MMI Task Force on Diabetes

House Staff Curriculum

Objectives
1. Identify a situation in which regular insulin is preferred instead of aspart for correction insulin. 2. Discuss the appropriate basal insulin adjustments at the time of hospital discharge based on morning fasting blood glucose.

Patient #1

A 62 yo female is admitted with acute coronary syndrome and is made NPO for likely cardiac catheterization. Her home insulin regimen is Lantus 60 Units QHS, Aspart 20 TID with meals and no sliding scale. Regarding her Lantus, would you a. Stop it because she is NPO b. Continue at home dose of 60 U c. Give 30 U

Patient #2

A 75 yo male is admitted with ischemic stroke. He now has severe dysphagia and is started on continuous tube feeds. His previous home regimen only included metformin. Regarding his sliding scale insulin, would you start a. Aspart q4h b. Aspart q6h c. Regular q4h

d. Regualr q6h

Insulin Regimen

Maynard et al., 2008. J Hosp Med (3) S5

Patient #3

A 35 yo male was admitted with cellulitis and you have diagnosed him with diabetes. His hemoglobin A1C is 10.2. You have already started 10 U lantus QHS and appropriate meal time and sliding scale insulin. His am fasting blood glucose was 155 today and 160 yesterday. He is being discharged today. Regarding his Lantus, would you. a. Leave it at 10 U and defer to his PCP to increase. b. Increase the dose to 12

c. Increase the dose to 14

d. Increase the dose to 18

Insulin at Hospital Discharge

OMalley et al., 2008. J Hosp Med (3) S5

Insulin at Hospital Discharge

Titrate based on the morning fasting blood sugar: Decrease 4 units if below 60 mg/dL, Decrease 2 units if 60 to 80 mg/dL, No change if 80 to 100 mg/dL, Increase 2 units if 100 to 120 mg/dL, Increase 4 units if 121 to 140 mg/dL, Increase 6 units if 141 to 160 mg/dL, Increase 8 units if 161 to 180 mg/dL, Increase10 units if fasting blood sugar is >180 mg/dL.
OMalley et al., 2008. J Hosp Med (3) S5

References
1. Maynard et al. 2008. Subcutaneous Insulin Order Sets and Protocols: Effective Design and Implementation Strategies. J Hosp Med (3) S5. 29-41. 2. OMalley et al. 2008. Bridge Over Troubled Waters: Safe and Effective Transitions of the Inpatient with Hyperglycemia. J Hosp Med (3) S5. 55-65.