Endocrinology Book

http://www.fpnotebook.com/

Insulin Dosing

Aka: Insulin Dosing
  1. Protocols
    1. See Insulin Dosing in Type I Diabetes
    2. See Insulin Dosing in Type II Diabetes
    3. Insulin Adjustment with Carbohydrate Counting
  2. Protocol: Goal Blood Glucose for Type I and Type II Diabetes
    1. Hemoglobin A1C <7%
    2. Goal: >50% of blood sugars in range
      1. Pre-meal Blood Glucose 70-120 mg/dl
      2. Two hour post-prandial Blood Glucose <160 mg/dl
      3. Bed-time Blood Glucose 100-140 mg/dl
  3. Evaluation: Blood sugars
    1. Monitoring pointers
      1. Be consistent in monitoring
      2. Aim for 50% of Blood Glucoses in target range
    2. Look for consistent pattern in blood sugars for >3 days
      1. Compare blood sugar for same time each day
      2. For each time of day:
        1. Calculate Blood Glucose range
        2. Calculate median Blood Glucose
      3. Consider eating and activity patterns during day
      4. Ignore spurious values
    3. Adjust only one Insulin dose at a time
      1. Correct Hypoglycemia first
      2. Correct highest blood sugars next
      3. Maintain a 50:50 mix of Basal to bolus Insulin
  4. Evaluation: Adjustment of Insulin
    1. Adjustment factors (for lows and highs)
      1. Adjust Insulin in small steps at a time
      2. Adjustment steps based on Insulin amount
        1. Insulin dose <10 units: Adjust by 1 unit
        2. Insulin dose 10-20 units: Adjust by 2 units
        3. Insulin dose >20 units: Adjust by 10% Insulin dose
      3. Adjustment steps based on diabetes type
        1. Type I Diabetes Mellitus: 1-2 units change
        2. Type II Diabetes Mellitus: 2-4 units change
    2. Correction protocol for Hypoglycemia
      1. General measures to consider
        1. Increase carbohydrate preceeding low
          1. Carbohydrate at prior meal or
          2. Snack or
          3. Pre-Exercise carbohydrate
        2. Adjust Exercise timing during the day
      2. Basal Insulin (e.g. Lantus) adjustment
        1. Blood Glucose low in AM
          1. Decrease basal Insulin (Lantus)
      3. Rapid acting Insulin (e.g. Lispro) adjustment
        1. Blood Glucose low before lunch
          1. Decrease rapid Insulin (Lispro) at breakfast
        2. Blood Glucose low before dinner
          1. Decrease rapid Insulin (Lispro) at lunch
        3. Blood Glucose low before bedtime
          1. Decrease rapid Insulin (Lispro) at dinner
    3. Correction protocol for hyperglycemia
      1. General measures to consider
        1. Decrease carbohydrate preceeding high
          1. Carbohydrate at prior meal or
          2. Stop or decrease snack
        2. Increase Exercise prior to meal
      2. Adjust Insulin based on Carbohydrate Count
        1. See Insulin Adjustment with Carbohydrate Counting
        2. One Unit covers each 10-15 grams carbohydrate
        3. Add 1-2 units for every 50 mg/dl glucose >150
      3. Indications to adjust basal Insulin (e.g. Glargine)
        1. All Blood Glucoses >200 mg/dl
          1. Increase basal Insulin by 0.1 units/kg
        2. All Blood Glucoses high (within 50 mg/dl)
          1. Increase basal Insulin per adjustment above
        3. Pre-supper Blood Glucose high
          1. Adjust basal Insulin per adjustment above
        4. Fasting (AM) Blood Glucose high
          1. Perform 3 am blood sugar checks
          2. Critical to distinguish 3 AM low BG from high BG
            1. Dawn Phenomena (relative Insulin deficiency)
              1. Increase basal Insulin by adjustment above
            2. Somogyi Phenomena (Rebound Hyperglycemia)
              1. Decrease basal Insulin by adjustment above
      4. Indications to adjust bolus Insulin (e.g. Lispro)
        1. Two hour post-prandial >40-60 mg/dl over premeal
          1. Increase rapid acting Insulin before meal
        2. Blood Glucose low before meal
          1. Decrease rapid Insulin before prior meal
    4. Average Insulin doses after titrating from start
      1. Type I Diabetes Mellitus: 0.7 units/kg
      2. Type II Diabetes Mellitus: 1.2 units/kg
  5. Resources
    1. AIDA Diabetes Insulin Simulation
      1. http://www.2aida.org/online

Insulin (C0021641)

Definition (CSP) protein hormone secreted by beta cells of the pancreas; insulin plays a major role in the regulation of glucose metabolism, generally promoting the cellular utilization of glucose and is also an important regulator of protein and lipid metabolism; insulin is used as a drug to control insulin-dependent diabetes mellitus.
Definition (NCI) A short-acting form of insulin. Regular insulin is obtained from animal or recombinant sources. The onset of action of regular insulin occurs at 30-90 minutes after injection; its effect lasts for 6 to 8 hours. Endogenous human insulin, a pancreatic hormone composed of two polypeptide chains, is important for the normal metabolism of carbohydrates, proteins and fats; it has anabolic effects on many types of tissues. (NCI04)
Definition (NCI) Human insulin protein (110 aa, 12 kDa) is encoded by the human insulin (INS) gene. This cytosolic protein, a heterodimer of disulfide-linked alpha and beta chains, is produced in pancreatic islet beta cells. Binding of insulin to its receptor stimulates glucose uptake, accelerates both glycolysis and the pentose phosphate cycle and increases glycogen synthesis in the liver. Insulin regulates protein and lipid metabolism. It also decreases blood glucose concentration by shuttling molecules into cells to be used for energy. Decreased expression of insulin protein causes familial hyperproinsulinemia.
Definition (MSH) A 51-amino acid pancreatic hormone that plays a major role in the regulation of glucose metabolism, directly by suppressing endogenous glucose production (GLYCOGENOLYSIS; GLUCONEOGENESIS) and indirectly by suppressing GLUCAGON secretion and LIPOLYSIS. Native insulin is a globular protein comprised of a zinc-coordinated hexamer. Each insulin monomer containing two chains, A (21 residues) and B (30 residues), linked by two disulfide bonds. Insulin is used as a drug to control insulin-dependent diabetes mellitus (DIABETES MELLITUS, TYPE 1).
Concepts Amino Acid, Peptide, or Protein (T116) , Pharmacologic Substance (T121) , Hormone (T125)
MSH D007328
SnomedCT 67866001, 39487003, 412222002
English Insulin, insulin, INSULIN PREPARATIONS, Insulin preparation, NOS, Regular Insulin, Regular insulin preparation, Unmodified insulin preparation, Insulin Regular, INSULIN, insulin preparations, insulin preparations (medication), A22 INSULIN PREPARATIONS, insulin regular, Insulin (ox), 8A-L-threonine-10A-L-isoleucine-30B-L-threonine-, Insulin [Chemical/Ingredient], [HS501] INSULIN, Insulin regular, insulin products, insulin preparation, insulin product, regular insulin, insulins, Insulin, Soluble, Soluble Insulin, Insulin, Regular, Insulin product, Insulin (substance), Insulin preparation, Insulin product (product), Regular insulin product, Unmodified insulin product, Insulin preparation (substance), Regular insulin (substance), Regular insulin
Swedish Insulin
Czech insulin, inzulin
Finnish Insuliini
French Insuline ordinaire, Insuline
Russian INSULIN, ИНСУЛИН
Spanish producto con insulina (producto), preparado insulínico, insulina (producto), producto con insulina, insulina (sustancia), insulina, preparado de insulina (producto), preparado de insulina (sustancia), preparado de insulina cristalina de cinc, preparado de insulina cristalina de zinc, preparado de insulina no modificada, preparado de insulina, insulina regular (sustancia), insulina regular, Insulina
Italian Insulina regolare, Insulina
Croatian INZULIN
Polish Insulina
Japanese インスリン, インスリン亜鉛水性懸濁液, インシュリン
German Insulin
Portuguese Insulina
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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