Jordan Ellis
Managing insulin regimens for inpatients in a hospital setting is a complex process that requires careful consideration of various factors. It involves addressing the three components of insulin replacement: basal, nutritional, and correctional requirements. The selection of an insulin regimen depends on several factors, including the patient's diabetes control, insulin experience, and comorbidities. The goal is to maintain optimal glucose levels, prevent hypoglycemia, and tailor the regimen to the patient's specific needs. Insulin therapy is the cornerstone of inpatient management, with intravenous insulin therapy being the treatment of choice in critical care settings. However, managing insulin regimens in hospitals can be challenging, and pharmacists play a crucial role in proactively adjusting regimens to avoid hypoglycemic events.
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What You'll Learn
Understanding the different types of insulin
Rapid-Acting Insulin
Rapid-acting insulin is a fast-acting form of insulin that starts to work within 15 minutes of injection. It typically reaches its maximum strength (peak time) between 1 to 3 hours after injection and has a duration of 3 to 7 hours. Some examples of rapid-acting insulin include insulin lispro (brand names: Admelog, Humalog), insulin aspart (brand names: Fiasp, NovoLog), and insulin glulisine (brand name: Apidra). This type of insulin is often used to cover carbohydrate intake from food or to address unpredictable hyperglycemia.
Short-Acting Insulin
Short-acting insulin has a slightly slower onset compared to rapid-acting insulin, taking about 30 minutes to start working. It peaks at around 2 to 3 hours after injection and has an effective duration of approximately 5 to 8 hours. Regular insulin, with brand names like Humulin R and Novolin R, falls under this category. Short-acting insulin is used in correctional doses to address hyperglycemia before meals.
Intermediate-Acting Insulin
Intermediate-acting insulin takes a longer time to start working, typically between 2 to 4 hours after injection. It reaches its peak effectiveness at about 4 to 12 hours and can last for up to 18 hours. NPH insulin, with brand names such as Humulin N and Novolin N, is an example of intermediate-acting insulin. This type of insulin is often used in basal-bolus regimens to provide a sustained release of insulin.
Long-Acting Insulin
Long-acting insulin is designed to provide prolonged control of blood glucose levels. It starts working several hours after injection and can last for 24 hours or more. Examples include insulin glargine (brand name: Lantus), insulin detemir (brand name: Levemir), and insulin degludec (brand name: Tresiba). Long-acting insulins are often used in basal regimens to mimic the body's natural insulin production and maintain a stable baseline of insulin.
Combination Insulin or Pre-Mixed Insulin
Combination insulin combines different types of insulin into a single injection. It starts working within 5 to 60 minutes, with varying peak times and durations ranging from 10 to 24 hours. Examples include Humalog Mix 75/25, NovoLog Mix 70/30, and Novolin 70/30. Combination insulin is used to simplify the injection process and provide a balanced insulin response.
It is important to note that the specific insulin regimen for hospitalized patients will depend on various factors, including their diabetes type, nutritional status, renal function, and individual response to insulin. The goal is to maintain optimal blood glucose levels, avoiding both hyperglycemia and hypoglycemia, to promote better patient outcomes and wound healing.
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Factors influencing insulin dosage
Several factors influence the dosage of insulin administered to patients in hospitals. Firstly, the patient's diabetes status is crucial. This includes whether the patient is insulin naïve, has good or poor baseline diabetes control, or has type 1 or type 2 diabetes. For instance, patients with type 2 diabetes and renal impairment are often prescribed a lower insulin dosage of 0.25 units per kg per day to reduce the risk of hypoglycemia.
Secondly, the patient's current health condition and medical history are considered. This encompasses their current oral intake, comorbidities, and other medications, nutritional status, and the severity of their illness. For instance, if a patient is fasting, blood glucose testing is recommended every four to six hours, and the insulin dosage is adjusted accordingly. Additionally, for patients taking less than 50% of their recommended oral diet, basal and bolus insulin doses are reduced by half.
Thirdly, the patient's previous experience with insulin therapy is relevant. This includes their experience with and adherence to prior outpatient insulin therapy. If the patient has been well-controlled at home, the hospital may continue their home regimen or reduce the dosage to prevent hypoglycemia.
Furthermore, the patient's weight and body mass index (BMI) can influence the dosage. Weight-based doses are considered in some cases, and correctional insulin is often ordered based on BMI.
Lastly, the availability of specific insulin types and the hospital's standardized protocols also play a role in determining the dosage. For example, some hospitals may prefer using basal-bolus regimens over insulin mixtures for patients with type 2 diabetes to reduce the risk of hypoglycemia. Additionally, the use of sliding scale insulin regimens, which are reactive treatments for hyperglycemia, is not recommended due to their ineffectiveness in controlling glucose levels.
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How to transition between insulin types
Transitioning between insulin types is a key step in inpatient diabetes care. The transition from intravenous (IV) to subcutaneous (SQ) insulin is a common procedure in hospitals, especially for patients with diabetes or hyperglycemia. This transition can be safely managed by following a stepwise approach.
Firstly, it is important to calculate the patient's Total Daily Dose (TDD) of insulin, based on the most recent insulin infusion rate. For safety, it is recommended to use 80% of this calculated dose. The basal insulin dose can be determined by dividing 80% of the TDD by half. If the patient is receiving tube feeds, divide 80% of the TDD by 10 for the nutritional dose, which can be administered every 4 hours (rapid-acting insulin) or 6 hours (regular insulin). If the patient is not receiving nutrition, do not order nutritional insulin. Correctional insulin should be ordered based on the total insulin dose or BMI.
The first basal insulin SQ injection should be administered 1-2 hours before discontinuing the infusion. If the transition occurs in the morning, a one-time AM NPH injection or half of the daily glargine or detemir dose can be given to bridge until bedtime. Glucocorticoids can significantly increase postprandial BG levels, so the nutritional insulin dose may need to be increased by 50% from before glucocorticoid use.
For patients with type 1 diabetes, an insulin regimen with basal and correction components is necessary, with the addition of prandial insulin if the patient is eating. Patients with type 1 diabetes should always be treated with insulin, and a transition protocol is recommended when discontinuing intravenous insulin to reduce morbidity and costs. The dose of basal insulin for these patients can be calculated based on the insulin infusion rate during the last 6 hours of stable glycemic goals.
Pharmacists play a crucial role in establishing an appropriate insulin regimen for patients with type 1 and type 2 diabetes, especially in acute and critical care settings. They can proactively adjust insulin regimens based on potential procedures, nutritional status, and intake to avoid hypoglycemic events. The American Diabetes Association (ADA) provides clinical practice guidelines for inpatient diabetes management, recommending insulin therapy for persistent hyperglycemia. The ADA also recommends basal insulin or a basal-plus correction regimen for patients with poor oral intake and basal, prandial, and correction insulin for those with good nutritional intake.
In summary, transitioning between insulin types in inpatient hospital settings requires careful calculation of insulin doses, consideration of nutritional status, and adherence to clinical guidelines. Safe transitions can be achieved by following established protocols and adjusting doses based on individual patient needs.
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The importance of controlling hyperglycemia
Hyperglycemia, or high blood sugar, is a condition where a person's blood glucose level is higher than normal. It commonly affects people with diabetes mellitus but can also develop in non-diabetics. Glucose is a sugar that serves as the body's primary energy source, and it is derived mostly from carbohydrates in our diet. When the body is unable to effectively control glucose levels, hyperglycemia can occur. This can happen when the body does not produce enough insulin or does not respond to insulin correctly.
To manage hyperglycemia in hospitalised patients, insulin therapy is often employed. Insulin is a hormone that helps move glucose from the blood into cells, thereby lowering blood glucose levels and providing cells with energy. Injected insulin is the primary method of treating hyperglycemia episodes. However, the dosage and regimen of insulin therapy depend on various factors, including the patient's diabetes history, nutritional status, comorbidities, and other medications.
Pharmacists play a crucial role in insulin regimen management, especially in acute and critical care settings. By being aware of potential procedures, nutritional status, and intake changes, pharmacists can proactively adjust insulin regimens to avoid hypoglycemic events. It is important to monitor blood glucose levels regularly and adjust insulin doses accordingly to ensure effective hyperglycemia control and prevent potential complications.
In addition to insulin therapy, lifestyle factors such as dietary changes and exercise plans can also help manage hyperglycemia. For people with Type 2 diabetes who do not require injected insulin, lifestyle and dietary changes, along with oral diabetes medications, can be effective in managing hyperglycemia. Overall, controlling hyperglycemia through appropriate treatment and regular monitoring of blood glucose levels is essential to reduce the risk of complications and improve patient outcomes.
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How to manage insulin regimens for surgical patients
Insulin management for surgical patients is a complex process that requires careful consideration of various factors. The goal is to maintain optimal glucose control while minimizing the risk of complications such as hyperglycemia and hypoglycemia. Here is a detailed guide on how to manage insulin regimens for surgical patients:
Preoperative Phase:
During the preoperative phase, it is crucial to conduct a comprehensive patient history and physical examination. This includes identifying diabetic patients at risk by considering factors such as the type of diabetes, glycemic control, and susceptibility to hypoglycemia. Patients should communicate the specifics of their surgical procedure to their endocrinologist or internist. In collaboration with the anesthesiologist, adjustments to their current medication regimen can be advised to minimize the risk of complications.
For patients on oral regimens, it is generally recommended to discontinue these medications on the day of surgery. For instance, drugs like sulfonylureas and metformin may need to be stopped due to the risk of hypoglycemia and lactic acidosis, respectively. Short-acting insulin may be administered subcutaneously or as a continuous infusion to maintain glucose control during this time.
For patients using premixed insulin, it is preferable to switch to a long-acting insulin regimen the evening before surgery. If this is not feasible, the premixed insulin dose should be reduced by 50% on the morning of the surgery, and dextrose-containing intravenous solutions should be initiated. During fasting, nutritional insulin is typically withheld, and subcutaneous correctional insulin is initiated with frequent blood glucose monitoring.
Intraoperative Phase:
The use of insulin pumps is common for continuous subcutaneous insulin infusion. However, for surgical procedures longer than 2 hours, the pump should be replaced with an intravenous insulin infusion to ensure better control. The decision to continue or discontinue the pump intraoperatively depends on the practitioner's judgment.
Postoperative Phase:
In the post-anesthesia care unit (PACU), it is crucial to closely monitor glucose levels and manage hyperglycemia with either intravenous or subcutaneous insulin. Stable ambulatory surgery patients who can tolerate oral intake may be discharged home while continuing their previous antihyperglycemic regimen.
For non-critically ill patients requiring hospitalization, subcutaneous insulin is typically administered. The insulin regimen should include basal, nutritional, and correctional components based on the patient's oral intake. For patients with poor or no oral intake, basal plus correctional insulin is preferred.
Overall, the management of insulin regimens for surgical patients requires a collaborative effort among healthcare professionals, including endocrinologists, internists, anesthesiologists, and surgeons. The regimen should be tailored to individual patient needs, considering their diabetes type, nutritional status, and other medications.
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Frequently asked questions
The three components are basal insulin, meal or nutritional bolus insulin, and correction insulin. Basal insulin provides a constant 24-hour peakless level of insulin to suppress the liver's release of glucose during fasting and between meals. Nutritional bolus insulin prevents the predicted postprandial rise in glucose.
All patients have basal, nutritional, and correctional requirements that must be met with endogenous or exogenous insulin. It is important to be aware of risk factors such as acute kidney injury, inappropriate timing of BG checks, and changes in medications that impact BG levels. Preventing and treating hyperglycemia can reduce infections and minimize fluid and electrolyte abnormalities.
For patients who were on insulin before admission, the best indicator of their insulin requirement is their total daily dose (TDD) before admission. It is recommended to use a basal/bolus regimen during their hospital stay. Correctional insulin can be given using a low-, intermediate-, or high-dose correction scale depending on the total daily dose.
