Day 2 - Management of Type II Diabetes

Insulin management principles:

• Do NOT using sliding scales alone - this is a reactive approach that can result in significant swings in glucose levels

• Use a “basal, bolus, supplemental” regimen to avoid this

  • Combination of daily long-acting ie. lantus; meal-time bolus ie. novorapid, humalog, humulin R; and supplemental scale to be administered as needed with same meal-time insulin

• In most patients, target pre-prandial CBG of 5-8mmol/L (8-10mmol/L in critically ill)

Approach:

1. Calculate Total Daily Dose (TDD) of Insulin, generally 0.5units/kg/day

2. Divide between long-acting and pre-prandial

   1. 40% of TDD given as long-acting, generally qhs

   2. Remaining 60% divided between 3 meals (ie. 20% with breakfast/20% lunch/20% dinner)

   3. Add supplemental scale to be given if CBG is above target range, generally guided by patient’s correction factor, ie. CBG correction/1 unit insulin

3. If sugars too high, increase insulin based on timing of highs:

   1. Breakfast - increase basal dose ~10%

   2. Lunch - increase breakfast dose ~10%, etc

4. If sugars too low, follow same principals as above to decrease

Management of hypoglycemia:

• If conscious: 15g oral carbohydrate ie. 225mL juice or 5 x 3g glucose tablets

  • Repeat CBG q15min and continue to administer until CBG >4

• If unable to eat or unconscious: 1amp D50W IV

  • Repeat CBG q15min and continue to administer until CBG >4

Commonly used Insulins and duration of action - from McMaster Internal Medicine Red Book (2017)