA insulin also needed.

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Have a Discharge PlanTailored to Patient!

• Diabetes and insulin education, survival skills
  START EARLY and repeat
• Follow up and community resources
• Covered by insurance
• Patient and family can understand
• Reconcile medications
• Language, health literacy, and cultural barriers
• Use HbA1c
• Insulin requirement may decrease post discharge