OPTIMIZING INSULIN THERAPY

مشاركات: 10840
اشترك في: الخميس إبريل 04, 2013 10:28 pm

OPTIMIZING INSULIN THERAPY

مشاركةبواسطة دكتور كمال سيد » الاثنين يناير 07, 2019 5:46 pm

OPTIMIZING INSULIN THERAPY
by proff Sulaf Ibrahim A/Aziz


1- Human insulins are effective as insulin analogues.
2- Rapid acting insulins could be administered before, during or after eating.
3- Insulin analogues showed lower risk of hypoglycemia.
4- Bed time NPH (Neutral Protamine Hagedorn)should be given after 11 pm to avoid nocturnal hypoglycemia and smogyi phenomenon.

NPH stands for neutral protamine Hagedorn, and the words refer to neutral pH (pH = 7), protamine (a protein),
(and Hans Christian Hagedorn (an insulin researcher

Brand names include Humulin N, Novolin N, Novolin NPH, Gensulin N, SciLin N, Insulatard, and NPH Iletin II.
**
NPH insulin, also known as isophane insulin, is an intermediate–acting insulin given to help control blood sugar levels in people with diabetes. It is used by injection under the skin (SC) once to twice a day. Onset of effects is typically in 90 minutes and they last for 24 hours.
Trade name: Novolin N, Humulin N, others

NPH insulin is made by mixing regular insulin and protamine in exact proportions with zinc and phenol such that a neutral-pH is maintained and crystals form
This mixture only needed to be shaken before injection
It has an intermediate duration of action, meaning longer than that of regular and rapid-acting insulin, and shorter than long acting insulins (ultralente, glargine or detemir).

An insulin analog is an altered form of insulin, different from any occurring in nature, but still available to the human body for performing the same action as human insulin in terms of glycemic control. Through genetic engineering of the underlying DNA, the amino acid sequence of insulin can be changed to alter its ADME (absorption, distribution, metabolism, and excretion) characteristics. Officially, the U.S. Food and Drug Administration (FDA) refers to these as "insulin receptor ligands", although they are more commonly referred to as insulin analogs.
https://en.wikipedia.org/wiki/NPH_insulin

Hypoglycemia or low blood glucose in the late evening causes a rebound effect in the body, leading to hyperglycemia or high blood glucose in the early morning. This phenomenon, known as the Somogyi effect, is widely reported but remains controversial due to a lack of scientific evidence.Jun 20, 2017
صورة
https://www.medicalnewstoday.com/articles/317998.php

The Somogyi effect can occur any time you or your child has extra insulin in the body. To sort out whether an early morning high blood sugar level is caused by the dawn phenomenon or Somogyi effect, check blood sugar levels at bedtime, around 2 a.m. to 3 a.m., and at your normal wake-up time for several nights.

تابع
صورة

مشاركات: 10840
اشترك في: الخميس إبريل 04, 2013 10:28 pm

Re: OPTIMIZING INSULIN THERAPY

مشاركةبواسطة دكتور كمال سيد » الاثنين يناير 07, 2019 7:31 pm

(Insulin analogs are preferred for basal, mealtime, and correction doses instead of human insulin (regular and NPH *
I*Insulin analogs have a more predictable absorption and action profile in addition to less pharmacokinetic fluctuation in patients with renal insufficiency.

How do you manage a pt. in hospital?

FOR EVERY 50mg/dl above 180 give 1U RI (Regular Insulin)…..type 1DM
0.005-0.01U/Kg……type 2DM

181-220……..2U
221-260……..4U
261-300……..6U
301-340………8U

(adjusted as per pt response b/o differing insulin sensitivity)

*************
5. Insulin infusion should be used to control hyperglycemia in the majority of critically ill patients in the ICU setting, with a starting threshold of no higher than 180 mg/Dl.

6. Once IV insulin therapy has been initiated in a critically ill patients, the glucose level should be maintained between 140 and 180 mg/dL.

7. In the treatment of hyperglycemia in critically ill patients, targets lower that 110 mg/dl are not recommended.

8. IV insulin protocols should take into account the patient’s current and previous BG levels (and, therefore, the
(rate of change in BG

TARGET GOALS FOR BLOOD GLUCOSE

9- (The starting rate of (VRIII) Variable rate i.v. insulin infusion (units/hour
current blood glucose - 60) X 0.02 =
(the multiplier)

10. Adjust multiplier (initially 0.02) to obtain glucose in target
range 140
to 180 mg/dL

: IF AFTER 1 HOUR
• If BG >180 mg/dl and not decreased by 15%, increase by 0.01.
• If BG <140 mg/dl, decrease by 0.01.
• If BG 140 to 180 mg/dl or decreased by 15%, no change in multiplier.

11. During VRIII, if the blood glucose falls below 90, give glucose 50% CC
according to the following equation = (100 – BG) x 0.4.

12. During Variable rate i.v. insulin infusion (VRIII), it is recommended to
continue basal insulin.
360mg/dl
(360-60)x0.02= 6U/hr
After 1 hr
If BS >180 and not dropped by 15% (54mg/dl)290
Inc. multiplier by 0.01 (0.03)
Above (300-60)x0.03=7.2U/hr
If BS <140
Decrease multiplier by 0.01
صورة

مشاركات: 10840
اشترك في: الخميس إبريل 04, 2013 10:28 pm

Re: OPTIMIZING INSULIN THERAPY

مشاركةبواسطة دكتور كمال سيد » الاثنين يناير 07, 2019 7:53 pm

13. Withhold all other diabetes medication during VRIII.

14. Always avoid i.v insulin if the patient is eating and drinking normally.

15. All patients with type 1 and type 2 diabetes should be transitioned to scheduled SC insulin therapy from IV insulin.

16. Patients without a history of diabetes, who have hyperglycemia requiring more than 2 units of IV insulin per hour, should be transitioned to scheduled SC insulin therapy.

How do you transfere pt to s/c?

Ordering 50% of TDD (Total Daily Dose) as basal insulin and the other 50% of TDD as mealtime insulin divided equally into 3 mealtime doses.
Glucose targets were reached in the majority of patients in the basal bolus intervention group with minimal hypoglycemia.
: Conversion from IV to SC insulin commonly occurs
When the critical illness resolves,
When the patient is extubated,
Off vasopressors, and ready to begin eating, or
Is at a stable tubefeeding rate.

17. Basal bolus regimen is the recommend regimen to use for shifting from IV insulin to SC insulin.
What is a basal-bolus insulin regimen?
A basal-bolus routine involves taking a longer acting form of insulin to keep blood glucose levels stable through periods of fasting and separate injections of shorter acting insulin to prevent rises in blood glucose levels resulting from meals.
A basal-bolus insulin regimen involves a person with diabetes taking both basal and bolus insulin throughout the day. It offers them a way to control their blood sugar levels. It helps achieve levels similar to a person without diabetes.Mar 28, 2017

What is a short acting bolus insulin?

Bolus insulin, or a “bolus” refers to insulin that is fast acting and is given to cover the carbohydrates in a meal or to bring down high blood glucose. Bolus insulin include Humalog, Novolog and Apidra.


What are the types of basal insulin?

Two types of this insulin currently on the market are detemir (Levemir) and glargine (Toujeo, Lantus, and Basaglar). This basal insulin begins working 90 minutes to 4 hours after injection and remains in your bloodstream for up to 24 hours. ... There isn't a peak time for this type of insulin.Jun 1, 2017

Is basal insulin Long acting?

Long-acting insulins are also called basal or background insulins. They keep working in the background to keep your blood sugar under control throughout your daily routine. There are currently four different long-acting insulin products available: insulin glargine (Lantus), lasts up to 24 hours.Feb 19, 2016

When should I take bolus insulin?

People with diabetes take bolus insulin at meal times, to keep blood sugar levels under control after eating. Bolus insulin needs to act quickly, and so is known as "short-acting" or "rapid-acting" insulin. It works in about 15 minutes, peaks in about 1 hour, and continues to work for 2 to 4 hours.Mar 28, 2017

18. Short- or rapid-acting insulin should be administered 1 to 2 hours before discontinuation of the IV insulin to maintain effective blood levels of
insulin.
19. The initial dose and distribution of SC insulin at the time of transition
can be determined by extrapolating the IV insulin requirement over the
preceding 6- to 8-hour period to a 24-hour period.
•Administering 60% to 80% of the total daily calculated dose as basal insulin has been demonstrated to be safe and efficacious in surgical
patients.
• Dividing the total daily dose as a combination of basal and bolus insulin has been demonstrated to be safe and efficacious in medically ill patients.
صورة

مشاركات: 10840
اشترك في: الخميس إبريل 04, 2013 10:28 pm

Re: OPTIMIZING INSULIN THERAPY

مشاركةبواسطة دكتور كمال سيد » الاثنين يناير 07, 2019 9:15 pm

A Guide on Insulin Types for People with Diabetes

Type Brand Name Onset (length of time before insulin reaches bloodstream)
Rapid-acting Humalog Novolog Apidra 10 - 30 minutes
Short-acting Regular (R) 30 minutes - 1 hour
Intermediate- acting NPH (N) 1.5 - 4 hours
Long-acting Lantus Levemir 0.8 - 4 hours

19. The initial dose and distribution of SC insulin at the time of transition
can be determined by extrapolating the IV insulin requirement over the
preceding 6- to 8-hour period to a 24-hour period.
•Administering 60% to 80% of the total daily calculated dose as basal insulin has been demonstrated to be safe and efficacious in surgical
patients.
• Dividing the total daily dose as a combination of basal and bolus insulin has been demonstrated to be safe and efficacious in medically ill patients.
20. A basal plus correction insulin regimen is the preferred treatment for patients with poor oral intake or who are
(taking nothing by mouth (NPO

*CORRECTION/SUPLEMENTAL DOSE

FOR EVERY 40mg/dl above 180 give 2U of regular insulin

1- Discontinue OAA
2- If pt already on insulin, continue with home dose and make adjustments
# IF
GOOD ORAL INTAKE

give mixed insulin BD -1
0.5 - 1 U/Kgbw
+
2- (correction doses with regular insulin (RI with BG >180
+
3- Glucocheck : FBS, 2hr After each meal
+
4 - (Adjust Mixed Insulin Dose Next Day (TDD

# IF
POOR ORAL INTAKE
1- Basal Insulin Insulatard 5 U BD
+
Lantus 10 U OD
2- Correction Doses* Of Regular Insulin With BS >180
+
3- Glucocheck : FBS, 2hr After Each Meal
+
4- (Adjust Insulin Dose Next Day (TDD

** In many studies the total daily dose of insulin (TDD)was calculated by multiplying the patient weight in kilograms by either 0.4 or 0.5 units/kg.
صورة

مشاركات: 10840
اشترك في: الخميس إبريل 04, 2013 10:28 pm

Re: OPTIMIZING INSULIN THERAPY

مشاركةبواسطة دكتور كمال سيد » الاثنين يناير 07, 2019 9:31 pm

A Guide on Insulin Types for People with Diabetes

For all non-critically ill patients, a basal/bolus insulin regimen is the preferred method of glycaemic control.
During illness, basal insulin requirements rise with any physical stress, including surgery, infection, infarction, or fever.
Basal insulin suppresses hepatic glucose efflux between meals and overnight.
Laboratory analysis of plasma is the best means of measuring blood glucose levels, but this approach is too slow for use in the ICU.

Bedside glucometers may be inaccurate (by more than 20%), particularly when used to assess samples from patients with:
Lower glucose levels
(To assess fingerstick capillary samples from patients with tissue edema (which has a diluting effect
Hypoperfusion
Anemia

صورة
صورة


العودة إلى medicine

الموجودون الآن

المستخدمون المتصفحون لهذا المنتدى: لا يوجد أعضاء مسجلين متصلين و 1 زائر