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8/8/18

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Initiating and Adjustment of the Insulin Pump

Celia Levesque RN, MSN, CNS-BC, NP-C, CDE, BC-ADM

Objectives:

• Prescribe insulin pump therapy• Initiate insulin pump therapy• Calculate initial insulin pump doses• Adjust insulin pump settings• Prevention of acute complications• Manage the insulin pump patient in special

situations that affect glucose• Prescribe continuous glucose monitoring

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Normal Insulin Secretion Prevalence of insulin pumps: 75-1 Million Worldwide?

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1.0

2.0

3.0

4.0

5.0

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12am 4am 8am 12pm 4pm 8pm 12am

Bolus

Temporary basalBasal rate

Units

of i

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in Bolus

Bolus

First pumps Current Insulin Pumps

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Hybrid close loop

• Auto Mode– No SF needed– Bolus for CHO

• Suspend before low

• Guardian sensor 3

• Age 7 +

• May not be safe if less than 8 units/day

Candidate Selection

• Desires insulin pump• Check BG frequently• Able to operate pump• Able to afford pump• Able to troubleshoot• Works with medical

team

• Hypoglycemia• Busy schedule• Athletes• Dawn phenomenon• Elevated HbA1c

despite best efforts• Gastroparesis

Pre Pump Education

• Carbohydrate counting• Insulin to carbohydrate ratio• Sensitivity factor• Sick day management• Prevention of DKA / ketone testing• Hypoglycemia treatment• BG testing / BG goals / record keeping

Calculating insulin pump doses

1. Calculate the total pump total daily dose (TDD)

2. Calculate a single basal rate

3. Calculate the insulin to carb ratio

4. Calculate the correction factor

5. Choose a target BG range

6. Choose the active insulin time

Calculating Total Pump Total Daily Dose (TDD)

Method 1• Pre-pump TDD x 0.75

Method 2• Weight:

– kg x 0.5 – lb. x 0.23

Grunberger, G, Abelseth, J., Bailey, T, et. al. Consensus statement by the American Association of Clinical Endocrinologist/American College of Endocrinology Insulin Pump Management task force. Endocrine Practice. 2014;20(5):463-489.

Clinical considerations

• Average values from methods 1 & 2

• Frequent hypoglycemia: start at lower dose

• Hyperglycemia, éHbA1c, preg: start higher dose


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Example: Calculate Pump TDD

• Average total daily dose = 50 units• Weight = 100 kg

• Method 1: 50 units x 0.75 = 37.5

• Method 2: 100 x 0.5 = 50

• Average: 37.5 + 50 ÷ 2 = 43.75

Initial Single Basal Rate (50% TDD)

• Pump total daily dose x 0.5 ÷ 24 hrs = basalOr

• Pump total daily dose ÷ 48 = basal rate

• Example: TDD = 30 units30 x 0.5 = 1515 ÷ 24 hours = 0.625 units per hour

Grunberger, G, Abelseth, J., Bailey, T, et. al. Consensus state by the American Association of Clinical Endocrinologist/American College of Endocrinology Insulin Pump Management task force. Endocrine Practice. 2014;20(5):463-489.

Carbohydrate Ratio

• 450 ÷ TDD before pump

• Alternate methods:– 6 x wt. in kg ÷ TDD or 2.8 x wt. in lb. ÷ TDD– Fixed Meal Bolus = TDD x 0.5 ÷ 3 equal meals– Continue existing CR from MDI regimen

– Example: Total dose before pump = 45 units– 450 ÷ 45 = 10 – 1 unit for every 10 grams of carbohydrate


Sensitivity/Correction Factor

• 1700 ÷ Pump TDD

• Example: Total pump dose = 85 units

• 1700 ÷ 85 = 20

• 1 unit will decrease the BG by ~ 20 mg/dL

Grunberger, G, Abelseth, J., Bailey, T, et. al. Consensus state by the American Association of Clinical Endocrinologist/American College of Endocrinology Insulin Pump Management task force. Endocrine Practice. 2014;20(5):463-489.

Continuous Glucose Monitoring

• Measures interstitial fluid glucose• Subcutaneous catheter attached to a transmitter• The receiver displays a new result every 5

minutes– Pump screen– Stand alone receiver– Phone

Interstitial Fluid Glucose

• Does not always match blood glucose

• Interstitial glucose lags behind blood glucose

• The faster the change in BG, the greater the difference between IFG and BG

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What happens between fingersticks Benefits

• Reduce risk for hypoglycemia secondary to alarms

• Reduce risk for extreme hyperglycemia secondary to alarms

• Reduce risk for wide BG fluctuations• Behavior modification / learning

Dexcom Medtronic Enlite

Guardian Connect Freestyle Libre

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Eversense CGM

CGM Basal Testing

• Select a basal period to test

• Plan to skip a meal during the test period

• Wait 4-5 hours after eating the last meal or snack before the test begins

• Check pump to make sure there is no active insulin on board at the start of the test

Basal Testing Periods

• Overnight– Eat early dinner– Monitor BG hs, q 3 hrs., and waking– Ends at breakfast

• Morning– Skip breakfast– Monitor BG q 1-2 hrs.– Ends at lunch

Basal Testing Periods

• Afternoon– Skip lunch– Monitor BG q 1-2 hrs.– Ends at dinner

• Evening– Skip dinner– Monitor BG q 1-2 hrs.– Ends at bedtime

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Adjusting Basal Rates

• Adjust according to trends over 2-3 days

• Adjust to maintain a stable BG between meals and during sleep

• Begin new basal rate 1-2 hours before the problem


Basal Testing

• Monitor BG at start of the test

• Do not start if BG < 90 or > 150 mg/dL

• Stop the test if BG < 70 or > 250 mg/dL

• Daytime tests: check BG q 1-2 hrs.

• Overnight test: check hs BG, 2 am, and waking

Basal Testing

• Repeat testing 2-3 times to ID trend

• Adjust basal rate if fluctuations of > 30 mg/dL

• Change by 5-10%

• Make changes before BG starts to trend up or down. It make take 2.5 to 4 hrs. for basal to change

• Assess effectiveness of the basal change

Overnight Basal Test

24022020018016014012010080

Start 3 hr. 6 hr. 9 hr. 12 hr.BG 120 137 147 161 172Time 9 pm 12 am 3 am 6 am 9 amBasal 1.1 1.1 1.1 1.1 1.1

Morning Basal Test

24022020018016014012010080

Start 1 hr. 2 hr. 3 hr. 4 hr. 5 hr. 6 hr.BG 140 137 130 125 110 100 90Time 6 am 7 am 8 am 9 am 10 am 11 pm 12 pmBasal 1.1 1.1 1.1 1.1 1.1 1.1 1.1

Testing CHO Ratio

• Eat a known amt of CHO between 45-70 g

• Eat a balance of CHO, protein, fat

• Wait 4-5 hrs after last food to start the test

• Make sure no insulin on board at start of test

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Testing CHO Ratio

• Monitor BG– Start of test and q 1 hr. for 5 hrs.

• Do not start test if BG < 90 or > 150 mg/dL

• Eat meal 15 minutes after bolus

• Do not eat during test

• Stop test if BG < 70 or > 250

Testing CHO Ratio

• BG should be within 30 mg/dL from starting BG

• Repeat test several times

• Adjust CHO ratio as needed

Bolus Test

24022020018016014012010080

Start 1 hr. 2 hr. 3 hr. 4 hr. 5 hr.BG 91 170 190 142 129 107Time 6 am 7 am 8 am 9 am 10 am 11 amBasal 1.1 1.1 1.1 1.1 1.1 1.1

Bolus Test

24022020018016014012010080

Start 1 hr. 2 hr. 3 hr. 4 hr. 5 hr.BG 130 109 104 142 160 180Time 12 pm 1 pm 2 pm 3 pm 4 pm 5 pmBasal 1.1 1.1 1.1 1.1 1.1 1.1

Testing Correction Factor

• Start test when – BG is > 200 mg/dL

– No food for 4 hours before start of test– No bolus for 4 hours before start of test

• Monitor BG at start of test, and q 1 hr. x 5 hrs.

• Do not eat or bolus during test• Stop test if BG < 70 or > 250 mg/dL and treat

appropriately

Testing Correction Factor

• End BG should be within 30 mg/dL of target

• Repeat test several times

• Adjust as needed

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Correction Factor Test

24022020018016014012010080

Start 1 hr. 2 hr. 3 hr. 4 hr. 5 hr.BG 240 210 200 190 180 170Time 11 am 12 pm 1 pm 2 pm 3 pm 4 pmBasal 1.1 1.1 1.1 0.95 0.95 0.95

Correction Factor Test

24022020018016014012010080

Start 1 hr. 2 hr. 3 hr. 4 hr. 5 hr.BG 200 150 100 90 80 75Time 11 am 12 pm 1 pm 2 pm 3 pm 4 pmBasal 1.1 1.1 1.1 0.95 0.95 0.95

Troubleshooting Hyperglycemia

• Insulin– Loss of potency– Wrong insulin in

pump

• Infusion set– Bent catheter– Air in tubing– Infusion site problem

• Insulin pump– Programming error– Pump malfunction

• Behavior– Missed bolus– Bloused after eating– Did not correct– Miscount CHO

BG > 250 mg/dL

• Take correction bolus• Recheck BG in 1 hour• If not trending down, check ketones and

BG > 250 mg/dL

Negative ketones1. Inject insulin w syringe

2. Drink SF flds

3. Recheck BG in 1 hr

4. If decreasing, change site

w new insulin

5. BG not dec, inject w

syringe w new insulin, ck

ketones, call HCP or go to

ED

Positive ketones1. Contact HCP or go to ED if

urine ket mod/lg or Bld >

0.6

2. Inject insulin w syringe do

not use pump

3. Drink SF fluids

4. Continue ck BG/ket q 1 hr

5. Inject rapid acting insulin

q 2-3 hrs

Beta-hydroxybutyrate

Precision Xtra• 0.6 – 1.5 = call MD• > 1.5 = go to ER

NovaMax• 0.6 – 1.5 = call MD• > 1.5 = go to ER

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Supplies Needed

• Insulin• Syringes• Pump supplies• Monitoring supplies• Hypoglycemia

treatment• Ketone testing:

urine/blood• DM identification• Glucagon

Hypoglycemia

• 20% of T1DM will die from hypoglycemia

• 40% of T1DM will have severe hypo if duration of > 15 years

• Annual rate of severe hypoglycemia requiring emergency medical services: 7.1%

• Mortality rate 1 year after severe hypoglycemia T1 & T2 combined = 17%

UK Hypoglycemia Study Group. Diabetologia 2007; 50: 1140-1147.

Leese GP, et al. Diabetes Care 2003; 26: 1176-1180

Poster 389, American Diabetes Association 72nd Scientific Sessions

BG< 70 mg/dl: DM vs. Non DM

No Diabetes• Insulin levels drop• Glucagon secreted • Epinephrine release• Norepinepherine • Cortisol release• Growth hormone• Neurotransmitters

T1DM or low C-Peptide• Insulin levels high• Glucagon not

secreted• Epinephrine release• Norepinepherine• Cortisol release• Growth hormone• Neurotransmitters

Severe Hypoglycemia Treatment

• Converts glycogen to glucose

• 1 kit = 1 mg raises BG ~ 50 mg/dl

• Given SC, IM, or IV

• 1 mg for child > 4• ½ mg for child < 4

Mini Dose Glucagon

• Pt unable to swallow CHO

but is awake & alert with BG

< 80 mg

• 2 “units” for 1 yo

• 1 “unit” per year of age for 2

years & older

• Max 15 “units”

• If not above 80 mg/dL in 30

min, double the dose (max

30)

Haymond, M. W. & Schreiner, B. Mini-dose glucagon rescue for hypoglycemia in children with type 1 diabetes. Diabetes Care. 2001; 24 (4): 643-645.

Counting CHO: Reading Labels

1. Look at serving size2. Decide how many

servings will be consumed

3. Multiply the number of servings by the total grams of carbohydrate

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Effects of CHO, Fat & Protein on BG High GI vs Low GI on BG

Glucose vs White Rice vs Apple Total Available Glucose

Food Serving size GM CHO TAGMeat 1 oz. 0 4Milk 1 cup 12 17Casserole 1 cup 30 38Cheese pizza, thin

¼ of 10” 30 34

Chili with beans

1 cup 30 38

Bean soup 1 cup 20 24

University of Washington Medical Center. Carb Counting Class (2nd ed). Downloaded May 9, 2015 from https://healthonline.washington.edu/document/health_online/pdf/CarbCountingClassALL3_05.pdf

Nutrition and Diabetes Management Apps

• Calorie King• My Net Diary• Spark People• GoMeals• Fooducate• dLife diabetes• WaveSense• My Glucose Buddy

-20

0

20

40

60

80

100

BG C

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g/dl

All slow bolus

2 bolus

1 bolus

Fast / slow

0.5 1.0 1.5 2.0 4.0 5.0Hours from Baseline

Adapted from Chase et al: Diabetic Medicine 2002;19:317-321

Bolus for High Fat Meal

https://healthonline.washington.edu/document/health_online/pdf/CarbCountingClassALL3_05.pdf

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Total Available Glucose

Hormel Cheezy Mac ‘n FranksServing Size 1 container 7.5 ouncesCalories per serving 280Total fat 18 gramsTotal carbohydrate 20 gramsFiber 1 gramSugar alcohol 0Protein 10 grams


Pizza Hut Thin ‘n Crispy Cheese Pizza 1 slice from 12” PizzaServing Size 1 sliceCalories per serving 190Total fat 8 gramsTotal carbohydrate 22 gramsFiber 1 gramSugar alcohol 0Protein 8 grams


Chick-fil-A NuggetsServing Size 8 nuggetsCalories per serving 270Total fat 13 gramsTotal carbohydrate 10 gramsFiber 1Sugar alcohol 0Protein 28 grams

Exercise

• Most studies show little impact on A1c for T1DM

• Benefits of exercise same as non DM

• If exercise performed within 90 min of a meal, may reduce mealtime bolus

Bolderman, K. M. (2012). Putting your patients on the pump: Initiation and maintenance guidelines (2nd ed). Alexandria, VA: American Diabetes Association.

Metabolic Response to Light & Moderate Exercise

Normal• Insulin level

decreases• Glucagon increases• Free fatty acid

mobilization increases• Restriction of glucose

by non exercising skeletal muscle

T1DMInsulin level fails to change at the onset of exercise• Insulin excess: muscle

glucose uptake exceeds liver glucose production

• Insulin deficiency: liver glucose production exceeds muscle uptake; FFA release and ketone body formation increase

• Adequate insulin: liver glucose output matches muscle glucose uptake

Bode, B.W. 2004. Medical management of type 1 diabetes (4th ed). Alexandria, VA: American Diabetes Association.

Bolus Reduction if Exercise within 90 minutes after a meal

Short duration20-40 minutes

Moderate duration40-60 minutes

Long duration> 60 minutes

Low intensity - 10% - 20% - 30%

Moderate intensity

- 25% - 33% - 50%

High intensity - 33% - 50% - 67%


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CHO Replacement gm/30 min of Exercise

Weight 50 lb.23 kg

100 lb.45 kg

150 lb.68 kg

200 lb.91 kg

250 lb.114 kg

Light activity

3 5 8 10 12

Moderate 5 8 10 12 15

Intense 8 12 18 24 30


Basal Adjustment for Prolonged Activity

• Exercising < 90 minutes: do not change basal

• Exercise > 2 hours– Starting point: decrease basal by 50%– If more intense activity: 70-80% reduction– Start reduction 1-2 hrs. before prolonged exercise– Resume full basal rate prior to stopping

prolonged exercise

• Delayed hypoglycemia may occur after prolonged/intense activity


Exercise Induced Hyperglycemia

• Weight lifting

• Intermittent bursts of activity (softball, golf,

martial arts, sprints, judged events

• If hyperglycemia is consistent:

– take extra insulin in preparation: 50% of the amount expected to offset the rise in BG: give

30-60 min before the expected rise


Hyperglycemia Prior to Exercise

• Lack of insulin– If explainable:

• hydrate, take 50% of usual correction bolus

– If unexplainable:• Check ketones

– If negative: hydrate, take 50% of usual correction bolus, exercise

– If positive: hydrate, administer full correction dose, hyperglycemia protocol, do not exercise


Special Situations

• Kids• Pregnancy• Illness• Menstrual cycle• Sex• Travel• Surgery• Steroids• Gastroparesis

Kids & Pumps

• Pump therapy in kids requires commitment and motivation on the part of caregivers

• Children require frequent dose changes

• Tend to need more bolus and less basal insulin compared to adults

• Teens are usually insulin resistantBolderman, K. M. (2012). Putting your patients on the pump: Initiation and maintenance guidelines (2nd ed). Alexandria, VA: American Diabetes Association.

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Kids & Pumps

• Common problems– Missed boluses– Bent catheters– CHO counting is an adult concept– Not finishing meal after bolus given– Unpredictable, impulsive, erratic activity


Kids and pumps

• 3-4 yo: – Can deliver bolus but needs to verify amt before

activating– Use block feature in young kids

• 7-12 yo: – Tend to be excited about pump– Need help deciding on how much to bolus– Begin to carb count can calculate insulin to carb

ratio– Usually can achieve good control

Kids and pumps

• Teens:– Least reliable group– Learn quickly– Preoccupied with many other things, Pump

not priority– Forget to bolus– Do better on a pump than shots but not as

good as younger kids– NEED PARENTAL INVOLVEMENT

Pumps in school

• Train teachers & school nurse• Care plan for pump issues• Phone numbers for diabetes care team• Extra insulin for pump &/or insulin pen for

injection• Pump supplies, numbing cream if used• Ketone and glucose testing supplies• Pump batteries• Insulin syringe and/or pen needles

Pumps on the playing field

• If NOT going to detach:– May need to reduce basal rate– May consume CHO if needed

• If going to detach:– Less than 1 hour: no adjustments– Bolus q 1 hr during breaks for missing basal– Small bolus with snacks during breaks

Pregnancy

• Target BG: – Premeal: 60-99 mg/dL– Post meal 1 hr.: < 130 mg/dL

• Target HbA1c: < 6%

• If frequent hypoglycemia, severe hypoglycemia, or hypoglycemia unawareness: customize target BG

• Evaluate control twice weekly and adjust


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Pregnancy: BG > 200

• Check ketones

• Give insulin via syringe or insulin pen

• Change infusion set


Labor and Delivery

• Follow the hospital protocol

• Hourly blood glucose checks

• BG goal 80-120 mg/dL

• For elective C-section: decrease basal rate by 30% 8 hours before delivery while NPO and if prone to hypoglycemia, reduce 50%

• Active labor: reduce basal rate 30-50%

• Reduced insulin requirements after delivery


Illness

• Frequent BG and ketone testing• Need basal to prevent DKA• Do not reduce basal unless hypoglycemia• Basal rates may need to be increased for fever,

infection, surgical stress, etc.• Use hyperglycemia protocol as previous outlined• If prolonged fasting: sensitivity factor may need

to be changed


Illness

• Increase noncaloric fluids• Need some CHO to prevent ketosis• If can’t eat solid food: may substitute with liquid

CHO• Teach pt. to call if:

– Fever > 100– Nausea, vomiting, diarrhea > 4 hrs.– Moderate or large urine ketones, or > 0.6 on

betahydroxybuterate testBolderman, K. M. (2012). Putting your patients on the pump: Initiation and maintenance guidelines (2nd ed). Alexandria, VA: American Diabetes Association.

Menstrual Cycle

• Effect on BG varies

• Increased insulin requirements 2-3 days to 1 week before cycle due to changes in estrogen and progesterone causing insulin resistance

• Decreased insulin requirements the day after cycle starts

• May need to adjust both basal and bolusBode, B. W. Medical management of type 1 diabetes (4th

Travel

• If sedentary during the travel: may need temp increase in basal rate 10-20%

• Bring 50% more supplies than usually needed for the time away– Spare pump if available– Hypoglycemia treatment including glucagon– Extra insulin with syringes– Extra monitoring supplies including spare

meter, lancing device, ketone testing productsBolderman, K. M. (2012). Putting your patients on the pump: Initiation and maintenance guidelines (2nd ed). Alexandria, VA: American Diabetes Association.

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Travel

• Know where the nearest pharmacy, and medical care available

• Extra glasses if needed• Pack all medical supplies in a carry on bag• Insulin stable for 28 days at room temperature• Protect insulin from extreme heat• Low dose x-ray screening and total body

scanners: contact pump manufacturer• Check with airline and TSA for any changes in

rulesBolderman, K. M. (2012). Putting your patients on the pump: Initiation and maintenance guidelines (2nd ed). Alexandria, VA: American Diabetes Association.

Travel

• When changing time zones:

– Keep the pump clock the same at departure and then change it to the new time zone after arriving to the new destination

– If a large time zone change• Change pump clock 2 hours towards the

new destination daily until the correct time is achieved


Surgery/Procedure

• What type of surgery?• How long is the surgery?• What time will the surgery start?• How long will the patient fast?• What kind of diet will the patient have after

surgery?• Will the patient be receiving IV dextrose?

Surgery / Procedure

• What type of anesthesia?• Can the patient skip a meal without

hypoglycemia?• Does the patient have a history of severe

hypoglycemia?• Does the patient have hypoglycemia

unawareness?

General Anesthesia

• Neuroendocrine stress response– Epinephrine– Glucagon– Cortisol– Growth hormone

• Inflammatory cytokines– interleukin-6– tumor necrosis factor-alpha

Metabolic Abnormalities from Surgery/Anesthesia

• Insulin resistance• Decreased peripheral glucose utilization• Impaired insulin secretion• Increased lipolysis and protein catabolism• Hyperglycemia• In some cases: ketosis

• General anesthesia is associated with larger metabolic abnormalities as compared to epidural anesthesia

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Glycemic Goals for Surgery

• Avoidance of marked hyperglycemia

• Avoidance of hypoglycemia

• Maintenance of fluid and electrolyte balance

• Prevention of ketoacidosis

Options:

• Take pump off and replace basal insulin:– 1 injection of basal prior to surgery – ½ dose prior to surgery, ½ dose 12 hrs. later– Patient given corrections for hyperglycemia using Regular

or Rapid-acting analog insulin

• Leave pump on at full basal rate– Patient given corrections for hyperglycemia using Regular


• Leave pump on at reduced basal rate• Patient given corrections for hyperglycemia using Regular


Gastroparesis

• Stomach emptying is variable esp. if BG levels are variable

• Many have gastroparesis without sx

• Use special bolus features as needed to match stomach emptying

• Generally: gastroparesis diet is low fat, low fiber

Steroids

Steroid Equivalent Onset DurationBetamethasone 20 0.6 mg RapidCortisone 1 25 mg Slow 30-36 hDexamethasone 2020-30 x > than HC5-7 x > Prednisone

0.75 mg Rapid 72 hours

HC acetate 1 20 mg Slow LongHC sodium phosphate 1

20 mg Rapid Short

HC sodium succinate 1

20 mg Rapid Short

MP 5 4 mg Rapid 30-36 hPrednisolone 4 5 mg Rapid 18-36 hPrednisone 4 5 mg Rapid

Steroids

• Low dose steroids: less than equivalent of Dexamethasone 40 milligrams– 40% basal– 60% bolus

• High dose steroids: equivalent of Dexamethasone 40 milligrams or higher– 25% basal– 75% bolus

Steroids

• Total initial insulin dose:

– Low dose steroids: start at 0.6-0.8 units/kg

– High dose steroids: start at:• 0.9 units/kg if on metformin• 1.2 units/kg if not on metformin

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