Inpatient insulin management and adjustment

Insulin management, in truth, deserves a whole chapter of a textbook, but here are a few quick-and-dirty methods I’ve learned for type 2 diabetics in the hospital:

Selecting a type of insulin:

  • I often try to use lantus over NPH if I have a choice, because lantus is longer-acting and doesn’t have a peak-decrease response
  • I also avoid 70/30 mixed insulin unless a patient uses that at home because 70/30 is more prone to giving people labile blood sugars
  • Short acting insulins, like aspart (lispro) and humalog (humulin) I think of as more interchangeable
Type

Brand Name

Onset
(length of time before
insulin reaches bloodstream)
Peak
(time period when
insulin is most effective)
Duration
(how long insulin
works for)
Rapid-acting

Humalog
Novolog
Apidra

10 – 30 minutes 30 minutes – 3 hours 3 – 5 hours
Short-acting Regular (R) 30 minutes – 1 hour 2 – 5 hours Up to 12 hours
Intermediate-
acting
NPH (N) 1.5 – 4 hours 4 – 12 hours Up to 24 hours
Long-acting Lantus
Levemir
0.8 – 4 hours Minimal peak Up to 24 hours

(Table credit: The Joslin Center)

Calculating an initial dose of long acting (basal) insulin: Body weight (kg) x 0.2 if insulin naive; and x 0.5 if already on insulin.

Calculating the appropriate sliding scale instead of using your hospital’s predetermined one: 5% of total daily insulin requirement. For example, someone who requires 20 units of basal insulin should start with a sliding scale of 1 unit when glucose 150-200, 3 units when 201-249, etc.

Adjusting insulin on a daily basis: Add up the sliding scale units they received over the last 24 hours. Assign 50% to long-acting insulin and 50% to mealtime insulin. So, if someone is getting 10 units long-acting insulin and 2 units mealtime, and required an extra 12 units yesterday, they should now get 13 units long-acting insulin and 4 units at each mealtime.

 

 

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