basal and meal time insulin case study davida f. kruger, msn,apn-bc,bc-adm certified nurse...
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Basal and Meal Time InsulinCase Study Davida F. Kruger, MSN,APN-BC,BC-ADM
Certified Nurse PractitionerDivision of Endocrinology, Diabetes, Bone and
Mineral DisordersHenry Ford Health System
Detroit, Michigan
Betty• 56 years old• Weight 182 lbs, b/p 136/82• Metformin 100omg BID• glyburide 10 mg BID • MNT, working on portion size and
learning carb counting• SMBG, usually twice daily but has been
checking when feels low or high• Wants to improve her A1c which has been
running between 7.8 and 8.4.
Fix The Fasting FirstBB LL SS HSHS
SaturdaySaturday 198198 156156
SundaySunday
176176
168168 199199
MondayMonday 184184 170170 179179
Basal Insulin Replacement Basal Insulin Replacement TherapyTherapy
Time (hours)s.c. injection
Normal Insulin Secretion at Meal Time
Ch
an
ge
in S
eru
m in
su
lin
NPH Insulin
Insulin Glargine/Detemir
Start a Basal Insulin“Treat to Target”
Continue oral agent(s) at same dosage Do NOT stop insulin secreting agent
Add single, evening insulin dose (0.1 - 0.2 U/kg)10 - 20 unitsGlargine, Detemir or NPH (bedtime)
Increase insulin dose every 3-4 days as neededIncrease 3 - 5 U if FBG >150 mg/dL
Increase 1 - 2 U if FBG = >110,<150 mg/dL Treat to target FBG (usually <120 mg/dL)Determine maximum insulin increase till
call clinic 6-596-59
Starting Basal InsulinStarted Betty on 10 units at 10 PM of
Glargine.Focus on fasting blood glucoseIncrease 1-2 units every 3 days until FBS at
target with out hypoglycemiaCan us 3/0/3 rule Ask patient their comfort levelCall clinic when patient taking XX units
Glargine Started…Is Premeal Coverage Needed?
BB
prepre
2 hr2 hr
postpost
LL
prepre
2 hr2 hr
postpost
SS
prepre
2 hr2 hr
postpost
MM
16u 16u GG
109109 188188 142142 200200 155155 189189
TuTu 116116 135135 118118 177177 179179 202202
WW 120120 154154 132132 167167 162162 190190
ThTh 9797 127127 122122 154154 177177 211211
BettyTaking 30 units of glargineNo issues with low blood glucoseWorking on learning carbohydrate counting
and portion sizesBlood glucose monitoring increased to look at
2 hr post prandial blood glucoseA1c 8.2 %
Bolus Insulin Replacement Bolus Insulin Replacement Therapy Therapy
Time (hours)s.c. injection
Normal Insulin Secretion at Meal Time
Ch
an
ge
in S
eru
m in
su
lin
Rapid-acting Analogue
Regular insulin
Apidra
Humalog
Novolog
Insulin lispro or aspart Insulin glargine
Basal-Bolus Insulin Therapy: Insulin Glargineat HS and Mealtime Lispro or Aspart
B DL HS
Insu
lin E
ffe
ct
Adapted with permission from Leahy J. In: Leahy J, Cefalu W, eds. Insulin Therapy. New York, NY: Marcel Dekker Inc.; 2002:87
Traditional “Sliding Scale”An arbitrary insulin dosing algorithm
based only on pre-meal blood glucose valuesPre-Meal BG (mg/dl)Pre-Meal BG (mg/dl) Insulin Dose (units)Insulin Dose (units)
Less than 151Less than 151 00
151-200151-200 22
201-250201-250 44
251-300251-300 66
301-350301-350 88
351-400351-400 1010
Adjusting meal insulinSliding scale not specific to patient needs
Not flexible for carbohydrate in mealsBreakfast meal may need more insulin –
hormonal influenceNo meal insulin if less than 100mg/dl??Use of correction insulin??
Starting Meal Time Insulin Stop insulin secreting agentAdd Bolus insulin before meals (REG or analog). Do
not need to do all meals at once, look at patterns, fix what is broken first
For all meals Add 10 units and redistribute total dose 50/50
Pt taking 30 units Lantus already Add 10 units to a new total dose of 40 units 50% will be new basal (20 units) 50% in divided doses will be the meal time bolus (i.e. 7/6/7)
Carb counting and correction factorsBG checks a must! Do not know where goingSAFETY
Total Daily InsulinTotal daily insulin requirement is calculated
by body weightT1: need about 0.6 units/kg (range 0.4 - 0.8)T2: need about 1.2 units/kg (range 1 – 1.4)
BGs at goal without hypoglycemia.40-50% basal (background)50-60% bolus (meal doses)
Calculating “Basal–Bolus” Insulin
Calculate TDDT1: need about 0.6 units/kg (range 0.4-0.8)T2: need about 1.2 units/kg (range 1 – 1.4)
Basal dose: 40 – 50% of TDDBolus dose: 50-60% of TDD:
Divide equally for three meals ORSensitivity Factor = 1700/TDD
1 unit will drop BG by XX points
Carbohydrate Ratio = 500/TDD 1 unit for every XX gm carbs
(Pt BG – target) / (SF) = CORRECTIONNow add carb ratio for meal.
For Example250 pound T2DM (114 kg) Calculated TDD: 114 x 1.2 = 137 u/dayBasal Dose: 68 units a day (50% of TDD)Bolus Dose: (other 50% of TDD)
Isocaloric meals: 68/3 = 23 units before each meal
Carbohydrate ratio: 500/137 = 3 1 unit for every 3 grams of carbs
Insulin Sensitivity: 1700/137 = 12 1 unit will lower BG 12 mg/dL
What’s the dose range?Type 2: 0.3 to 1.2 units/kg
“Thin type 2’s” are more insulin deficient“Heavy type 2’s” are more insulin resistant
Most pts with T2DM need insulin doses of 1 to 1.2 units/kg to achieve an A1c <7% (basal dose of 0.5 to 0.6 units/kg per day)
HypoglycemiaMost common side effect of insulin therapyGlucose levels less than 70 mg/dl are treatedSymptoms of hypo are treated regardless of
glucose levelUsual treatment is 15 gm glucose/ wait 15
min and repeat if needed ( Rule of 15/15)
Hypo TreatmentLiquid glucose preferred to solid
Orange juice is better than a piece of cakeSimpler forms of sugar are better than
sugars with fatJelly beans are better than chocolate
All patients need to carry on them a hypoglycemic treatment at all times
Know What Insulin is WorkingTesting Times
AM (fasting) indicates action of evening basal or intermediate insulin
Pre- lunch indicates action of AM short actingPre-supper ………………….pre lunch short
acting HS……………………pre-supper short acting
Carb CountingReferral to dietitianFlexible and adaptableMeal specificProvide web sites and carb counting booksRead labels
Betty: Book knowledge and the patient before you
Weight 182 lbs/83 kgWill need up to 1-1.4 units per kg/body
weightGo low and slow, use blood glucose to direct Figure dose needed then decide on which
meal (s)Look at A1c to help guideBasal Insulin now30 units at 10 PM, FBS are
well controlled, concentrate on 2 hour ppPrevent hypoglycemia
Betty: ContinuedBasal insulin 30 units1 unit per kg/body weight is 83 units TDD53 units/3 meals is 18 units per meal Start with breakfast and dinner, add lunch as
needed, if no breakfast, add at lunch and dinnerORCarb counting and sensitivity factor:500 ./. 83 = 6 1 unit to cover 6 grams carb 1700 ./. 83 = 20 1 unit of insulin to drop
20mg/dl Blood glucose goal is 100mg/dl before meals
ExampleInsulin SensitivityBlood glucose before meal is 180mg/dlGoal is 100mg/dl180-100 = 80 (correct for)80 ./. 20 = 4 units (insulin sensitivity)Carb CoverageDinner meal: 2 Hambugers, 2 rolls, ½ cup
applesauce, ½ cup green beans, ½ cup cornApprox 60 grams of carb1 unit covers 6 grams of carb = 6 units of
meal time unsulin Total for this meal: 10 units meal time insulin
PearlsOnce insulin sensitivity and carb ratios
determined not as difficulty as it may appearWhen patients consume less and blood
glucose improve less risk of hypoglycemiaBlood glucose monitoring is keyConsider Continuous Blood Glucose
Monitoring as an aid Lack of understanding of Nutrition is often
what prevents patients from getting to treatment goals
Insulin dosing is a moving target……..