diabetes management

Types of insulin

short acting: regular; onset 30 min - 1 hour
rapid acting: NPH, lispro; onset 15 - 30 min
Lantus (glargine): given sometimes once and sometimes twice a day.
Levemir (detemir): does not last 24 hours, only lasts 12
NPH: 12 hours, give 2x/day
Humulin-R: 6 hours, give with meals, only use if can't afford others
U-500: 500 units of concentrated insulin, use when using more than 300 u/day. Use like humulin R but like a basal. 60% in morening, 40% at night or 40-30-30
70/30: mixed
- 70% basal (NPH), 30% short acting
- start at 0.5/u/kg/day
- dosed BID
- only use if struggling with injections
- You can convert to long acting by multiplying 70% of total 70/30
SSI: check glucose, then give insulin based on sugar and food given

Goal:

Start with metformin, then go to basal insulin (long acting), then add meal time insulin (short acting)

start metformin and add oral agents
start basal insulin if using 3 or more agents or if A1C > 10%. Target FBG
once fasting is under controlled, recheck A1C in 3 months
- A1C high: start meal time insulin with largest meal of day, then go up to 3x/day if needed

Meal time insulin:

2 ways of calculating meal time:
- 10% basal dose = meal time. E.g. 60 units basal insulin, 6 x 3 = 18 units / meal
- 1/2 basal. E.g. 60 units basal, 30 units total / 3 = 10 units / meal
Can use GLP in place of meal time insulin

A1C to glucose conversion:

Goal inpatient and ICU: 140-180
TF: use regular insulin q6h
SSI: Use correction factor TDD/1800 = how much glucose drop
- e.g. 100/1800 = 18mg.dl drop
Insulin pump but not on pump: either use weight based or TDD from pump

Smogyi effect: theory of hyperglycemia in early morning due to hypoglycemic events during late evening
Dawn phenomenon: morning hyperglycemia is due to the decreased levels of endogenous insulin secreted at night. Similar to Smogyi but without hypoglycemic events