Diabetes

Insulins
 Insulin agents
• Categorized on the basis of duration after injection
i. Rapid acting: Insulin aspart (two formulations),
lispro, glulisine, and inhaled insulin
ii. Short acting: Regular human insulin
iii. Intermediate acting: Neutral protamine Hagedorn
(NPH)
iv. Long acting: Insulin glargine, degludec and detemir
Note : Regular- and short-acting insulins target postprandial glucose
concentrations. while Intermediate- and long-acting insulins target fasting
glucose concentrations
 Insulin agents
• Combination insulin products
(intermediate or long acting, regular or rapid acting):
70/30, 75/25, insulin degludec and glargine available in
combination with GLP-1 agonist
• Higher-concentration insulin products
i. More commonly used in patients with T2D needing
significant daily insulin doses
ii. U-300 glargine (300 units/mL), U-200 degludec (200
units/mL), U-200 lispro (200 units/mL),
U-500 regular insulin (500 units/mL)
 Insulin lispro Insulin aspart
Insulin regular

Insulin glulisine
Insulin glargine
Insulin detemir
Insulin degludec Insulin NPH
Regular insulin 30%
Regular insulin 50%
Insulin NPH 70%
Insulin NPH 50%
Management of Insulin therapy in Type 1
Diabetes
Weight-based estimate if insulin naïve 0.3–0.6 unit/kg/day

• With older insulin formulations (NPH and regular insulin)

i. Two-thirds of TDI is given before the morning meal. Two-thirds
of this is given as NPH, and one-third is given as regular insulin.

ii. One-third of TDI is given before the evening meal. Either with
two-thirds given as NPH and one-third given as regular insulin or
in a 1:1 ratio.
• Basal-bolus insulin therapy (i.e., physiologic insulin therapy)
i. Basal insulins: Insulin glargine or degludec once daily or insulin
detemir once or twice daily
ii. Bolus insulins: Rapid-acting insulin (can use short-acting
insulin)
vi. Basal requirements are typically 50% of estimated TDI, but
some practitioners may prefer more or less.
 Correctional insulin needs
i. Always a need to correct for hyperglycemic excursions, despite
optimal basal-bolus therapy
ii. “1800 rule”: 1800/TDI = milligrams per deciliter of glucose
lowering per 1 unit of rapid-acting insulin
(a) For example, if TDI is 60 units, 1800/60 = 30, suggesting that
1 unit of rapid-acting insulin will reduce BG concentrations by 30
mg/dL.
(b) Also called insulin sensitivity factor
(c) Alternative: “1500 rule” when using regular human insulin
(i.e., 1500/TDI)
iii. More patient-specific than traditional sliding-scale insulin
Note: Sliding scale insulin regimen (bolus insulin on a prn basis)
 Sliding scale insulin
• Sliding scale insulin regimen (bolus insulin on
a prn basis) according to level of glucose in
blood
 Case
A patient weighing 65 kg with symptoms of hyperglycemia and a
fasting glucose concentration of 298 mg/dL is given a diagnosis
of type 1 diabetes (T1D). The patient’s physician asks for a
recommendation of an appropriate starting dose of basal insulin
and estimates the total daily insulin (TDI) needs of 0.4
unit/kg/day. Which recommendation is most appropriate?

A. 13 units of insulin detemir.

B. 13 units of insulin aspart.
C. 26 units of insulin glargine.
D. 26 units of insulin glulisine.
 Case
A female patient weighing 75 kg with type 1 diabetes (T1D). Her
current total daily insulin (TDI) needs is 0.6 unit/kg/day and she
take insulin glargine 20 unit at bedtime and the other units
before meal, The patient’s physician asks for a recommendation
of an appropriate dose of insulin if her random blood sugar 350
mg/dl despite basal insulin. Which recommendation is most
appropriate?
A. 5 units of insulin detemir.
B. 4 units of insulin aspart.
C. 7 units of insulin glargine.
D. 6 units of insulin glulisine.
Management of Insulin therapy in Type 2
Diabetes
 Case
A 61 years old 70 kg male patient known to be diabetes type II
hypertensive , hyperlipidemic come to clinic with
uncontrolled hyperglycemia
His vital signs are B.P 118/71 , HR 72 , RBS 271 , HbA1C 8.6
His current medication are
 Ramipril 5mg once daily
 Metformin 1000 mg twice daily
 Liraglutide 1.2 mg SC once daily regardless to meals
 Rosuvastatin 5mg once daily
 Insulin glargine (Lantus) 10 unit once daily at bedtime
Physician asks your recommendation?
 Case
A 56 years old 80 kg female patient who is type II diabetes in
insulin treatment , the physician started insulin 2 months ago , she
came back to the clinic with her daughter complains Peripheral
tingling , in the clinic her Random blood sugar is 284 and HbA1C
8.1. Her current medication is Metformin 1000 mg twice daily and
NPH Insulin 40 IU before bedtime
Which recommendation is most appropriate?
A. 10 unit of insulin NPH at bedtime and 20 unit at morning.
B. Liraglutide 1.2 mg SC once daily.
C. 4 units of insulin glulisine before largest meal.
D. All of the above
Management of Hyperglycemia in
Hospital settings
Pharmacologic Therapy of Inpatient
Hyperglycemia

Antihyperglycemic Therapy

SC Insulin via OADs

“Basal-Bolus” Not generally
Recommended for recommended
most medical-surgical
patients Continuous IV Infusion
Selected medical-surgical
patients
 Management of Hyperglycemia in ICU

Hyperglycemia is a common complication of critical

illness.
Patients in intensive care unit with stress hyperglycemia
have significantly higher mortality compared to patients
with previously confirmed diabetes or normo-glycemia.
For most critically ill patients in the ICU setting, insulin
infusion is the preferred route of insulin used to control
hyperglycemia, with a starting threshold of no higher
than 180 mg/dL .
Glycemic goals for critically ill patients:
 Once intravenous insulin is started, the glucose level should be
maintained between 140 and 180 mg/dL.
 Lower blood glucose targets may be appropriate for some
patients, but 110 mg/dL should be considered the lower limit for
all patients.
Regimen for Continuous Insulin Infusion
A. Preparation : 50 units of regular insulin dissolved in 50 mL normal
saline (NS) in a 50 mL disposable syringe
B. Mode of administration: IV infusion with an electronic syringe
pump/infusion pumps.
Titration of insulin dose according
to blood glucose levels
MONITORING OF BLOOD GLUCOSE
 If blood glucose falls >100 mg/dl or >20% of previous level in the first hour
then decrease calculated insulin dose by 0.5 -1.0 unit.
 If blood glucose does not fall by 50 mg or 10% of previous level within 2
hours of starting insulin infusion, then increase calculated insulin dose by
0.5-1 unit.
 If BG is < 50 mg/dL Administer 50 mL of dextrose (25 %), check blood sugar
at 15 minutes and if blood glucose increases to more than 100 mg/dL, start
insulin infusion after 1 hour
 If BG between 50 mg/ dL and 75 mg/dL Infuse 50 mL dextrose (25 %) if
hypoglycemia manifests clinically. If asymptomatic, give half dose of the
above solution. Check blood sugar after 15 minutes and start insulin 1 hour
after BG reaches > 100 mg/dL.
Insulin dose calculation during transition
from intravenous to subcutaneous regimen
Example: Baseline insulin requirement while NPO = 2 units/hour
Step 1 Adjusted basal dose calculation
• Patient’s hourly insulin infusion rate while NP = 2 units/hour
• 24 hours basal insulin dose = 24 × 2 = 48 units
• Adjusted basal dose accounting for stress reduction = 2/3
×48 = 32 units of basal insulin/24 hour
Step 2 Total SC dose calculation
• 2 × Adjusted basal dose = 2 × 32 = 64 units
Step 3 Mealtime bolus dose calculation
• Patient just started to eat, so 10% of basal dose can be
started with each meal = 0.1 × 32 = 3 units with each meal
 Case
A male patient weighing 70 kg admitted intensive care unit with
symptoms of hyperglycemia and a random glucose concentration
of 298 mg/dL. Physician start insulin infusion by 3 unit / hour
after 1 hour, blood glucose level become 65 mg/dl. The patient’s
physician asks for a recommendation.
Which recommendation is most appropriate?

A. Give 60 ml of dextrose 10 % .
B. Decrease rate of infusion to 1 unit / hour.
C. Give 50 ml of dextrose 25 g.
D. Give 100 ml of glucose 10 g.