1. Ellen Coonerty, RN, BSN, BA, CDE
Clinical Diabetes Nurse Specialist
In-Patient Diabetes Team: MSKCC – Main Campus
August 14, 2013

3. Healthy Insulin Profile
Phase 1 and Phase 2 Insulin Response
People without diabetes – typical insulin profile
8 am 12 noon 6 pm 10 pm

4. Rapid - Fast Acting Insulins:
Designed to mimic 1st phase insulin response– BOLUS
Bolus insulin is also called ‘Nutritional or Prandial Insulin’
Name Onset Peak Duration
Novolog
Aspart
5-15 min 60 to 120 min 3-5 hrs
Humalog
Lispro
5-15 min 60-90 min 3-4 hrs
Apidra
Glulisine
5-15 min 60 to 90 min 3-4 hrs
Regular (R)
*Use for IV insulin use,
TPN, Continuous Tube
Feeds
30-60 min 2-4 hrs 6-8 hrs

5. Intermediate Insulin
Can be used as a Basal Insulin …
“N” (NPH) insulin can last anywhere from 12-14-16-24 hours
duration
NPH and Prednisone and Methylprednisolone go perfectly together!
Name Onset Peak Duration
Novolin N
No longer called
NPH insulin
1 - 2 hrs 6 – 10 hrs 12 - 16 -20
hrs

6. Long-Lasting Insulin
Designed to mimic 2nd phase insulin response - BASAL
Name Onset Peak Duration
Lantus
(Glargine)
AACE, ADA, ACE:
Lantus does not
cause cancer!
1-2 hrs No Peak
Reaches steady
state ~ 6 hours
20-24 hrs
Levemir
(Detemir)
1-2 hrs Dose-
dependent
Dosing needs to be 0.3
to 0.4 units/kg/day to
reach 24 hours
duration.
* Maximum effect of
dose is within the
first 12 hours of use.

7. Pharmacokinetics of Insulin Preparations
Short acting Analog
Regular
8 AM 6 PMN 10 PM
InsulinEffect
6-23
8 AM
NPH
Glargine
Detemir

8. Outcome/Goal:
Maintain good to optimal glucose control throughout the
hospitalization period
without causing hypoglycemia
Titrate DAILY
Don’t do nothing … Inertia breeds inertia!
Treat Hyperglycemia using pt. history, patient
condition, calculations, and BG results
Korytkowski, Mary MD Professor of Medicine, University of Pittsburgh School of Medicine 3-2011

9. In the APACHE II trial . . .
“even a
single episode of severe hypoglycemia
conferred an increased risk of mortality.”

10. Hypoglycemia Order Set on CIS
Every time you order insulin …
order the Hypoglycemia Order Set

11. Obtain patient weight in kg

T2DM: Calculate Total Daily Dose (TDD) as
0.2 to 0.5 units per kg/day
(0.4 is this CDE’s safety #)
*WILL NEED MORE INSULIN IF TAKING STEROIDS
WILL NEED LESS INSULIN IF TYPE 1DIABETES

Choose the dosing schedule
Give 50% of TDD as Basal Insulin
Give 50% of TDD as Bolus Insulin (premeal or nutritional) and
divide by 3 – for 3 meals

Adjust according to results of BGM
Adjust dose for NPO status or changes in clinical status
Korytkowski, Mary MD Professor of Medicine, University of Pittsburgh School of Medicine 3-2011

12. 
What are BG goals for MSKCC non-critical hospitalized
patient?
FBG: 90 to 150 mg/dl
ac and HS: 90 to 180 mg/dl


13. John: T2DM x 5 years. Wgt = 150 Kg. BMI 42.00
Takes 3 oral diabetes meds at home. HBA1c = 9.4 % .
Admitted to MSKCC for newly Dx Prostate Cancer
 First, D/C all oral diabetes medication
 Pt. with uncontrolled diabetes
 Pt. is overweight – high BMI = Insulin Resistance
 WGT = 150 Kg. Pt is naive to insulin.
 150 Kg x 0.05 units/Kg = 75 units (TDD- Total Daily Dose)
 Divide TDD by 2 for Basal/Bolus = 37 Basal and 37 Bolus
 Divide the Bolus of 37 units by 3 meals = 12.3 units
 Calculation = 37 units Lantus at HS
 Target BG = 100 to 149 mg/dL

14. Did you know that there are only 2
doses of Insulin????
Enough
and
Not Enough

15. Let’s think … Insulin naïve – feels like a high dose –
maybe scale back a little – make sure pt is eating!
BG
mg/dL
Breakfast
Novolog
Lunch
Novolog
Dinner
Novolog
HS
Novolog
HS
(9-10 PM)
Lantus
70-99 8 8 8 0 (37?) 30
100-149 (12?)10 10 10 0
150 - 199 12 12 12 0
200-249 etc 14 14 0
250-299 16 16 0
300-349 18 18 0
350-399 20 20 0
> 400
mg/dL
22 22 0

16. Patty: Age= 56. T2DM x 15 years. WGT= 122 Kg. Colon Cancer. Home insulin regimen=
Lantus 80 units at HS. Takes 25 units Novolog before BKFT and Lunch, and 30 units ac
Dinner. HBA1c = 10.3%.
CURRENT INSULIN REGIMEN
Breakfast Lunch Dinner Bedtime
BG Level Lantus 40 units
Novolog Novolog Novolog
70-99 12 12 12
100-149 14 14 14
150-199 16 16 16
200-249 18 18 18
250-299 20 20 20
300-349 22 22 22
350-399 24 24 24
 400 26 26 26
BLOOD-GLUCOSE RESULTS
Date Before Breakfast Before Lunch Before Dinner Before Bedtime
How much is
too much
insulin????
265 (20) 279 (20) 276 (20) 310 (L=40)
302 210 258 233
288 224 301 277

17. Edward: 45 yrs old; T2DM x 10 yrs; Wgt = 100 Kg; BMI=35; PMHx- HTN,
hyperlipids, pancreatitis. Admitted with newly Dx CLL. Induction chemotherapy.
DECADRON 40 MG X 5 DAYS
CURRENT INSULIN REGIMEN
Breakfast Lunch Dinner Bedtime
BG Level Novolog Novolog Novolog Lantus 10 units
70-99 0 0 0
100-149 2 2 2
150-199 4 4 4
200-249 6 6 6
250-299 8 8 8
300-349 10 10 10
350-399 12 12 12
 400 14 14 14
BLOOD-GLUCOSE Results
Date Before Breakfast Before Lunch Before Dinner Bedtime 10 PM
5-31-13 321 (10) 345 (10) 401 (14) 10
6-1-13 369 289 444
6-2-13 398 275 320

18. Thomas: Type 2 DM x 8 years. Age-72; HBA1c – 7.3%. WGT – 74 Kg. Admitted
with SOB 2/2 lung mass upper R lobe. No steroids yet. Lives alone. Eating.
CURRENT INSULIN REGIMEN
BG Level Breakfast Lunch Dinner Bedtime
Novolog Novolog Novolog Lantus 10 units
70-99 0 0 0
100-149 0 0 0
150-199 4 4 4
200-249 6 6 6
250-299 8 8 8
300-349 10 10 10
350-399 12 12 12
 400 14 14 14
BLOOD GLUCOSE LEVELS
Date Before Breakfast Before Lunch Before Dinner
Bedtime 10 P
Lantus 10 units
6-14-13 133 (0) 204 (6) 177 (4) 181 (10)
6-15-13 151 189 153 142
6-17-13 154 161 189 191

19. Steroid-Induced Hyperglycemia
Think … Insulin … Insulin, …Insulin
David Baldwin, MD – Endocrinologist at Rush Institute in Chicago
Managing Hyperglycemia in Special Situations:
What are the Pitfalls of QAM Prednisone?
1. Prednisone only raises the blood glucose for ~ 18 hours (in system about 36-48 hrs)
2. Generally sulfonylureas or metformin will have no effect on steroid-exacerbated
hyperglycemia
• Lantus (Glargine) will usually outlast QAM prednisone and so BG in the PM may
be ok … but fasting BG in the AM will be hypoglycemic
______________________________________________________________________
Managing Hyperglycemia in Special Situations:
Best Solution to the Pitfalls of QAM Prednisone
• The Pharmacokinetic profiles of:
QAM prednisone and QAM NPH insulin are very similar.
• Therefore the safest and most efficacious therapy for hyperglycemia in patients
treated with QAM prednisone is NPH and rapid-acting analog QAM and rapid-
acting analog QPM
• Avoid Lantus (Glargine) or sulfonylureas

20. Jeff: 59 years; lung cancer. SOB. Wgt 96 Kg. T2DM: Takes
Metformin and Glimepiride at home. HBA1c = 8.8 %.
BGs running in 230+ . Ordered Prednisone 20 mg BID.
(The same rules would apply for Methylprednisolone)
BG
mg/dL
Breakfast
NPH
(2/3 and 1/3)
Breakfast
Novolog
Lunch
Novolog
Dinner
Novolog
HS
NPH
70-99
20
8 8
10
100-149 10 10 10
150 - 199 12 12
200-249 14
250-299 16
300-349 18
350-399 20
> 400 22

21. A few hints:
 Know your target and work daily to get there!
 Titrate Insulin Daily
 If pt. on insulin at home – order ½ their doses to start
and titrate daily.
 Routine insulin calculation: 0.04 to 0.05 units/Kg/day
 Steroids: 0.07 units/Kg/day
 Renal Failure: 0.3 units/Kg/day
 Type 1 Diabetes or Pump: 0.1 or 0.15 or 0.2 (Call endocrine)
 If YOU are not comfortable with the dose, go lower !
 Please keep re-assessing your pt. Keep in mind the pt.
condition, eating status, NPO, BG targets, titrate daily.